Don’t call me Karen, Cheryl, Nancy, Reshma, Cornelia, Caryn, Sharon, … call me “Doctor.”

A study that found gender bias in introductions of women speakers has awakened memories of decades of disrespect, women leaders in oncology said to The Cancer Letter.

The study, led by Narjust Duma, an assistant professor and thoracic oncologist at Carbone Cancer Center at the University of Wisconsin-Madison, analyzed 781 introductions from the 2017 and 2018 ASCO annual meetings.

Women speakers were addressed less often by their professional title compared with men speakers, 62% versus 81%, the study found. (See related story here.)

Men were less likely to use a professional title when introducing women speakers compared with women who introduced men speakers, 53% versus 80%.

Men introducers were more likely to address women speakers by first name only compared with women introducers.

Women leaders in oncology said they’ve been aware of this bias throughout their careers.

All the women we spoke with said that since the paper was published in the Journal of Clinical Oncology in October, they have been taking efforts to make sure the next generation of women in oncology are treated with respect.

It’s something we can change, and it’s easy to change … It’s a call to action.

Karen E. Knudsen laughed knowingly when she first read the title of the Duma et al. paper: “Evaluating Unconscious Bias: Speaker Introductions at an International Oncology Conference.”

“I mean, I sighed, and then I chuckled—because I thought ‘Oh yeah, I know this story,’” Knudsen said. “This happens all the time. it happens more frequently than it should in a variety of different formats.”

Knudsen wasn’t surprised at all. Why?

“I’m a woman in academic medicine. This happens to me too regularly. If it is the case that I am introduced as Karen instead of, you know, ‘Dr. Smith,’ that automatically, unconsciously, puts us on a different playing field. I’m not seen or viewed in the same light.”

At conferences, Knudsen said she is referred to as “Karen” frequently. As the 2020 chair of the ASCO Genitourinary Symposium and AACR Advances in Prostate Research, she is planning to draw attention to this issue.

“I will and I have taken more notice of it in regard to conferences. Prior to the article I might not have thought to,” Knudsen said. “I’m really appreciative of the fact that this group got together, documented probably what many of us already held to be true, because they raised awareness. To me, that’s the real benefit in this article, because it’s something we can change, and it’s easy to change … It’s a call to action. It’s something we could easily modify in our behavior starting today.”

Knudsen said she has distributed the paper to faculty and staff at Thomas Jefferson.

“[This study is] a small step toward the greater good of really achieving parity in the workforce,” Knudsen said. “If the end goal is parity in the workforce, especially in leadership, then it has to start in the beginning. That means that everyone is viewed based on the merit of what it is that they have accomplished and what their contribution is to the workplace and to the field.”

Nine of the 71 NCI-designated cancer centers are headed by women directors, and the number of women in deputy-director positions at cancer centers is alarmingly low.

“I’m always impressed by how many people who ask ‘What’s it like to be a PhD and a cancer center director,’ when at last count I think there’s something like 16 or 17 non-MD cancer center directors,” Knudsen said. “There are a lot of us. No one ever says ‘Wow, isn’t it interesting there are so few women [cancer center directors]’—except the women.”

During the last NCI site visit to Thomas Jefferson, Knudsen and her leadership team required that all doctors would be addressed by title, regardless of gender. The decision was made before she read the Duma et al. study.

“We did it, because we wanted there to be continuity in how we discussed and talked about each other,” Knudsen said. “So we said, ‘Look, it has to be one or the other—we were either going to use first names or we were going to use titles.’ And we elected to use titles.”

It made a difference.

“I remember an unnamed person from the NCI who was at the site visit saying to us, ‘Wow, we really remarked at how consistent your team was of using titles for everyone,’” Knudsen said. “I’ve been on a lot of site visits, and I’ve seen a lot of variances. So, I like to think we’re leading the way on this, and it just is a small step toward what we want to achieve—parity.”

I’ll see my male colleagues referred to as ‘Dr. So-and-so,’ and I’m referred to as my first name, despite the fact that I’m one of the most experienced and longest-serving cancer center directors.

Cheryl L. Willman has been referred to by her first name since she was in medical school at Mayo Clinic in 1981. She was referred to by her first name during her residency at the University of New Mexico School of Medicine in 1984 as well. To this day, men colleagues often refer to her as just “Cheryl” at meetings of directors of cancer centers as well as on NCI advisory boards.

“I’ll see my male colleagues referred to as ‘Dr. So-and-so,’ and I’m referred to as my first name, despite the fact that I’m one of the most experienced and longest-serving cancer center directors,” Willman said.

One surgeon Willman encountered on cardiovascular rotation during her training holds a place of distinction in a parade of rogues:

“He would say that the women on the team should—I don’t think he ever said ‘girls,’ which was good, but he did say that the women on the team should wave palm fronds when he walked into the room with his patients—as a joke. But it’s really not a joke; right? You just realize that in that environment, you’re not going to say anything.”

As Willman moved up the ranks, she observed gender bias in the institutions where she worked.

“Surprisingly to me—as you rise higher in national groups, like the NCI Board of Scientific Counselors and the Board of Scientific Advisors, even our center directors meeting—it was shocking to me to see this still going.”

Willman circulated the Duma et al. study to her institution’s committee of chairs and health science center—“to make a point.”

“We’ve talked about this in our meetings. I find that particularly men constantly forget; it’s part of their own acculturation. They just need constant reminders,” Willman said. “I find, with gentle reminders, or modeling appropriate behavior when I refer to my female colleagues by their title, men actually pick up on that pretty quickly.”

Formal introductions are essential at international meetings, because they imply respect, Willman said.

“To me, a failure to do that is an indication that the person doesn’t have an equal respect for the achievements of a woman who is serving in the same role. And that’s really disappointing,” she said.

A few years ago, at an American Association for Cancer Research meeting, Willman led a program about women in leadership, where women trainees, residents and fellows raised concerns about informal introductions in professional settings.

“They had actually noticed during the meeting that women were too often referred to in—they used the word pejorative fashion—by first name, or not fully acknowledged with their title and their institution when they were a speaker,” Willman said. “It just makes you realize sometimes what you’re up against. And it’s disappointing.”

In surveys conducted at the University of New Mexico, women have said they are less likely to raise concerns of unconscious bias in regard to gender, race or ethnicity.

“They feel that will harm them,” Willman said. “While I think the conversation has evolved and improved to where I would be comfortable—but I’m a pretty senior leader.”

The best way to call out this behavior?

“Usually, gently and with a smile on my face,” Willman said. “If I’m angry about an issue, which I may feel inside, then the power of my words is lost. If I’m gentle about an issue and speak quietly, and sort of have a smile on my face, it makes everyone uncomfortable, and it has an impact,” Willman said.

“Whether people in the room roll their eyes and say ‘There goes Cheryl again,’ you know, too bad. That’s my role.”

You know, I’m established. I can live with this, [but] the notion that we’re giving this message to somebody who is just starting her career strikes me as very distressing for our profession.

Before Nancy E. Davidson read the Duma et al. study, she thought that the discrepancy in introductions—addressing women by first name, no honorific—was a once-in-a-while mishap.

She has since thought about incorporating the results into her daily work, and she suspects the implications of the study aren’t limited to oncology.

“I like to think that I’ve been very good at [introductions],” Davidson said. “But I’m trying to be more thoughtful and mindful about this going forward, to make sure that I always emphasize this.”

Recently, Davidson introduced a young faculty member during a meeting at her institution.

“It’s obvious to me that the person giving this talk is a physician, but she is a she, and she’s a woman of color, and that’s the kind of situation where you want to make sure that you really do emphasize her title and her credentials,” Davidson said. “That this is ‘Dr. So-and-so,’ and she got her bachelor’s degree here, and her medical degree there, and her training here, and now she has this faculty position—to make sure that it’s really clear that this is a person who is qualified and credentialed, and an authority on this topic that you’re going to hear about so that there’s no ambiguity.”

Davidson experienced gender bias earlier this year, when she was on a panel at a local business conference:

“When we were all introduced to come up to the panel, the five men were introduced by their first and last names: ‘Dr. John Smith, etc.’ The two women were introduced as ‘Nancy’ and ‘Mary.’”

Davidson and “Mary,” both well-established in their fields, “walked up there together and said, ‘Wow, we don’t even get our last names?’” Davidson said. “I was impressed by how that really diminished the qualifications of both of the women who were up there. I would say that this is a pretty pervasive problem.”

In another instance, at a philanthropic award event she attended in Seattle, Davidson witnessed an even more distressing display of disrespect.

All but one of the award recipients were men.

“The woman with her PhD was not recognized as ‘doctor,’ but all of the other people, who were men, were recognized as ‘doctor’—’Dr. Smith this, Dr. Smith that,’” Davidson said. “They went through her whole biography and at the end said: ‘Jane Smith’ is getting this award.’”

The problem isn’t limited to large medical conferences. Rather, “it’s permeating our society at large,” Davidson said.

“You know, I’m established. I can live with this,” she said. “[But] the notion that we’re giving this message to somebody who is just starting her career strikes me as very distressing for our profession.”

The Duma et al. study “brings a large data set to the table for us to look at. To me, it validates what we might have felt in these one-off situations, and says it’s actually a more common problem than I could’ve imagined,” Davidson said. “Big data leads to knowledge—so I think these data have allowed us to really know more about the problem. And knowledge is going to hopefully lead to solutions.”

Showing the data can be so important in leading to behavior change of pushing people along that spectrum, from precontemplation to contemplation, to actually realizing there’s a problem here.

“For years I’ve been told it’s all in my head,” Reshma Jagsi said.

Of course, she understood that she was being asked to accept being called “Reshma” in the same professional settings where her men colleagues got the honorific “Dr.” Of course, it wasn’t in her head, but here, in the Duma et al. study, the data dispel gaslighting decisively, once and for all.

Just the other day, an administrator referred to Jagsi as Reshma three times in an email. That would have been just fine had the same email not bestowed a “Dr.” upon her men colleagues.

“I felt really disrespected,” Jagsi said. “I am the deputy chair of this department. One of the four doctors that was mentioned was the chair, but the other faculty members were not senior to me, and arguably were junior to me.”

Younger doctors tell Jagsi that they deal with this nonsense daily.

“Most of my female residents tell me they introduced themselves as doctor ‘last name’ to try to avoid that,” Jagsi said. “And even when they do that, sometimes patients will call them by their first name.”

The Duma et al. study is indicative of “a deep phenomenon that extends well beyond introductions at formal academic events—this is symptomatic of a very deep issue rooted in our culture,” Jagsi said.

Ultimately, the discrepancy in title introductions causes a “downstream impact of gender inequity in leadership,” Jagsi said.

“What this study is elucidating is a mechanism by which one of many mechanisms that contributes to the disparity that we see at senior levels because it does matter what one is called,” she said. “It influences the way that others respond in the audience when someone is introduced as someone worthy of respect versus introduced in a more informal way.”

The issue is personal, too.

“I have a white male husband who doesn’t have the same lived experience that I do,” Jagsi said. “He is able to appreciate what that must be like, and really, showing the data can be so important in leading to behavior change of pushing people along that spectrum, from precontemplation to contemplation, to actually realizing there’s a problem here.

“There is something going on here that is disadvantaging women.”

We all have to pay attention to the power of language, because that’s what we use and that’s what we as humans respond to.

Cornelia Ulrich grew up with a language that excludes women from professional roles, including those in medicine.

“The German language, in Germany itself, is entirely male-centric,” Ulrich said. “Every prescription note will refer to the physician as the male physician. Every document will refer to that physician as the male physician, and also to the male patient.

“The reason that is given is that it’s very cumbersome to use both the male and female form, and it clearly will extend the text.”

The Duma et al. paper points to an all-too-familiar feeling of exclusion, reminding Ulrich of a lack of recognition and respect—that women don’t belong here.

“It does result overall in women being presented, perhaps, with less credibility and respect— and unintentionally so,” Ulrich said. “It’s important that we are mindful, and are working towards a really true, equal environment.

“That means that if there are multiple speakers, that all the men and women are equally introduced either by their first names or all by their last name—that there are no differences made. What we should say is that the professional titles are critical.”

Whether it’s an issue of the German language or first-name introductions, “it’s so important that we actually pay attention to that, because the effects are there,” Ulrich said.

“[Language] is something that I think has a huge impact, subconsciously, already on young women and children. Because they do not identify themselves with the role, or the trade around them that are usually professional roles.”

A man colleague was the first to send Ulrich the Duma et al. study.

“It certainly made me aware of something that I didn’t anticipate to be such a big difference. I’ll pay more attention to it, both when I introduce myself or when I get introduced,” Ulrich said.

When it comes to language, Ulrich’s solution is to teach her German-speaking students to include male and female pronouns, or to use a neutral plural pronoun.

The best way to create equality in introductions is to point out the problem, Ulrich said.

“The more we can find ways to highlight these facts and bring it up in a neutral, observing way— and there are many men who are very eager to also change this and getting them on board and involved—the better,” she said.

Before she moved to the United States, Ulrich hadn’t realized how male-centric the German language is.

“When I came to the U.S., I read children’s books to my kids. And it was very funny, because in my mind, in my German mind, it was so clear that the male pronoun would be used for something,” Ulrich said. “And then, all of a sudden, it said ‘she.’ And I felt like I stumbled over it so many times, because it was an incongruence with my role understanding. It made me really aware of that.

“We all have to pay attention to the power of language, because that’s what we use and that’s what we as humans respond to.”

I think having tangible evidence is useful, because there’s something actionable in this. There’s something we can do about it.

Caryn Lerman hasn’t noticed gender bias in introductions at conferences, but she has witnessed it elsewhere—and not just in oncology.

“I’ve observed it anecdotally in how announcements are made, perhaps of new faculty appointments, where men might be more often referred to as ‘doctor,’ and women by their first names,” Lerman said.

The Duma et al. paper proves that it’s a systemic problem, Lerman said.

“It makes us all aware of it, men and women, aware of our biases—gender biases, or other biases,” she said. “In academic settings, we value data to inform on whether our perceptions are validated with evidence. And I think having tangible evidence is useful, because there’s something actionable in this. There’s something we can do about it.”

For Lerman, like others, “it’s an important issue professionally, to show the same level of respect for women and men.”

If Lerman has experienced an informal introduction, she hasn’t noticed it.

“I can’t say that I have experienced it myself or been aware of it for myself, maybe because I share the same unconscious bias. But I haven’t perceived it for myself,” Lerman said. “It may be because I tend to be more informal in my style, and so it probably wouldn’t have bothered me personally.”

Why, then, are women introduced by their first names, instead of by professional title?

“Perhaps women, in general, tend to be less formal in their interactions; perhaps they invite that lack of formality, perhaps they don’t,” she said. “I’m not suggesting that that’s the case, but I think that it would be interesting to gather data from women about their preferences for titles.

“If you consider women in leadership positions, how likely are men versus women to say that they are comfortable with having their direct reports call them by their first name instead of by doctor? That would be evidence.

“We have to study it in some way to know why this is reflected in titles.”

The next steps in documenting gender bias could be to evaluate the impact of bias training and workshops, Lerman said. ASCO is implementing implicit gender bias workshops ahead of the 2020 annual meeting, in addition to providing session chairs with instructions on how to introduce speakers.

“It would be interesting to actually look at changes in how male versus female leaders are referred to before and after training, either in written announcements or as they’re announced to the podium in a conference,” Lerman said.

“I don’t believe at all that there is malice on the part of our male colleagues, or any intention to diminish women in any way in this setting,” she said. “I think it would be interesting to do a survey and try to explore what might be behind this.”

As a senior scientist, I think we have the responsibility to call it out when we see it. You’re almost complicit if you don’t call it out.

Impressed by the Duma et al. study, Sharon Stack sent the paper to the diversity committee in the Department of Chemistry and Biochemistry at Notre Dame.

“THIS IS CRAZY,” one person replied.

“Yes it is,” Stack concurred. “The data were unequivocable, and the ranges were not subtle.”

The department chair said he would discuss the paper at the department’s next faculty meeting.

“I’m going to be more aware of it, going forward, and I think this is an important issue with all unconscious bias, whether it’s based on gender or race,” Stack said.

Implicit bias extends further than just introductions, and men aren’t the only perpetrators, Stack said.

“There are dinosaurs of both genders, and I think the problem is we’re not waiting for these dinosaurs to die off, we’re still making new dinosaurs,” Stack said.

As a basic scientist, Stack is used to a lack of formality at the smaller conferences she attends.

“The impact of not using that honorific title of doctor is probably magnified in the medical community relative to basic science community,” Stack said.

Junior faculty feel the adverse effects of bias more acutely, because they aren’t in a position of power, Stack said.

“But as a senior scientist, I think we have the responsibility to call it out when we see it,” Stack said. “You’re almost complicit if you don’t call it out. And whether that makes you sound like a complainer—I think it’s important for us, as established scientists in the field, to call out instances of bias when we see it, and make our colleagues aware that this is not OK.”

Studies that demonstrate these types of unconscious bias “are really important,” she said.

“Until you actually measure it—and it’s really hard to measure that—then you can’t really say whether or not it’s the case,” Stack said. “This is one of the things where you say ‘OK, now we have the data, what are we going to do about it?’”

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