By Christina Chapman, MD
In June 2019, I served as the discussant for an important abstract by Narjust Duma, MD, and colleagues presented at the ASCO Annual Meeting. In Dr. Duma’s study, a group of investigators watched videos of scientific presentations from two recent ASCO annual meetings and recorded whether speakers were introduced with a professional form of address (e.g., Dr. Last Name) or an informal address (e.g., speaker’s first name or Dr. First Name without last name). They found that women and Black individuals were less likely to be introduced with a professional form of address. They also found that men were more likely than women to introduce speakers informally. The abstract was subsequently published as a full length manuscript in the Journal of Clinical Oncology.1 Although the data on gender were published, the data on race were omitted from the final manuscript, which I discuss below. This research project was modeled after an earlier project that similarly demonstrated gender bias in speaker introductions at the Mayo Clinic’s Internal Medicine Grand Rounds. These studies add to the existing literature that demonstrates the pervasiveness of gender bias in medicine and biomedical research.
Christina Huang, MS, Fumiko Chino, MD, and colleagues performed a similar analysis focusing on recent ASTRO Annual Meetings. They did not find a statistically significant difference in speaker introductions on the basis of gender. However, their presentation prompted a series of conversations on Twitter during the 2020 ASTRO virtual Annual Meeting. Although they suggested that all speakers be introduced with a professional form of address, multiple male members conveyed opposing viewpoints. One was that formality in conference speaker introductions reinforces hierarchies that impair collegiality and free exchange of ideas. Another viewpoint was that calls for consistency are unnecessary in light of the study’s failure to demonstrate gender bias. One may wonder why such varied opinions exist on this topic. An examination of the existing evidence may shed light on why opinions differ strongly across gender and racial lines.
In general, people are less likely to support or see the need for formalized systems, rules or laws if they are treated justly without them. Those who are oppressed under current systems instead recognize that “honor systems” and informal structures often fail to produce justice in inequitable societies. In short, the marginalized clearly see the need for guardrails, while those who are centered may claim to be unaware that there is a dangerous cliff nearby. This cliff is well described in the literature, however, so it is incumbent upon everyone to recognize the bias, whether it directly affects them or not.
Although professional credentials are not the only factors that influence career success, they certainly help drive it. Furthermore, numerous studies have demonstrated racial, gender and other biases in the way that individuals with identical credentials are perceived. These facts demonstrate the dangers of informality in professional settings. Even if men and women are introduced informally at the same rates, the penalties are greater for women and the advantages are greater for men. When women’s credentials are not formally displayed, the audience is less likely to perceive them as a physicians or scientists. This does not hold true to the same extent for men, who are more likely to be perceived at the top of hierarchies or to possess advanced credentials regardless of their actual standing. When a male-presenting individual offers, “Just call me Jake,” it is somewhat disingenuous to think that this eliminates or substantially mitigates hierarchies, because he is still perceived to possess academic credentials and be perceived as a man, both of which elicit a certain level of respect in hierarchical and biased society.
To be clear, there are two types of hierarchies relevant here. They can be distinguished by whether they are publicly accepted as just or unjust. Most people will state publicly that racial or gender hierarchies are unjust while stating that hierarchies based on academic credentials or achievement are generally just if equitably implemented. For example, most departments would find it acceptable to deny an application for an academic radiation oncology faculty position from someone without training beyond a bachelor’s degree. Many conference attendees would also find it acceptable that scientific discussants are selected based on their training and content expertise. Without display of their formal credentials, however, women are perceived to be at lower levels of accepted hierarchies, leading to discrimination that is repackaged to make it appear justifiable (e.g., “Oh, I didn’t even realize she was a funded immunologist. I thought she was a student presenting her lab mentor’s research.”) Women then experience additional discrimination when the unjust hierarchy of gender inequity is applied, as in the context of two people perceived to be students with identical credentials: “I thought that male student was more competent than the female student.”2
Simply put, informality, even if applied evenly, leads to inequality in an unjust world. Formality serves to mitigate the impact of gender and other biases. If individuals or groups want to reduce the impact of hierarchies on scientific progress, one high yield place to start is eliminating hierarchies that have no basis in science: those based on gender. Furthermore, it could serve the field well to challenge the notions underlying just hierarchies by recognizing a broader array of scientific methods and topics as legitimate and important (e.g., qualitative research, health equity research) and recognizing that junior members of the field can make groundbreaking contributions. Converting to informal forms of address without challenging these underlying beliefs is unlikely to amplify the voices that we need to hear more clearly to advance our field.
Finally, it would also serve the field and broader community well to consider intersectionality and other forms of bias in their own right. When the Duma et al. paper was published, the significant finding of bias in introductions against Black speakers was removed because race was not self-reported. Study team-assigned race was not actually a major limitation of the study, given that it still measures an important endpoint (i.e., how individuals perceived to be Black are treated). Furthermore, there is little evidence that there would have been high discordance between the study team assignments and self-report, so it also would have likely given a reasonable approximation of the impact on self-reported Black individuals. Instead, important science was lost, despite the tremendous effort on the part of the study team to efficiently investigate multiple forms of bias. Problems like this can be mitigated by eliminating the scientific hierarchies that downplay the expertise of health equity researchers and instead appropriately elevating them to reviewer and leadership positions in journals.
Solutions to minimize the impact of hierarchies on medicine and science must be definitive and not performative. Informal introductions will lead to failure to recognize excellent science and scientists, which will be further compounded by biases that exist when equivalent credentials are made explicit. Calls for equity from the marginalized should not be minimized by those who are often centered, lest we run the risk of slowing progress in a field that sorely needs it.
Join the Gender Equity community on the ROhub to continue the discussion on this important topic by answering this question: In addition to speaker or clinic introductions, where else do you think greater consistency should be implemented to advance equity?
Christina Chapman, MD, is a health equity researcher and radiation oncologist specializing in head and neck and lung cancer. She obtained her BA in Biomedical Engineering from the Johns Hopkins University, her MD from the University of Pennsylvania Perelman School of Medicine, and her MS in Health and Healthcare Research from the University of Michigan, where she also completed her radiation oncology residency training.
1. Duma N, Durani U, Woods CB, et al: Evaluating Unconscious Bias: Speaker Introductions at an International Oncology Conference. J Clin Oncol. 2019;37:3538-3545.
2. Moss-Racusin CA, Dovidio JF, Brescoll VL, et al: Science faculty’s subtle gender biases favor male students. Proceedings of the National Academy of Sciences. 2012;109:16474-16479.