The Academic Life in Emergency Medicine (ALiEM) Faculty Incubator was hard at work during the pandemic to bring you the fifth volume of the Education Theory Made Practical series. This series strives to make theory accessible to educators by distilling the background and key literature of each theory and grounding them in practical education scenarios.
The Faculty Incubator is a year-long professional development course for medical educators centered around a virtual community of practice (a concept we have all started to appreciate during quarantine). Teams of 2-3 participants from around the world authored primers on education theories and different teams offered a first round of peer review on each post. As in prior years, they will be serialized on the ICE Blog for review and comment. You can learn more here.
They have published three e-book compendiums of this blog series (Volume 1, Volume 2, Volume 3) and you can find the Volume 4 posts here (the e-book is in progress!) As with the previous iterations, final versions of each primer will be complied into a free eBook to be shared with the health professions education community.
Your Mission if you Choose to Accept it:
We would like to invite the ICE Blog community to peer review each post. Your comments will be used to refine each primer prior to publication in the final ebook. No suggestion is too big or small – we want to know what has been missed, misrepresented, or misconstrued. Comments as small as grammatical errors all the way to new scenarios for practical applications or new citations are welcome. (Note: The blog posts themselves will remain unchanged.)
This is the fifth post of Volume 5! You can find the previous posts here: Banking Theory; Constructive Alignment; IDEO’s Design Thinking Framework and, R2C2 Feedback Model.
Authors: Lauren Evans, MD (@LaurenEvansMD1); Dolly Yadav, MD (@EP_Dr_Dolly)
EDITOR: Sreeja Natesan, MD (@sreeja_natesan)
Main Authors or Originators: Malika Sharma
Part 1: The Hook
As she prepared for Trauma Surgery rounds, medical student Jane Adams felt she was as prepared as she could be. She had arrived early to interview their patient, Frank, and had been through all the labs twice. She again ruffled through her notes as the other student on the service, John Smith.
“You’re late again,” she sighed.
“I know, I know” he replied as he quickly jotted down the latest vital signs.
He had missed his chance to examine Frank that morning. Dr. Fox, the Attending Surgeon, had already arrived so they quickly rushed off after him. As they arrived at Frank’s room, Jane started with the presentation and John added in the additional vital signs and stated that Frank appeared in a better mood this morning.
As they walked into the room, Dr. Fox again introduced the students.
“Good morning, you remember student doctor Jane and student doctor Smith.”
“Yes,” Frank stated, “I remember them! It’s good to see you again Dr. Smith and Jane.”
Jane watched Dr. Fox, and hoped he would correct Frank but instead he just nodded along. John quickly responded to the patient with, “It’s good to see you again. I’m happy to see you doing so well.”
As they walked out of the room, Frank called out to ask for juice. Dr. Fox turned to Jane and asked her to go down the hall and grab the juice for him. She rushed off so that she could meet the needs of her patient, but when she arrived back on rounds, Dr. Fox had just finished discussing the plan for Frank that day. Dr. Fox commented on the excellent rapport John had with Frank and announced that John would be the student to join him in the operating room that afternoon. Jane wondered what she could do about this disparaging situation.
Part 2: The Meat
Feminism has been defined by feminist scholar and author, bell hooks, as “a movement to end sexism, sexist exploitation and oppression”. While there exists no singular feminst theory, Sharma describes “a family of critical theories and approaches that enable us to understand complexity”. Sharma also wrote a scoping review examining feminist theory as it relates to medical education and medical education research and found four overarching topics that exist in the Feminist theory literature:
- Assessment of what is taught in medical curricula: Addressing the need for more education in women’s health and gender sensitivity.
- Female experiences in medical training: Perspectives of female trainees, including challenges faced.
- Pedagogical approaches to medical education: Scrutinizing hidden curriculum and assumptions.
- Methodologies and inquiries in medical education research: What questions are asked and is there action based on these questions.
In 1848, a group gathered in Seneca Falls, New York seeking equal rights for women, including suffrage, education, and property rights, but later focused mainly on the right to vote. This first-wave feminism ultimately led to the 19th amendment being passed in the United States in 1920. The movement continued in other countries, and Saudi Arabia became the last country to allow women to vote in national elections (2015). After women’s suffrage was passed, there was a decline in the movement in the United States. In the 1960’s, a second-wave feminism was born and since that time feminism has been a constant, evolving theory. Second-wave feminism focused primarily on workplace rights and reproductive rights. They sought equal pay, equal job opportunities, and improved childcare options. Third-wave feminism challenged gender identity and the rights of underrepresented females, and fourth-wave feminism has focused on sexual harassment.
Sharma identifies 11 different feminist theories that are present in the medical literature, including examples and critiques. These broad theories show the diversity of the topic and the avenues for future research.
Modern takes or advances
Organizations, such as FemInEM, have created online communities of practice directed at gender equity and empowering all physicians. They aim to “address gender disparities in a positive way.” This community has open access to resources for gender studies in medicine directed at both personal and group development. They also have in-person events available for further networking and education. FemInEM also supports research into gender equity in medicine. SheMD is another example of an organization that uses the online social media platform of Twitter to educate on topics of gender equity, workplace disparities, and more. National organizations such as ACEP, SAEM, and others have created Women In Medicine committees to also help advocate for policy changes, increase education on gender equity issues, and allow networking and creation of a community for women in medicine.
Other examples of where this theory might apply in both the classroom & clinical setting
In the classroom, Feminist theory has recognized the “one-sex body” present in the pre-clinical curriculum. Studies have found that anatomy textbooks have more anatomic illustrations of male figures than females as the “norm”. The concerns that arise are that medical students are less likely to fully recognize the normal female anatomy or the differences between the sexes. In Emergency Medicine, we can see an example of this with the teaching of thoracostomy tubes. One of the most commonly used books for procedures, Roberts and Hedges’, uses a male figure to show anatomy and states “the fifth intercostal space is approximately at the level of the nipple,” but “the position of the female breast mass leads to variance” with no further information provided. The concern is that students who use these resources will be less prepared to properly care for a female patient compared to their male counterpart.
Feminist theory has also looked broadly at the experience of females in the clinical setting. There has been literature that focuses on the different experiences of female and male medical students, residents, and faculty. This research has identified significant challenges including sexual harassment and hostile work environment. There has also been significant research into the reduction of female career advancement and the lower numbers of female editors in medical journals.
Annotated Bibliography of Key Papers
Babaria P, Bernheim S, Nunez-Smith M. Gender and the pre-clinical experiences of female medical students: a taxonomy. Med Educ. 2011;45(3):249‐260. doi:10.1111/j.1365-2923.2010.03856.x 
A qualitative study looking at female’s pre-clinical experiences relating to gender. The students reported multiple negative experiences that left them isolated and questioning of a future in the medical field.
Cheng LF, Yang HC. Learning about gender on campus: an analysis of the hidden curriculum for medical students. Med Educ. 2015;49(3):321‐331. doi:10.1111/medu.12628 
This paper examines posts by medical students from multiple schools posted on an online communication board. Authors found biased treatment of women and overt sexual harassment present from both students and faculty. Among the strategies suggested to promote gender sensitivity is recounting examples of the lived experiences of those who have been discriminated against in medical curricula.
MacLeod A, Frank B. Feminist pedagogy and medical education: why not now? Med Educ. 2013;47(1):11‐14. doi:10.1111/medu.12095 
This paper examines the need for social sciences such as gender and race studies in medical curriculum.
Mendelsohn KD, Nieman LZ, Isaacs K, Lee S, Levison SP. Sex and gender bias in anatomy and physical diagnosis text illustrations. JAMA. 1994;272(16):1267‐1270. 
This paper looks at the disproportionate number of male illustrations in anatomy textbooks used during pre-clinical years. Thus further perpetuating the male body as the medical standard and limiting medical student’s understanding of female anatomy. Also, female images were disproportionately higher in the reproductive chapters versus male’s.
Sharma notes that there appears to be a deficit in the number of publications referencing feminist theory in medical education. She notes that this is possibly related to a publication bias. There has been literature that identifies a male dominance in the editorial boards of prominent medical journals, with up to only 21% of editorial board members found to be female. There has also been research into the underrepresentation of female authorships in both medical[13, 14], and general sciences[15, 16], literature.
Part 3: The Denouement
Jane focused on the morning’s events wondering what she could have done differently. She knew that she had been better prepared for the day than John, but felt frustrated that she had still missed out on the afternoon surgeries. She discussed the problem with her roommate and he suggested that she speak to John about it tomorrow.
“Maybe he didn’t realize what was happening?” he asked.
The next morning when John arrived, Jane brought up the topic. Initially John felt frustrated because he knew he deserved to see the surgeries. She reminded him that he had been late that day and hadn’t even examined Frank.
She then asked him “Did you notice how Frank called you Dr. Smith and then referred to me as Jane and Dr. Fox just ignored it?”
She reminded him that Dr. Fox had sent her to go get juice instead of hearing about the plan for her patient. The more examples of the sexism that had occurred, the more John realized the struggles that Jane faced.
“I didn’t realize what was happening or I would have said something!” John said.
Jane believed him, but wondered what could be done to prevent it from happening again. She had heard about some medical schools that were incorporating gender awareness into their curriculum and thought maybe her school could do the same. John agreed that it was needed and asked to be a part of this new project. They set off that afternoon to find a mentor for their new curriculum and to figure out ways to disseminate this to the faculty and staff as well.
Don’t miss the sixth post in the series, coming out Tuesday, August 24, 2021!
PLEASE ADD YOUR PEER REVIEW IN THE COMMENTS SECTION BELOW
1.hooks, bell, 1952-. Feminism Is for Everybody : Passionate Politics. Cambridge, MA: South End Press, 2000.
2. Sharma M. Applying feminist theory to medical education. Lancet. 2019;393(10171):570-578. doi:10.1016/S0140-6736(18)32595-9
3. Burkett E, Brunell L. feminism | Definition, History, & Examples. Encyclopedia Britannica. https://www.britannica.com/topic/feminism. Published 2020.
4. FemInEM. FemInEM. https://feminem.org/about/. Published 2020.
5. Mendelsohn KD, Nieman LZ, Isaacs K, Lee S, Levison SP. Sex and gender bias in anatomy and physical diagnosis text illustrations. JAMA. 1994;272(16):1267-1270. doi:10.1001/jama.1994.03520160051042
6. Thomsen, and Jerris R. Hedges. Roberts and Hedges’ Clinical Procedures in Emergency Medicine., 7th ed. Elsevier; 2014.
7. Wear D, Aultman JM, Borges NJ. Retheorizing sexual harassment in medical education: women students’ perceptions at five U.S. medical schools. Teach Learn Med. 2007;19(1):20-29. doi:10.1080/10401330709336619
8. Raj A, Kumra T, Darmstadt GL, Freund KM. Achieving Gender and Social Equality: More Than Gender Parity Is Needed. Acad Med. 2019;94(11):1658-1664. doi:10.1097/ACM.0000000000002877
9. Jagsi R, Tarbell NJ, Henault LE, Chang Y, Hylek EM. The representation of women on the editorial boards of major medical journals: a 35-year perspective. Arch Intern Med. 2008;168(5):544-548. doi:10.1001/archinte.168.5.544
10. Babaria P, Bernheim S, Nunez-Smith M. Gender and the pre-clinical experiences of female medical students: a taxonomy. Med Educ. 2011;45(3):249-260. doi:10.1111/j.1365-2923.2010.03856.x
11. Cheng LF, Yang HC. Learning about gender on campus: an analysis of the hidden curriculum for medical students. Med Educ. 2015;49(3):321-331. doi:10.1111/medu.12628
12. MacLeod A, Frank B. Feminist pedagogy and medical education: why not now? Med Educ. 2013;47(1):11-14. doi:10.1111/medu.12095
13. Silver JK, Poorman JA, Reilly JM, Spector ND, Goldstein R, Zafonte RD. Assessment of Women Physicians Among Authors of Perspective-Type Articles Published in High-Impact Pediatric Journals. JAMA Netw Open. 2018;1(3):e180802. Published 2018 Jul 6. doi:10.1001/jamanetworkopen.2018.0802
14. Hsiehchen D, Hsieh A, Espinoza M. Prevalence of Female Authors in Case Reports Published in the Medical Literature. JAMA Netw Open. 2019;2(5):e195000. Published 2019 May 3. doi:10.1001/jamanetworkopen.2019.5000
15. Gender imbalance in science journals is still pervasive. Nature. 2017;541(7638):435-436. doi:10.1038/541435b
16. Bendels MHK, Müller R, Brueggmann D, Groneberg DA. Gender disparities in high-quality research revealed by Nature Index journals. PLoS One. 2018;13(1):e0189136. Published 2018 Jan 2. doi:10.1371/journal.pone.0189136
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