Recently, a female physician we know shared an experience she had while considering taking a faculty position at a new institution: She had been communicating with the faculty chairperson for months and had been promised a faculty position with a designated leadership role. She had returned for a second set of interviews, but she was ready to sign.
Then, at the final meeting on the final day, she went to get coffee with another faculty member, who had been at the institution for more than a decade. The two had overlapping academic areas of interest and had collaborated on projects together. Over the years, she’d received an occasional strongly worded and aggressively toned email from him, the typical scenario being him complaining about feeling disrespected on writing projects with multiple authors. On one particularly memorable occasion, he had curtly and angrily accused her of not incorporating edits on which he claimed to have spent hours, only to later realize he’d been looking at the wrong draft.
At the coffee shop meeting, he took charge of the discussion. With pen and paper, he drew out his view of the position hierarchy for the faculty. He was on top. He then began to badger her with a barrage of questions: How much money did she make at her current job? Where else was she interviewing? With pressured, angry, and confrontational speech, he berated her for taking too much time to decide and accused her of dragging them along just so she could negotiate a better deal at her current institution. He asserted that he was in charge of her recruitment and then patronizingly asked her if her delays were because she had a hard time making decisions. Our physician friend quickly ended the meeting and left.
She was not particularly surprised by the encounter. Medicine just might be the perfect breeding ground for these kinds of outbursts, usually performed by men when their status is threatened. If you ask women in medicine, many of us will tell you about similar experiences. Demonstrations of status anxiety, defined as fear or concern for one’s place, standing, or position specifically in the work environment, abound. In his 2004 book, Status Anxiety, author Alain de Botton explores the concept in depth. He posits that status anxiety was created, at least in part, by the move from aristocracy to democracy and meritocracy. In democratic meritocracies, all members of society perceive themselves as having equal opportunity, which means that access to education and, consequently, jobs is theoretically based on inherent intelligence, talent, and skill. In such a society, failure to rise in the ranks or loss in standing can cause people stress. What people do with that anxiety differs greatly, but perhaps one of the most memorable violent outbursts of status anxiety that we’ve collectively witnessed in the past few months is Brett Kavanaugh’s performance at the Supreme Court hearing where his ascent to the bench was in question. In the case of Kavanaugh, and in the case of the physician described above, the manifestation of this fear is verbal, aggressive rage.
Arguably, medicine raises its young to have status anxiety, thanks to its ruthlessly competitive environment and intensely hierarchical structure. Applicants seeking choice medical schools and specialty training positions face stiff competition. Once admitted, the trainee is socialized to a pyramidlike structure: medical students at the bottom, residents in the middle, the attending at the top. Aggressive behavior is rewarded, specifically in men. Even violent behaviors, such as angry surgeons throwing surgical instruments, has historically been allowed, as long as the surgeon has the power that comes with seniority. Certainly, other elite fields have similarly intense competition and structures, but in medicine, there’s also an added twist: Public perception of the field—doctors are assumed to be morally decent human beings with unimpeached empathy and professionalism—makes these behaviors at once more hidden and more toxic. But recent data suggest that in fact there are more problematic behaviors in medicine than in other scientific fields.
It’s impossible to fully understand how status anxiety plays out in medicine without also understanding the problematic gender relations that still pervade the field. Medicine has a long history of male domination. Despite medical schools enrolling classes of more than 50 percent women, women have not gained equity in attaining the top academic promotions or leadership positions: Just 22 percent of full med school professors are women, 18 percent of department chairs are women, and 17 percent of medical school deans are women. Women are less likely than men to hold the rank of associate or full professor. And there is a persistent gendered pay disparity in the field, as evidenced by a 2016 paper documenting the sex differences in physician salaries.
In medicine as in any other field, this history of homogeneity is likely to slowly give way to increased balance in terms of gender, race, and ethnicity, given that diversity in both workforce and leadership have demonstrated benefit both for profit and for patient outcomes. As this happens, those used to being the dominant decision-makers and recipients of reward and recognition are, naturally, likely to feel some status anxiety. The problem? Many men in medicine have been given an environment in which and a message that it is OK to demonstrate their status anxiety though verbal outbursts, insults, and aggressive body language. Aggression toward women, as in our physician friend’s situation, is already common; it is therefore important to anticipate that the very efforts to correct such interactions and dynamics may lead to a backlash of further anxiety, with its attendant bad behaviors.
Individuals who feel uncomfortable as hospitals and health systems take active measures to diversify their employee and leadership rosters might benefit from reflecting on their feelings and doubling down on their commitment to a richly diverse workforce. Those who act out status anxieties in aggressive, destructive, or abusive manners must be held responsible by unit, department, and hospital leadership for violating standards of professionalism and equity. Serial violators of professional behaviors must not be allowed to advance in their careers without censure and restitution. Diversity goals must not be put in place without protections against the anticipated retaliation and aggression that comes with change and that prevent success for those who bring the diversity.
The female physician mentioned above did take that job. But only after she told the chairperson about her colleague’s angry outburst and how uncomfortable it made her. The chairperson told her that he was shocked—he had never personally witnessed nor heard of such behavior from this faculty member. A week later, he called her back and told her that after her report, he had “asked around.” It turned out that this was a known and long-term behavior pattern for this faculty member: More than 15 years of rage storms, twice even with his direct site supervisor, with little to nothing done in response. In fact, he had been steadily promoted over the years.
Why did she take the job? The chairperson thanked her for bringing it to light. He apologized for the situation in which he had unknowingly placed her. He removed that faculty member from her direct or indirect reporting structure and collaboration. And by adding her as a leader in the department, he diversified his own team