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Voices in the OR: A Self-Reflection and Examination of Unconscious Bias

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Our obstetric anesthesia team sat down to debrief after a particularly harrowing case. We had just replaced our patient's blood volume twice over after she went into labor with a placenta previa accompanied by a placenta accreta. The OR had been the usual controlled chaotic scene of multiple teams intensely focused on their responsibilities. It was noisy. Too noisy. I had to remind everyone to restrict themselves to essential conversations. With that command, the room quieted. Sitting in the conference room during our debrief, the obstetric anesthesia fellow asked how she could get people to listen to her during resuscitations. She had asked for quiet in the OR three times unsuccessfully before my request had obtained the desired result.

I had a ready answer to my fellow's question. Sheila Cohen, a legendary obstetric anesthesiologist, had been my mentor when I was a young doctor. She learned how to use her voice early in her career so that she could command the necessary authority to get the world to listen to her. I had heard her tell female residents to not end their sentences with a lilt in their voice, as if they were asking a question, a pattern linguists refer to as "upspeak." Sheila's guidance resonated with me and reminded me of my late wife's determination while training at Princeton Theological Seminary to abolish all hints of the surfer-girl speech patterns she had developed growing up in Laguna Beach. My current wife learned to speak with authority in law school so that she could go on to be a litigator. It was clear to me that my fellow had to stop sounding like she was asking a favor and speak with authority, as a male doctor would.

 The female resident anesthesiologist on our team said the people in the room listened to her, but her commands were met with glares from the female nurses and male physicians. She wanted to know how she could use a compelling voice without getting the stink eye. A more senior female resident sagely said not to worry about the feelings of those who are offended when a female takes authority. I felt we had satisfactorily addressed the issue.

That night as we drove home from the movie “Bombshell,” I told my wife about the debrief, expecting her to endorse the lessons I had imparted to my trainees. After all, I had learned by listening to her and the other strong, dynamic women in my life. Instead, in an exhausted voice, she said, "Why should women have to sound like men to get people to listen to them? Why isn't it that everyone in the room should be quiet when she asks for quiet because she is a doctor asking for quiet?"

Somewhat chastened, I went to the place I always go for answers: the medical literature. The theme was clear. Women physicians do not get the same respect men get when dealing with emergencies. This is not because women are less competent or because of their position in the medical hierarchy, it is because they are women. In a Toronto study utilizing scripted scenarios, residents were asked to judge the leadership qualities of a person leading a resuscitation. They were randomized to watch a film of a resuscitation. The resuscitation leader was either a male or a female actor. The second level of randomization included telling half of the subjects that the resuscitation leader was either a physician or a nurse practitioner. The female leader, whether a doctor or nurse, was deemed inferior to the male leader even though they followed the same script, they wore the same clothes, and they were the same race. In other words, residents found a male nurse to be a better leader than a female doctor even when the two were doing and saying the same things. 

In retrospect, I did not need to rely on the medical literature to tell me women are generally not afforded the same respect as their similarly experienced male counterparts. All I needed to do was reflect on my 35 years in medicine with an open mind. Through the years, I have seen the awards, appointments, and promotions of distinguished female physicians dismissed by the graybeards of my department. Young male doctors refer to support groups for female patients as “estrogen fests.” There was also the resident graduation ceremony when, as our former chair introduced each graduate, he gave a quick summary of their successes. For every male graduate, he mentioned their awards, publications, or other professional accomplishments. For every female graduate, he talked about the fact that they had recently given birth, gotten married, or some other milestone in their personal life. I did not realize this had happened until my female colleagues and late wife started discussing it at the post-mortem after-party. When I recalled the speech, they were correct. I felt clueless that I had missed this subtle but clear example of misogyny. Of course, the women in the audience caught it. It was their daily reality.

Evaluating myself in light of this very recent revelation of my own misogyny, I see that I have unconsciously internalized the tropes my colleagues and I have used to justify our biases: "Women don't have natural leadership skills," "Women's voices don't command authority in acute situations," or "They are too bossy when they give orders." I realize misogyny has infected the base from which I have responded to the world. Many people may bristle at my characterization of my reaction as misogyny. However, we can only change our biases if we first name them, own them, and face the reality of how our prejudices affect our interaction with the world. The effects of endorsing the male model of speech in the OR go beyond the undermining of the confidence of our female trainees. It results in bad patient care. Inclusive leadership is a better model for the OR environment than authoritarian leadership, and linguists characterize upspeak as a more inclusive speech pattern. 

Misogyny, conscious or unconscious, has no place in the hospital. Devaluing an idea or ignoring a request delivered by a female voice using upspeak is misogynistic. The next time I am in a room where a woman is leading the resuscitation and she is not given the quiet she asked for, the debrief will focus on changing the behavior of the noisemakers, not on the speech patterns of the voice they failed to heed. It will be more complicated to uncover other instances in which my unconscious biases similarly impede my ability to teach and mentor — and thereby to deliver optimal patient care. The first step will be listening more carefully to what the women in the room are saying, rather than their tone of voice.

The author recently had an essay published in the blog of the California Society of Anesthesiologists. It deals with unconscious gender bias in the OR.

Illustration by April Brust

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