Medical student gender and issues of confidence
Introduction
The last decade has seen a significant change in the gender composition of medical schools. According to the Association of American Medical Colleges, since 2002, each year female students have made up over half of all first time applicants to medical school [1]. This is up from just under a third of the applications coming from female students in 1982–1983. These numbers carry through to the percentages of females matriculating and graduating from medical school.
In order to develop training and curricula that produce the best possible physicians, regardless of gender, medical educators must understand the gender differences that exist in the medical student population. A comprehensive understanding is difficult because gender differences in this population are often reported in the context of one particular medical school, training program, evaluation technique, or attitude scale. However, when brought together, these largely disjointed results form a remarkably coherent picture of the gender differences in confidence and anxiety that exist in the medical school population.
The effects of gender on medical student anxiety and self-confidence are particularly consistent. Despite performing at a level equivalent to male medical students in academic competence and even excelling in clinical communication and patient-centered care, female medical students consistently report more anxiety and less confidence in their abilities than their male counterparts. These confidence-related behaviors and beliefs can have a significant and often detrimental impact on both internal and external perceptions of ability and can undermine ability and performance.
In this article, we present a review of the research on gender differences in self-confidence and anxiety of medical students that led us to these conclusions and we present our current research on perceptions of confidence in relation to medical student gender. We also examine the potential causes and effects of these gender differences, suggest several ways in which our findings can inform medical education, and propose possible directions for future research.
Well-being is an important element in medical school success and a large part of that success is in dealing with the stress and anxiety that the rigors of medical school often pose. In general, female medical students report a higher level of anxiety than male students [2], [3], [4], [5], [6], [7], [8], [9], [10]. Although the effect sizes are small in some cases [11], [12] or no significant gender difference is observed [13], [14], no studies showed males experiencing more overall anxiety than females. This gender difference in medical students’ anxiety has been examined mainly in the US, but occurs outside the US as well [9], [10].
Hojat et al. in 1999 and 2003, analyzed gender differences in the psychosocial profiles of medical students [11], [15]. Female medical students scored higher than their male counterparts on measures of general anxiety, test anxiety, and neuroticism. Females who experienced stressful life events also rated these events more negatively than males and were more likely to report that experiences of personal injury or illness had influenced them a great deal. In addition to reporting more stressful events than males in schoolwork and living conditions, female medical students were significantly less likely than males to report major personal achievements or completion of an educational program when asked to recall recent life changes [5].
Studies have established a gender-specific link between anxiety and self-perceived competence [8]. A study of first year medical students in the United Kingdom found that although there were no significant gender differences on a measure of general health/psychological morbidity, female students reported that their ‘personal competence’ caused them significantly more stress than was reported by male students [4]. Females also had significantly higher stress related to ‘learning the new curriculum’ and ‘assessment’, stressors related to confidence in performance. Males only experienced more stress than females about their ‘accommodations/living away from home’.
There is some suggestion in the literature that the relationship between female gender and increased stress over competence strengthens as medical school progresses. In first year students, there were no gender differences in worries about competence, workload, or finances. Yet by the third year, females worried significantly more than males did about their future capacity and competence [2]. There is also evidence that female medical students are particularly vulnerable to anxiety over competence in the later years of their medical education [16]. A study of third year students found that women reported significantly more anxiety than men [3]. The questionnaire on which this study was based addressed issues of confidence and perceived competence as a source of anxiety (e.g. “I feel confident about performing physical examinations on real patients” and “my previous clinical skills teaching has prepared me adequately to start on the wards”). Interpreted as a measure of perceived confidence, these third year female medical students reported more anxiety about their abilities than did their male counterparts.
Even in areas where females typically excel, they may feel less competent. Female medical students reported more apprehension about communication than male medical students [17]. Female medical students were also significantly more likely to be neutral or disagree that their communication skills and clinical knowledge were competent [18]. At the end of medical school, males seemed to have achieved a greater level of identification with the role of doctor than female students who had been through the same medical school experience. An analysis of the factors attributed to this role identification revealed that while both genders took into account medical school variables like perceived recording/clinical skills, only female students thought about their confidence in their knowledge when asked to assess their identification with the role of doctor [19].
Female medical students feel unsure about their competence as doctors and this can manifest itself when they are asked to make estimates about their abilities. Self-assessment is often a component of medical education and many argue that it is crucial in establishing a physician's professionalism [20]. In general, the literature shows that female medical students tend to underestimate their abilities, while males tend to overestimate their abilities [20], [21], [22], [23], even in cases where female students scored objectively higher than males [24]. This seems to exist across specialties, although the effect size may be smaller in certain groups of female medical students like those who choose traditionally male-oriented specialties, such as surgery [22]. Greater accuracy in self-assessment in women who enter surgical fields may be due to a selection bias. Women who choose to specialize in surgery may be particularly confident and self-assured.
Although clear differences are seen in studies of self-confidence, stress, and anxiety, the question remains whether gender differences are evident in clinical and academic performance. Gender differences in a variety of observable behaviors have been studied and have been shown to exist in the practicing physician population [25], [26], [27]. Nevertheless, there appears to be no consistent gender difference in academic performance as defined by grades and test scores. A recent review of predictors of academic success in medical school found a small, but consistent, body of literature showing that women outperformed men in medical training and clinical assessments [28]. It is important to note that research in this area has not been consistent, with some researchers finding no gender difference [29], [30], an advantage for female students [31], or an advantage for male students [32]. More research is needed to explore possible gender differences in academic performance; however, it does not appear that female students’ decreased self-confidence and high anxiety over competence are justified by objective criteria showing poor performance.
Although there appear to be no systematic differences between male and female medical students in academic performance, the literature on communication and interpersonal skills does reveal differences. Consistent with the research on physicians, research on communication and interpersonal skills in medical students shows that females excel in measures of communication performance [33], [34], [35], [36], [37], [38]. These assessments are usually global scores on communication skills or performance in objective structured clinical examination (OSCE) rated by a preceptor or standardized patient. This method of evaluation has been shown to be a reliable and valid way to measure medical student competence [39]. Gender differences that do exist are not attributable to evaluators’ gender biases [34]. Examinee gender, and not standardized patient, rater gender, or an interaction of these variables, affects ratings [40].
The literature is clear that despite equivalent or even advanced levels of performance in comparison to their male peers, female medical students self-report more stress and anxiety and are less confident in their own abilities. From a methodological perspective, self-reports are subject to a variety of biases. Female medical students may just be more willing to admit that they are feeling anxious, stressed, or that they lack confidence in their abilities. Male medical students might be feeling anxious or stressed to the same degree but are more reticent to admit these negative feelings. Gender differences in self-report response biases have been shown in other areas such as on scales of personality disorders [41], [42], depression inventories [43], and mathematics anxiety measures [44]. Although the literature on self-reports of confidence are convincing, a question remains as to whether female medical students are actually perceived as less confident. Specifically, does their style of interacting with patients also suggest a lack of self-confidence? To test this question we asked independent raters to judge the confidence of a large sample of medical students during a clinical encounter with a standardized patient.
Section snippets
Participants
Third year medical students at Indiana University School of Medicine who agreed to participate were videotaped during their objective structured clinical examination. The students interacted with a standardized patient in one of four medical scenarios: smoking cessation counseling, discussion of patient's father's illness and code status, stress headache diagnosis, and cough diagnosis. Each encounter lasted approximately 10–15 min. The encounters were ended after 15 min, even if the student had
Results
Perceptions of medical student confidence were assessed for 141 OSCE interactions. Of these, 76 (53.9%) were male students (Table 1). All four medical scenarios were represented approximately equally (smoking cessation n = 33, father's code status n = 38, headache diagnosis n = 38 and cough diagnosis n = 32). Self-reported age and ethnicity were available for a sub-sample of the medical students (n = 114 (81%) for age and n = 108 (77%) for ethnic information). The students ranged in age from 22 to 39 years
Discussion
A review of the research on medical students’ self-confidence indicates that despite performing equally as well as, or even superior to, their male peers, female medical students consistently report more anxiety about their performance, greater stress over competency issues, and less confidence in their abilities in medical school. The present research indicates that female medical students are also viewed as significantly less confident than male medical students by independent observers. This
Conflict of interest
There are no conflicts of interest.
Acknowledgements
The authors wish to thank Laura Bornstein, Margeaux Fischer, Lucas Frankel, Morgan Howard, Morgan Jensen, Ashley Smith, and Ashley Teixeira for their assistance in videotape preparation and coding.
Role of funding: This work was supported by a grant to the Relationship Centered Research Network from the Fetzer Institute, Kalamazoo, MI. The funding source had no involvement in data collection, analysis, or the preparation of this manuscript.
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