Gender and Inconsistent Evaluations: A Mixed-methods Analysis of Feedback for Emergency Medicine Residents.

Objectives: Prior research has demonstrated that men and women emergency medicine (EM) residents receive similar numerical evaluations at the beginning of residency, but that women receive significantly lower scores than men in their final year. To better understand the emergence of this gender gap in evaluations we examined discrepancies between numerical scores and the sentiment of attached textual comments. Methods: This multicenter, longitudinal, retrospective cohort study took place at four geographically diverse academic EM training programs across the United States from July 1, 2013-July 1, 2015 using a real-time, mobile-based, direct-observation evaluation tool. We used complementary quantitative and qualitative methods to analyze 11,845 combined numerical and textual evaluations made by 151 attending physicians (94 men and 57 women) during real-time, direct observations of 202 residents (135 men and 67 women). Results: Numerical scores were more strongly positively correlated with positive sentiment of the textual comment for men (r = 0.38, P < 0.001) compared to women (r = -0.26, P < 0.04); more strongly negatively correlated with mixed (r = -0.39, P < 0.001) and negative (r = -0.46, P < 0.001) sentiment for men compared to women (r = -0.13, P < 0.28) for mixed sentiment (r = -0.22, P < 0.08) for negative; and women were around 11% more likely to receive positive comments alongside lower scores, and negative or mixed comments alongside higher scores. Additionally, on average, men received slightly more positive comments in postgraduate year (PGY)-3 than in PGY-1 and fewer mixed and negative comments, while women received fewer positive and negative comments in PGY-3 than PGY-1 and almost the same number of mixed comments. Conclusion: Women EM residents received more inconsistent evaluations than men EM residents at two levels: 1) inconsistency between numerical scores and sentiment of textual comments; and 2) inconsistency in the expected career trajectory of improvement over time. These findings reveal gender inequality in how attendings evaluate residents and suggest that attendings should be trained to provide all residents with feedback that is clear, consistent, and helpful, regardless of resident gender.

Painful Feelings: Opioids as Tools for Avoiding Emotional Labor in Hospital Work.

How do clinicians manage the negative emotions that emerge when hospital patients are dissatisfied with their pain treatment? Drawing on a 21-month hospital ethnography, I show that clinicians view opioids as tools that can allow them to avoid engaging in emotional labor with dissatisfied pain patients. I detail two different strategies that clinicians pursued. Through permissive prescription, clinicians used intravenous (IV) opioids liberally to placate unhappy pain patients, temporarily minimizing patients' emotional needs. Through restrictive prescription, clinicians advocated for the more conservative use of IV opioids in the hopes that dissatisfied patients would leave the hospital, reducing their overall emotional workload. Divergent strategies for using opioids to avoid emotional labor led to hierarchical interprofessional conflict, which was itself a source of negative emotions that needed to be managed. Based on these findings, I argue that the desire to avoid emotional labor can shape patient care and workplace relationships.

Who Gets the Benefit of the Doubt? Performance Evaluations, Medical Errors, and the Production of Gender Inequality in Emergency Medical Education.

Why do women continue to face barriers to success in professions, especially male-dominated ones, despite often outperforming men in similar subjects during schooling? With this study, we draw on role expectations theory to understand how inequality in assessment emerges as individuals transition from student to professional roles. To do this, we leverage the case of medical residency so that we can examine how changes in role expectations shape assessment while holding occupation and organization constant. By analyzing a dataset of 2,765 performance evaluations from a three-year emergency medicine training program, we empirically demonstrate that women and men are reviewed as equally capable at the beginning of residency, when the student role dominates; however, in year three, when the colleague role dominates, men are perceived as outperforming women. Furthermore, when we hold resident performance somewhat constant by comparing feedback to medical errors of similar severity, we find that in the third year of residency, but not the first, women receive more harsh criticism and less supportive feedback than men. Ultimately, this study suggests that role expectations, and the implicit biases they can trigger, matter significantly to the production of gender inequality, even when holding organization, occupation, and resident performance constant.

"We were on our own": Mothers' experiences navigating the fragmented system of professional care for autism.

Autism is a developmental disorder that emerges in early childhood. Treatments for autism span a wide variety of professionals and paraprofessionals in the medical and educational realms. This article draws on data from a survey of 620 parents of autistic children, including 385 written narratives, to examine the experiences of mothers as they engage with this fragmented system of professional care for children with autism. Findings suggest that engagement with treatments sent families into a complex and confusing universe of diagnosis and treatment. The fragmentation of autism's professional jurisdiction between the medical and educational systems meant that mothers struggled to find comprehensive professional care that met the standards recommended by leading medical research organizations. Many mothers found it necessary to reduce their workforce participation in order to obtain and maintain their children's treatment regimes, a phenomenon that transcended social class. However, the consequences of reducing work had differential impacts on families. While married and high socioeconomic status mothers were more insulated from the potential negative effects of losing one partner's income, single and low SES mothers experienced greater precarity. These findings connect the structure and arrangement of professional jurisdictions to the experiences of parents, suggesting ways that the fragmentation of professional care for autism can have negative impacts for women, single mothers, and low SES families.