Using artificial intelligence to create diverse and inclusive medical case vignettes for education.

AIMS: Medical case vignettes play a crucial role in medical education, yet they often fail to authentically represent diverse patients. Moreover, these vignettes tend to oversimplify the complex relationship between patient characteristics and medical conditions, leading to biased and potentially harmful perspectives among students. Displaying aspects of patient diversity, such as ethnicity, in written cases proves challenging. Additionally, creating these cases places a significant burden on teachers in terms of labour and time. Our objective is to explore the potential of artificial intelligence (AI)-assisted computer-generated clinical cases to expedite case creation and enhance diversity, along with AI-generated patient photographs for more lifelike portrayal. METHODS: In this study, we employed ChatGPT (OpenAI, GPT 3.5) to develop diverse and inclusive medical case vignettes. We evaluated various approaches and identified a set of eight consecutive prompts that can be readily customized to accommodate local contexts and specific assignments. To enhance visual representation, we utilized Adobe Firefly beta for image generation. RESULTS: Using the described prompts, we consistently generated cases for various assignments, producing sets of 30 cases at a time. We ensured the inclusion of mandatory checks and formatting, completing the process within approximately 60 min per set. CONCLUSIONS: Our approach significantly accelerated case creation and improved diversity, although prioritizing maximum diversity compromised representativeness to some extent. While the optimized prompts are easily reusable, the process itself demands computer skills not all educators possess. To address this, we aim to share all created patients as open educational resources, empowering educators to create cases independently.

Minding menopause in patients with cognitive impairment: a patient's perspective and reflections on clinical practice.

Many women experience impairment in cognitive function during perimenopause. These symptoms are often not attributed to perimenopause by women themselves, by family and friends, or by healthcare professionals. In this article, we present a case in which perimenopausal complaints were attributed to early dementia and discuss mechanisms contributing to the low level of awareness of perimenopausal symptoms amongst patients and clinicians. Stigma amongst women and healthcare professionals impairs the recognition of perimenopausal complaints, and consideration of treatment options by clinicians. We advocate raising awareness in patients and physicians with more education, and the incorporation of potential menopause-related symptoms in general clinical guidelines.

"As a psychiatry resident I am invited to explore my identity. But when I accept that invitation, I still encounter a wall." A qualitative study on inclusion experienced by psychiatry residents with a migration background, sexual minority identity and/or working-class background.

Diversity in terms of class, sexual identity and migration background among medical students in high income countries has increased greatly in recent decades. Some research into the experiences of these new groups of doctors has been performed. However, no previous research into the experiences of psychiatry residents specifically, is known. This qualitative study investigates how psychiatry residents, from these minoritized groups, experience their training regarding inclusion. Inclusion is defined as the degree to which one's needs for connection and for being valued in one's uniqueness, is satisfied. In-depth interviews with 16 psychiatry residents were conducted. These interviews were transcribed and coded using MaxQDA software. Initial themes that were constructed, were explored further in subsequent interviews and linked to literature. Finally, the developed themes were ordered in a model conceptualizing inclusion. Participants reported high belongingness within psychiatry training. Their experienced value in uniqueness, however, was generally quite low. Participants reported to experience little interest in and sensitivity for their perspectives and lived experiences from their co-workers. When faced with stigmatization and discrimination, participants reported lack of support from their colleagues. Assimilation was found to be the most frequently used coping strategy in dealing with diversity. Participants seemed to conform to the 'neutral' norm and experienced barriers in expressing themselves. Through this mechanism of assimilation, the added value that participants might bring with their unique knowledge and lived experiences was not used, both in patient care and in creating an inclusive climate within the organization. Moreover, assimilation is associated with psychological strain.

Intersectionality in informal care research: a scoping review.

Aim: Informal caregivers share common experiences in providing care to someone with health and/or social needs, but at the same time their experiences differ across diverse backgrounds such as gender, age, culture, as these aspects of diversity co-shape these experiences. This scoping review aims to explore how aspects of diversity, across their intersections, are currently incorporated in informal care research and discusses how an intersectional perspective can further develop our understanding of informal care. Methods: A scoping review was performed to map relevant caregiving literature from an intersectionality perspective. Key terms 'informal care' and 'intersectionality' were used for a search in four databases resulting in the inclusion of 28 articles. All 28 studies were analysed based on a scoping review created intersectionality informed coding scheme. Results: Aspects of diversity are largely understudied in informal care research, in particular across their intersections and from a critical perspective. This intersectional informed analysis revealed that when studying diverse caregiving experiences the use of intersections of dimensions of diversity provides a nuanced understanding of these experiences. Conclusions: Adopting an intersectional perspective ensures that not only different categories or social identities of caregivers are included in future studies, but the mutual relationships between these categories embedded in their specific context are actually studied.

Observing, 'doing' and 'making' gender in Dutch paediatric type 1 diabetes care, at home and in the clinic: Multiple-stakeholder perspectives.

AIM: To investigate the perspectives of Dutch care professionals, parents and experts by experience on gender dynamics in paediatric type 1 diabetes care. DESIGN: Qualitative research design. METHODS: Fifteen semi-structured interviews were held with care professionals, supplemented by two focus groups with parents of children with diabetes (n = 12 parents) and three semi-structured interviews with two experts by experience and a mother. Two respondent validation interviews were conducted, one with two care professionals and one with an expert by experience. Participant observations were conducted at three clinics, a diabetes sports day, weekend for young people and their families, and a high-school. An inductive framework analysis was done, informed by relational theory on gender. RESULTS: Care professionals 'did' and 'made' gender differences together with young people, manifesting as communicative difficulties, in particular between female care professionals and young boys. Boys were considered less skilled in articulating their needs compared to girls. At home, care professionals and parents observed, 'did' and 'made' gender differences by perpetuating gendered divisions of labour. As traditional caretakers, mothers risk focusing excessively on the diabetes of their child whilst fathers remained more at a distance. CONCLUSION: Gender patterns have negative implications on those involved in paediatric type 1 diabetes. Leaving tacit the gendered communicative issues across child-parent and child-care professional dyads, can sustain invisible friction in a care system that normatively expects verbal participation and increased self-management. IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE: Findings may encourage care professionals and parents to engage with the potential impact of gender dynamics on diabetes practices. Incorporating these dynamics as conversational tools would contribute to improving type 1 diabetes care for young people.

Squeezed out: Experienced precariousness of self-employed care workers in residential long-term care, from an intersectional perspective.

AIM: To understand self-employed long-term-care workers' experiences of precariousness, and to unravel how their experiences are shaped at the intersection of gender, class, race, migration and age. BACKGROUND: In the Netherlands, increasing numbers of nurses and nursing aides in long-term care (LTC) opt for self-employment. Societal organizations and policy makers express concerns about this development, as self-employment is seen as a risk factor for poor health. Self-employment is not necessarily precarious work but can contribute to the precariousness of specific groups. Knowledge about inequities among self-employed nurses and nursing aides in long-term care is lacking. DESIGN: A participatory, qualitative interview study. The research team consisted of four academic researchers and five (un)paid care workers. METHODS: Semi-structured interviews with 23 self-employed nurses and nursing aides in LTC (2019-2020). Data were analysed from an intersectional perspective. RESULTS: First, we describe that feeling precarious as a hired employee-due to increasing workloads, health risks, poverty and discrimination-shapes care workers' choice for self-employment. Second, we describe inequities between self-employed care workers who could (financially) afford to turn to self-employment as a health strategy and those who felt squeezed out of the organizations due to poverty or discrimination. They more often dealt with precarious work in the context of precarious lives, negatively impacting their health. Third, we describe how negotiating an entrepreneurial identity with a caring identity required material sacrifices and thus contributed to self-employed care workers' financial precariousness, particularly as women. CONCLUSION: Our findings indicate that working in LTC is becoming increasingly precarious for all care workers, both for hired and self-employed, with younger, lower-paid and racialized women with unpaid caring responsibilities seemingly most at risk for precariousness. IMPACT: Our findings urge policy makers and care organizations to develop gender and diversity-sensitive policy responses to address these inequities.

What is gender awareness in health? A scoping review of the concept, its operationalization, and its relation to health outcomes.

Gender awareness emerged in the 1990s and aimed to provide awareness and sympathy toward the needs of women, measuring health-care providers' attitudes toward them and understand if providers possessed the knowledge for appropriate care. According to Miller et al.'s seminal model, gender awareness incorporates three sub-dimensions: gender sensitivity, gender ideology, and knowledge. Gender awareness has the potential to minimize gender bias in health care, improving the ecological validity of research. This scoping review provides an analysis of how gender awareness has been conceptualized, operationalized, and investigated in its relationship with health-related outcomes. A search was conducted on PubMed, PsycINFO, and ERIC. The relevance of 2.589 articles was assessed and 14 empirical studies were selected and included. Difficulties conceptualizing gender awareness were found and gender awareness and gender sensitivity were often presented as interchangeable. Most papers aimed to measure and compare levels of gender awareness among health professionals and the relationship between gender awareness and relevant health-related outcomes was not studied. Drawing upon a critical analysis of our findings, a proposal for a revised gender awareness conceptualization and operationalization is put forth as to inform novel research on its association with gender bias in health and health care.

Sex- and gender-sensitive public health research: an analysis of research proposals in a research institute in the Netherlands.

Taking sex and gender into account in public health research is essential to optimize methodological procedures, bridge the gender gap in public health knowledge, and advance gender equality. The aim of this study was to evaluate the current status of sex and gender considerations in public health research proposals in a Dutch research institute. We screened a random sample of 38 proposals submitted for review to the institute's science committee between 2011 and 2016. Using the Canadian Institutes of Health Research' Gender and Health Institute criteria for gender-sensitive research and qualitative content analysis, we assessed if, and how sex and gender were considered throughout the proposals (background, research aim, design, data collection, and analysis). Our results show that in general, both sex and gender were poorly considered. Gender was insufficiently taken into account throughout most proposals. When sex was mentioned in a proposal, its consideration was often inconsistent and fragmented. Finally, we identified common methodological pitfalls. We recommend that public health curricula and funding bodies increase their focus on implementing sex and gender in public health research, for instance through quality criteria, training programs for researchers and reviewers, and capacity building initiatives.

"At this age, a Moroccan woman's life's work is over"-older Moroccan-Dutch migrant women's perceptions of health and lifestyle, with a focus on Ramadan experiences: qualitative research integrating education and consultation.

BACKGROUND: Older Moroccan-Dutch migrant women exhibit high rates of diabetes, hypertension, overweight and obesity which is further compounded by their high risk of multi-morbidity. Healthcare professionals' efforts to encourage this group to adopt a healthier lifestyle have little success. We ask ourselves whether the concepts used in health education and promotion relate to these women's experiences and beliefs. Today's pluralistic Dutch society requires a more differentiated and applied approach, not in an essentialist way but in awareness that translation of rather individualized concepts like health and lifestyle is not always adequate, as the meaning and interpretation of such concepts may differ and may be related to women's other (fundamental) perceptions. This can have practical consequences for health promotion and education. The aim of this explorative, qualitative research, conducted between April and September 2015 and taking an intersectional approach, was to explore older Moroccan-Dutch women's perceptions of health and lifestyle and to analyse these in a broader context, related to other fundamental forms of identity such as gender, culture and religion. METHODS: We recruited women with Moroccan backgrounds by approaching Moroccan women's organisations and using the snowballing method (chain-referral sampling). Seven 'natural' group discussions were held (amongst women who regularly meet each other, aged between 22 and 69 years), and twelve in-depth interviews and an observation day (with women from 40 to 66 years). The transcripts were then analysed using thematic content analysis. RESULTS: Five major themes were identified. Health was perceived of in the terms used in prevailing health promotion discourses in the Netherlands, but lifestyle was interpreted in a much broader sense than the current health promotion debate allows; it is not seen as an individual responsibility or as something an individual could control on their own, and the social benefits of health behaviours appear to outweigh the health benefits themselves. Lifestyle was located in three main social identities of the women: Moroccan, Muslim and mother. Finally, Ramadan played a huge and dominant role in the lifestyle experience of older Moroccan women and was central in this research. CONCLUSIONS: The finding that lifestyle is not seen as an individual responsibility but is located in social identities, can be applied to other settings that older migrant-Dutch women occupy. Further research will clarify this.

Gender awareness in medicine: adaptation and validation of the Nijmegen Gender Awareness in Medicine Scale to the Portuguese population (N-GAMS).

Health care professionals' gender awareness has been presented as a mechanism to minimize gender biases in health. The present paper aimed to adapt and validate the Nijmegen Gender Awareness in Medicine Scale (N-GAMS, Verdonk et al. in Sex Roles 58:222-234, 2008. https://doi.org/10.1007/s11199-007-9326-x) to the Portuguese population, also addressing some limitations of its original study, namely by: (1) testing the scale's three-fold underlying structure and (2) extending the study of its criteria-related validity, by analyzing sex-related differences in medical students' gender awareness and the associations between gender awareness and empathy and sexism. One thousand and forty-eight medical students (Mage = 22.90; 67.1% women) filled out the Portuguese version of the N-GAMS (N-GAMS.pt) along with measures of Physician Empathy and Sexism. A Parallel Analysis and an Exploratory Factor Analysis suggested the presence of three factors. A Confirmatory Factor Analysis showed a good fit of the hypothesized three-factor structure: (1) gender sensitivity (n = 6 items; α = .713), (2) gender-role ideologies towards patients (n = 7 items; α = .858) and (3) gender-role ideologies towards doctors (n = 5 items; α = .837), with a positive association between the latter two (r = .570; p < .001). The N-GAMS.pt also showed good criteria-related validity. Namely, as hypothesized: (1) more empathic students reported more gender sensitivity and lower endorsement of gender-role ideologies; (2) higher hostile and benevolent sexism were associated to higher endorsement of gender-role ideologies; and (3) higher hostile sexism was associated to lower gender sensitivity. Implications of the N-GAMS for research and interventional purposes are discussed.

Parenthood does not explain the gender difference in clinical position in academic medicine among Swedish, Dutch and Austrian physicians.

Studies have continuously shown that fewer women than men achieve leadership positions in academic medicine. In the current study we explored gender differences in clinical position among academic physicians at three university hospitals, each in a different European country. These countries, Sweden, the Netherlands and Austria, differ in terms of gender equality. We analyzed whether the number of children, working hours or publications could explain gender differences in physicians' clinical position. In this cross-sectional questionnaire study 1333 (54% female) physicians participated. Physicians were asked about their gender, age, number of children, working hours and clinical position. We used structural equation models to explore the influence of gender on the physicians' clinical position in each of the three countries. We explored whether the association between gender and clinical position could be explained by number of children, working hours or publication activity. The analyses revealed that at all three university hospitals gender influenced clinical position. These gender differences in clinical position could be partly explained by gender differences in publication activity. Female physicians as compared to male physicians were likely to publish fewer articles, and in turn these lower publication numbers were associated with lower clinical positions. The number of children or working hours did not explain gender differences in publication activity or clinical position. Therefore, factors other than unequal allocation of household labor, such as the academic working environment, may still disproportionately disadvantage women's progress, even at universities in countries with high rates of gender equality such as Sweden.

Reproductive choices: a qualitative study of Dutch Moroccan and Turkish consanguineously married women's perspectives on preconception carrier screening.

BACKGROUND: Cousin marriages, in the Netherlands most frequently between Turkish or Moroccan couples, are at higher risk of having offspring with recessive disorders. Often, these couples not perceive or accept this risk, and it is hardly considered a reason to refrain from family marriages. Preconception carrier screening (PCS) is offered to Jewish groups, and more recently in the Netherlands, to genetically isolated communities. In this study, Dutch Moroccan and Turkish women's perspectives on preconception carrier screening (PCS) and reproductive choices were explored. METHODS: Individual interviews were held with Dutch Turkish and Moroccan consanguineously married women (n = 10) and seven group discussions with Turkish and Moroccan women (n = 86). Transcripts and notes were analyzed thematically. RESULTS: All women welcomed PCS particularly for premarital genetic screening; regardless of possible reproductive choices, they prefer information about their future child's health. Their perspectives on reproductive choices on the basis of screening results are diverse: refraining from having children is not an option, in vitro fertilization (IVF) combined with pre-implantation genetic diagnosis (PGD) was welcomed, while prenatal genetic diagnosis (PND), termination of pregnancy (TOP), in vitro fertilization with a donor egg cell, artificial insemination with donor sperm (AID), and adoption, were generally found to be unacceptable. Besides, not taking any special measures and preparing for the possibility of having a disabled child are also becoming optional now rather than being the default option. CONCLUSIONS: The women's preference for PCS for premarital screening as well as their outspokenness about not marrying or even divorcing when both partners appear to be carriers is striking. Raising awareness (of consanguinity, PCS and the choice for reproductive options), and providing information, screening and counseling sensitive to this target group and their preferences are essential in the provision of effective health care.

To select or be selected - gendered experiences in clinical training affect medical students' specialty preferences.

BACKGROUND: The literature investigating female and male medical students' differing career intentions is extensive. However, medical school experiences and their implications for professional identity formation and specialty choice have attracted less attention. In this study we explore the impact of medical school experiences on students' specialty preferences, investigate gender similarities and differences, and discuss how both might be related to gender segregation in specialty preference. METHODS: In a questionnaire, 250 Swedish final-year medical students described experiences that made them interested and uninterested in a specialty. Utilizing a sequential mixed methods design, their responses were analyzed qualitatively to create categories that were compared quantitatively. RESULTS: Similar proportions of women and men became interested in a specialty based on its knowledge area, patient characteristics, and potential for work-life balance. These aspects, however, often became secondary to whether they felt included or excluded in clinical settings. More women than men had been deterred by specialties with excluding, hostile, or sexist workplace climates (W = 44%, M = 16%). In contrast, more men had been discouraged by specialties' knowledge areas (W = 27%, M = 47%). CONCLUSIONS: Male and female undergraduates have similar incentives and concerns regarding their career. However, the prevalence of hostility and sexism in the learning environment discourages especially women from some specialties. To reduce gender segregation in specialty choice, energy should be directed towards counteracting hostile workplace climates that explain apparent stereotypical assumptions about career preferences of men and women.

Work-related change in residential elderly care: Trust, space and connectedness.

Increasing care needs and a declining workforce put pressure on the quality and continuity of long-term elderly care. The need to attract and retain a solid workforce is increasingly acknowledged. This study reports about a change initiative that aimed to improve the quality of care and working life in residential elderly care. The research focus is on understanding the process of workforce change and development, by retrospectively exploring the experiences of care professionals. A responsive evaluation was conducted at a nursing home department in the Netherlands one year after participating in the change program. Data were gathered by participant observations, interviews and a focus and dialogue group. A thematic analysis was conducted. Care professionals reported changes in workplace climate and interpersonal interactions. We identified trust, space and connectedness as important concepts to understand perceived change. Findings suggest that the interplay between trust and space fostered interpersonal connectedness. Connectedness improved the quality of relationships, contributing to the well-being of the workforce. We consider the nature and contradictions within the process of change, and discuss how gained insights help to improve quality of working life in residential elderly care and how this may reflect in the quality of care provision.

"A Somali girl is Muslim and does not have premarital sex. Is vaccination really necessary?" A qualitative study into the perceptions of Somali women in the Netherlands about the prevention of cervical cancer.

INTRODUCTION: Participation in Human Papillomavirus (HPV) vaccination and Papanicolaou Screening (Pap smears) is low among ethnic minorities in the Netherlands and hardly any information is available about the cervical cancer prevention methods of Somali women living in the diaspora. This qualitative study, based on the Health Belief Model (HBM) and an intersectionality-based framework, explores the perceptions of Somali women living in the Netherlands regarding measures to prevent cervical cancer. METHODS: Semi-structured interviews have been conducted with young Somali women aged 17-21 years (n = 14) and Somali mothers aged 30-46 years (n = 6). Two natural group discussions have been conducted with 12 and 14 Somali mothers aged 23-66 years. The collected data has been analyzed thematically for content. RESULTS: In this study, we have identified perceived barriers to the use of preventive measures across three major themes: (1) Somali women and preventive healthcare; (2) Language, knowledge, and negotiating decisions; and (3) Sexual standards, culture, and religion. Many issues have been identified across these themes, e.g., distrust of the Dutch health care system or being embarrassed to get Pap smears due to Female Genital Mutilation (FGM) and having a Dutch, male practitioner; or a perceived low susceptibility to HPV and cancer because of the religious norms that prohibit sex before marriage. CONCLUSIONS: Current measures in the Netherlands to prevent women from developing cervical cancer hardly reach Somali women because these women perceive these kinds of preventative measures as not personally relevant. Dutch education strategies about cervical cancer deviate from ways of exchanging information within the Somali community. Teachers can provide culturally sensitive information to young Somali women in schools. For Somali mothers, oral education (e.g., poetry or theater) about the Dutch health care system and men's roles in HPV transmission may be useful. An intersectional approach, grounded in the HBM, is recommended to promote equal access to preventive health care for Somali women.

Standing out and moving up: performance appraisal of cultural minority physicians.

Despite a growing diversity within society and health care, there seems to be a discrepancy between the number of cultural minority physicians graduating and those in training for specialization (residents) or working as a specialist in Dutch academic hospitals. The purpose of this article is to explore how performance appraisal in daily medical practice is experienced and might affect the influx of cultural minority physicians into specialty training. A critical diversity study was completed in one academic hospital using interviews (N = 27) and focus groups (15 participants) with cultural minority physicians and residents, instructing specialists and executives of medical wards. Data were digitally recorded and transcribed verbatim. A thematic and integral content analysis was performed. In addition to explicit norms on high motivation and excellent performance, implicit norms on professionalism are considered crucial in qualifying for specialty training. Stereotyped imaging on the culture and identity of cultural minority physicians and categorical thinking on diversity seem to underlie daily processes of evaluation and performance appraisal. These are experienced as inhibiting the possibilities to successfully profile for selection into residency and specialist positions. Implicit criteria appear to affect selection processes on medical wards and possibly hinder the influx of cultural minority physicians into residency and making academic hospitals more diverse. Minority and majority physicians, together with the hospital management and medical education should target inclusive norms and practices within clinical practice.

Are Barbie and Ken too cool for school? A case-control study on the relation between gender and dropout.

BACKGROUND: As school dropout is an important public health problem that needs to be addressed, we set out to examine whether and how, beyond the well-known effects of sex, gender beliefs and self-reported masculinity and femininity are related to school dropout. METHODS: The study used a case-control design, consisting of 330 dropout cases and 330 controls still attending school. The respondents, aged between 18 and 23 years, living in the south-east of the Netherlands, were sent a self-administered questionnaire. Separate logistic regression analyses for the male and female participants were used to explore the relation between dropout and gender, controlling for sociodemographic determinants. RESULTS: As indicated by significant curvilinearity, young women were less likely to drop out when they occupied an intermediate positions on the gender variables. Odds of dropout were elevated among highly masculine women (odds ratio = 2.1, 95% confidence interval: 1.1-4.1), and, as indicated by significant interactions, also among highly masculine men with strong normative masculine beliefs and in feminine men who simultaneously considered themselves low on masculinity. CONCLUSIONS: Beyond sex, gender is important in the explanation of school dropout. To prevent dropout, public health professionals should assess, monitor and intervene on the basis of gender characteristics.

Low control beliefs in relation to school dropout and poor health: findings from the SIODO case-control study.

BACKGROUND: There is cumulating evidence that health is compromised through adverse socioeconomic conditions negatively affecting how people think, feel, and behave. Low control beliefs might be a key mechanism. The reversed possibility that low control beliefs might set people on a pathway towards adverse socioeconomic and health-related outcomes is much less examined. METHODS: A case-control design was used, consisting of 330 cases who dropped out of school in the 2010-2011 school year and 330 controls who still attended school at the end of that year. The respondents, aged between 18 and 23, came from Eindhoven and surrounding areas in the south-east of The Netherlands. A questionnaire asked for current health status, recalled socioeconomic and social background, and recalled control beliefs (mastery and general self-efficacy). Logistic regression analyses were used. RESULTS: Recalls of low mastery and low self-efficacy were strongly related to both dropout and less than good health. Low socioeconomic background was also associated to odds of dropout, but did not confound or moderate the associations of low control beliefs with dropout and health. Odds ratios of dropout and less than good health indicated at least twice the odds of a poor outcome with recalls of low control beliefs. CONCLUSIONS: Independent of the socioeconomic background, low control beliefs are related to heightened odds of both poor health and school dropout. Individual differences in control beliefs might thus be as fundamental as socioeconomic conditions in generating life-course socioeconomic and health-related pathways. Although the findings should first be cross-validated in prospective studies, public health professionals working with youth might already start considering early interventions in youth with all too fatalistic and powerless mind-sets.

Show what you know and deal with stress yourself: a qualitative interview study of medical interns' perceptions of stress and gender.

BACKGROUND: Medical students report high stress levels and in particular, the clinical phase is a demanding one. The field of medicine is still described as having a patriarchal culture which favors aspects like a physicians' perceived certainty and rationalism. Also, the Effort-Recovery Model explains stress as coming from a discrepancy between job demands, job control, and perceived work potential. Gendered differences in stress are reported, but not much is known about medical interns' perceptions of how gender plays in relation to stress. The aim of this study is to explore how medical interns experience and cope with stress, as well as how they reflect on the gendered aspects of stress. METHODS: In order to do this, we have performed a qualitative study. In 2010-2011, semi-structured qualitative interviews were conducted with seventeen medical interns across all three years of the Masters programme (6 male, 11 female) at a Dutch medical school. The interview guide is based on gender theory, the Effort-Recovery Model, and empirical literature. Transcribed interviews have been analyzed thematically. RESULTS: First, stress mainly evolves from having to prove one's self and show off competencies and motivation ("Show What You Know…"). Second, interns seek own solutions for handling stress because it is not open for discussion (… "And Deal With Stress Yourself"). Patient encounters are a source of pride and satisfaction rather than a source of stress. But interns report having to present themselves as 'professional and self-confident', remaining silent about experiencing stress. Female students are perceived to have more stress and to study harder in order to live up to expectations. CONCLUSIONS: The implicit message interns hear is to remain silent about insecurities and stress, and, in particular, female students might face disadvantages. Students who feel less able to manifest the 'masculine protest' may benefit from a culture that embraces more collaborative styles, such as having open conversation about stress.