Invisible in White Coats: Unveiling the Hidden Barriers for Female Physicians Through Microaggressions and Intersectionality

Abstract

Despite decades of ongoing efforts to address gender equality, female physicians, particularly women of color, continue to face significant barriers in medicine, which are exacerbated by microaggressions. In this qualitative study, 133 female physicians recalled experiences with microaggressions and the impact of these experiences on their professional identities and career progression. Thematic analysis revealed four major themes: (1) disregard for professional status; (2) undermining contributions; (3) intersectionality; (4) impact on career mobility and professional confidence. Further, there was one emerging theme: leadership and culture. The results underscore the compounding effects of microaggressions for female physicians with intersecting identities. Highlighting the application of social identity theory, intersectionality, and organizational justice, this study provides a comprehensive view of the impact of microaggressions on female physicians, offering new perspectives on the intersectional nature of discrimination and its effects on professional identity and career satisfaction.

1. Background

Despite decades of ongoing efforts to address gender equality, significant disparities between women and men in medicine continue to exist [1,2,3]. Yet, there is still hope. According to the 2023–2024 State of Women in Academic Medicine report by the Association of American Medical Colleges (AAMC), there continues to be an upward trend towards gender equity in medical professionals [1]. In 2023, women were the majority of applicants and graduates in medical schools [1]. Over the past decade, the percentage of women in faculty positions increased by 7% from 38% to 45% [1]. Similarly, the number of women in leadership positions has continued to rise, with women holding 45% of senior associate dean positions, 34% of division chief roles, and 27% of deanships at U.S. medical schools [1]. However, challenges persist [1,2,3]. Women still represent only 25% of department chairs, and significant disparities in pay equity remain—disparities that are further compounded by factors of race, ethnicity, sexual orientation, and other underrepresented minority statuses in medicine [1,3,4]. Furthermore, one in three women in academic medicine report experiencing interpersonal stressors such as sexual harassment, incivility, and microaggressions. This highlights the need for continued efforts to address gender parity and create safer, more inclusive environments [1,2].

Within academic medicine, the overall climate for women has been widely referred to as “chilly” to emphasize the systemic exclusion, devaluation, and marginalization that women face in healthcare [5,6]. Such an environment undermines the contributions of women and creates barriers to their advancement, which further reinforces gender inequities in healthcare [2,3,6,7]. Previous research has demonstrated that a chilly climate in academic medicine is often driven by social, racial, and gender power dynamics, plus a desire to maintain the status quo within the profession [2,5,7]. For example, reports have shown that sex-based biases towards female physicians are aligned with societal expectations that men make better leaders and physicians than women [8,9]. In this context, for female physicians—especially women of color such as Black physicians—who have historically been excluded from healthcare professions, the climate is more likely to be perceived as chilly. These individuals are more susceptible to mistreatment in the workplace, as their presence challenges traditional norms and structures, making them more vulnerable to negative and discriminatory treatment [4,10,11].

While the overt discrimination and mistreatment of female physicians are still a concern, over the past few decades, there has been a rise in more subtle, covert forms of discrimination [2,4,12]. One such form that has garnered increasing attention is microaggressions—subtle, often unintentional slights or insults that women, particularly women of color, encounter in their working environment daily [13]. These microaggressions, while seemingly harmless, can accumulate over time, significantly impacting professional identity, mental health (e.g., anxiety, burnout, or depression), patient satisfaction, and career progression of female physicians, thus contributing to the overall chilly climate that exists [2,12,13]. Unlike racism, which occurs at a systemic and institutional level, microaggressions are more interpersonal and insidious in nature [14,15]. They are often referred to as death by a thousand cuts as over time they undermine the sense of belonging and psychological safety necessary for women to thrive in academic medicine [12,16,17].

Microaggressions can be categorized into four subtypes: Microassaults, which are “old-fashioned” discriminatory behaviors or comments that are intended to offend or demean the recipient, such as questioning qualifications or place of women in medicine [14,15]; Microinsults are subtle, often unintentional actions or comments that belittle or humiliate the recipient. For female physicians, microinsults occur when they are often mistaken for a nurse, janitor, or other support staff rather than a physician [14,15]. Microinvalidations are actions or comments that dismiss or negate an individual’s thoughts, feelings, or experiences. For female physicians this might be being told “you are being too sensitive or emotional” [14,15]. Environmental microaggressions occur at a broader institutional level, reinforcing systemic biases, which are usually embedded through the broader culture, policies, and climate in healthcare institutions. For example, displaying only portraits of white male leaders or implementing color-blind hiring policies that overlook racial disparities [14,15].

Although there is well-documented evidence of female physicians’ experiences of gendered microaggressions in the workplace [4,14,16], there are limited organizing frameworks to explain the underlying factors in place. To add to the growing body of research on microaggressions, in this paper, we use three theoretical frameworks, namely social identity theory [18], intersectional invisibility theory [19], and organizational justice theory [20], to discuss female physicians’ experiences with microaggressions.

1.1. Theoretical Frameworks

1.1.1. Social Identity Theory (SIT)

SIT posits that a significant part of the self-concept of individuals is derived from the social groups that they belong to (e.g., political affiliation, gender, race, and profession) [18]. As a result, individuals are likely to favor those who share the same social identity as themselves (those in their in-group) more positively than those whose social identities differ (those in their out-group). Consequently, when individuals are interacting with other members from their out-group, they are likely to hold biases and prejudices [18,21]. Similarly, Haslam et al. [21] stated that when one’s sense of identity is threatened (e.g., rejected by members of the in-group), this negatively impacts our psychological sense of self such that one loses their “psychological footing.” Furthermore, social identity is more than one’s social demographics (e.g., age, gender, and title) but rather is relative and in that it may hold different psychological meaning to the individual’s sense of self, which impacts self-esteem and well-being. In the context of female physicians in a male-dominated field like medicine, SIT helps explain how microaggressions undermine professional identity by questioning the legitimacy of their role as doctors. Hence, when female physicians encounter microaggressions such as being mistaken for a nurse or questioned about their qualifications, it threatens their sense of identity and belonging as a physician and in the medical profession [17,22,23].

In one qualitative study on gender identity and professional development in female residents, participants reported experiencing microaggressions from both patients and colleagues [24]. Participants reported being referred to as a medical student and less senior, particularly when male colleagues were present, and despite performing resident-level work. During this experience, female residents reported questioning whether such microaggressions could be attributed to their gender since their male counterparts did not report having similar experiences [24]. Similarly, research supports this, showing that consistently experiencing microaggressions can impact self-esteem, professional identity, and career satisfaction [4,23]. For example, in a mixed-methods study on gendered microaggressions, one female physician reported “I get misidentified as a nurse so often that it impairs my ability to do my job…” [23]. Likewise, Myers et al. [4] found that female physicians who experienced microaggressions on a regular basis were also more likely to report imposter syndrome and less likely to be promoted. These microaggressions contribute to a chilly climate that affects female physicians’ engagement with their work and their long-term career satisfaction [4,23,24].

1.1.2. Intersectional Invisibility Theory

Intersectionality asserts that at any given point in time, individuals with multiple marginalized identities—such as gender, race/ethnicity, immigration status, and sexual orientation—experience unique forms of exclusion and discrimination that cannot be understood by examining these identities in isolation [25]. In other words, for female physicians with multiple intersecting marginalized identities, such as race and gender, during interpersonal interactions, they may experience microaggressions due to both their race and gender [4]. Within the context of the workplace, this ultimately impacts their level of power and status based on a social hierarchy to create complex and often invisible forms of mistreatment that undermine their authority and professional standing in ways that their white or male counterparts may not experience [4,8,25].

As intersectionality scholarship grew, much of the focus was on exploring intersections through the lens of gender and race; however, as research has consistently shown, minority individuals are not a monolith, and as such, their experiences should not be treated as such. Hence, there came a call to dive deeper to examine the nuanced and often complex experiences of those with intersecting identities that may render them invisible [19,25]. Intersectional invisibility posits that individuals with marginalized intersecting identities do not look like what is considered to be the prototypical majority; therefore, they are more likely to be overlooked, ignored, and rendered almost invisible in the workplace [19]. For female physicians, this means that they do not look like the standard physician—white, older, male—as a result, their contributions and qualifications are likely to be dismissed. This is exacerbated by having multiple intersecting identities such as race × gender × sexual orientation × immigrant status [8,14,26]. As a result, this may hinder career advancement, impact patient care, reduce psychological safety, and lead to burnout [4,26,27].

Several studies have highlighted that the intersection of gender, race, and immigrant status creates distinct, unequal experiences of invisibility for female physicians of color [4,28,29,30]. For instance, in one qualitative study exploring the experiences of Asian Indian physicians, Murti [28] found that while Asian Indian physicians, in general, hold high social status, this perception depends on the gender of the physician. Compared to their male counterparts, Asian Indian female physicians reported being perceived as nurses, receiving less respect, and having their qualifications questioned more, despite wearing a white coat. Murti [28] attributes this to Asian Indian female physicians defying gendered racial expectations because as female physicians, they are seen as challenging the authority and success of men. As a result, they often experience more “social marginalization” than their Asian Indian male colleagues, where their career achievements are dismissed or devalued [28,30]. Similarly, Flores et al. [30] found that both Latina/o and non-Latina/o nurses and staff treated Latina/o physicians differently because of their gender. More specifically, Latino physicians were absolved by nurses from performing tedious tasks such as drawing blood, while younger Latina physicians reported higher levels of sexual harassment and their expertise questioned—experiences which Latino physicians did not report experiencing. Ultimately, these compounded forms of discrimination can make female physicians of color feel invisible and excluded, perpetuating a sense of career and social marginalization within the medical profession [28,30]. Intersectional invisibility theory will look to explain how the intersection of gender and race creates unique experiences of discrimination and exclusion in academic medicine.

1.1.3. Organizational Justice Theory

Organizational justice theory examines employee perceptions of fairness in the treatment of employees in the workplace [20]. There are three dimensions of organizational justice, namely (1) procedural justice which relates to fairness in decision-making, processes and procedures by which outcomes or rewards are distributed to employees (e.g., performance evaluations, promotions); (2) distributive justice which relates to perceived fairness in the allocation of outcomes and rewards for employees across the board (e.g., pay equity); (3) interactional justice which relates to fairness in interpersonal interactions and treatment of employees (e.g., being interrupted in meetings) and lastly informational justice which relates to how information is communicated across employees (e.g., given information in a timely manner for promotions) [20]. While research on organizational justice and female physicians is sparse, previous research on organizational justice in healthcare settings have shown an association with high levels of turnover, mental distress, and counterproductive work behaviors (e.g., absences) as well as lower levels of job satisfaction [31,32,33].

Through an organizational justice lens, female physicians who experience gendered microaggressions (e.g., not being seen as possessing leadership competency because of their gender) may perceive unfairness in promotions, pay, recognition, and career development compared to their male physician counterparts [24,27]. This can generate feelings of maltreatment that impact organizational justice, and which also have implications for job satisfaction, engagement, productivity, and patient care, to name a few [9,12]. Similarly, a perceived lack of organizational support in addressing microaggressions, incidences of incivility, and letting bad behavior go unchecked or downplayed can further exacerbate feelings of injustice and contribute to the chilly climate in medicine [9,17,22,26]. Female physicians may also perceive that they do not have access to mentors or sponsors to help them with career development, which may lead them to feel alienated or passed on for opportunities for advancement. Ultimately, this leads to a decrease in workplace engagement, feelings of imposter syndrome, and increased turnover intentions [4,31,33,34]. Overall, organizational justice provides a lens through which female physicians who experience microaggressions perceive fairness and equity in their profession.

1.2. Study Objectives

There has been a growing body of research examining the impact of microaggressions on the professional experiences and mental health of female physicians. Studies have shown that female physicians often encounter microaggressions that undermine their authority, devalue their contributions, skew their self-image, and negatively affect their career satisfaction and mental health [4,14,16]. For example, in one cross-sectional study, researchers found that compared to 49% of male physicians surveyed, 100% of female physicians in internal medicine, surgery, and emergency medicine reported being frequently mistaken for nurses or other non-medical roles, a microaggression that reflects societal biases about who can be a doctor [22]. Myers et al. [4] found that 84.6% of female physicians reported experiencing microaggressions, which resulted in feelings of imposter syndrome, acts of counterproductive work behaviors, and a lack of career advancement and pay equity. Similarly, in one study on physician experiences with gendered microaggressions from patients, Ahmad et al. [23] found that female physicians reported experiencing significantly more gendered microaggressions than their male counterparts. Consequently, female physicians who experienced microaggressions reported lower levels of job satisfaction and higher levels of burnout, perceived career impacts, and changes in behavior compared to male physicians.

Even with the growing body of research on female physicians’ experiences with microaggressions, key gaps remain [17]. This study seeks to address three significant gaps in the existing literature. First, many past qualitative studies have focused on a single specialty, level of training, or racial/ethnic group, limiting their ability to capture the broad and intersectional nature of female physicians’ experiences [14,17,22,23]. In contrast, our study casts a wider net by including female physicians from various specialties, career stages, and social identities such as racial and ethnic backgrounds [4]. This comprehensive approach allows us to explore how microaggressions manifest across different contexts and how they intersect with various aspects of identity, beyond gender and race.

Second, while there is substantial documentation of the emotional and professional impact of microaggressions on underrepresented groups in medicine [2,14,17,22], few studies have explored how these experiences shape professional identity [17]. Our study seeks to examine how gendered microaggressions affect female physicians’ professional identity, self-esteem, and long-term career satisfaction, contributing to a deeper understanding of the broader consequences of microaggressions, beyond immediate emotional distress [3,4,12].

Third, this study utilizes social identity theory (SIT) [18], intersectional invisibility theory [19], and organizational justice theory [20] to provide a robust framework for understanding the dynamics of gender microaggressions. SIT helps us understand how microaggressions impact professional identity formation and the sense of belonging within the medical profession [20]. Intersectional invisibility theory, rooted in intersectionality, a term coined by Kimberlé Crenshaw [25], allows us to explore how overlapping identities—such as gender, race, and immigrant status to name a few—intersect to create unique experiences of marginalization for women, especially those from racial and ethnic minority groups [19]. Finally, organizational justice theory offers insights into how microaggressions shape female physicians’ perceptions of fairness and justice within their medical institutions, influencing their career progression, opportunities, and overall experiences within the medical field [20].

This multi-theoretical approach will provide a comprehensive view of the impact of gender microaggressions on female physicians, offering new perspectives on the intersectional nature of discrimination and its effects on professional identity and career satisfaction. Moreover, this study will contribute actionable insights into how institutional policies and organizational cultures can be reformed to foster a more inclusive, equitable, and supportive environment for all physicians [4].

2. Methods

2.1. Study Design

This research is part of a mixed-methods study aimed at exploring the experiences of female physicians with gender microaggressions. While the quantitative component of the study, which explored the prevalence and correlates of microaggressions, has already been published [4], the qualitative portion of this study will focus on the experiences of female physicians with microaggressions. The aim is to capture the lived experiences of women in academic medicine in order to understand the impact of microaggressions on their professional lives and provide recommendations for interventions to reduce these barriers.

2.2. Data Collection

A cross-sectional study design with a convergent parallel mixed methods approach was employed, combining both quantitative (QUAN) and qualitative (QUAL) data collected simultaneously [35,36,37,38]. This approach utilized a self-report questionnaire distributed via email with a link to an anonymous electronic survey in Research Electronic Data Capture (REDCap). The link was sent from residency and fellowship program directors to all female physicians across the largest not-for-profit healthcare system in New York State [4]. Additionally, survey links were also distributed via listserv (e.g., Department of Medicine). Two additional follow-up emails were sent, with the first follow-up email sent two weeks after the initial invitation to participate was sent. Participants who answered “yes” to the question “have you previously taken this survey” were automatically excluded from completing the survey [4]. We used the secure, HIPAA-compliant system REDCap to collect all consent and qualitative and quantitative data.

For the current study, we analyzed qualitative data from the self-reported questionnaire collected during December 2020–January 2021. The quantitative study employed a descriptive, cross-sectional design to assess the impact of microaggressions on employees and organizational outcomes such as imposter syndrome, patient care and safety, pay and promotion equity, counterproductive work behavior, and gender salience [4]. Quantitative measures used in this study included age, race, ethnicity, gender, level of training (e.g., resident), number of years after graduating from medical school, and main area of practice (e.g., internal medicine). Microaggressions were measured using the 25-item Gendered Racial Microaggressions Scale [39]. A sample item included “Assumed I did not have much to contribute to the conversation.” Response choices ranged from 0 (not at all stressful) to 5 (extremely stressful) for stressful items; frequency items ranged from 0 (never) to 5 (once a week or more); and experience items ranged from 1 = I did not experience this event to 5 = I experience this event 7 or more times. Imposter phenomenon was measured using the 20-item Clance Imposter Phenomenon Scale [40]. Sample items included “I am afraid people important to me may find out that I am not as capable as they think I am.” Response choices ranged from 1 = not true at all to 5 = very true. Identity Salience was measured using a modified version of the six-item Centrality subscale of the revised Multidimensional Inventory of Black Identity (MIBI-Regard) [41,42]. Sample items included “Being a woman is unimportant to my sense of what kind of person I am.” Response choices ranged from 1 = strongly agree to 7 = strongly disagree, and where necessary throughout the survey, the word Black/Black people was replaced with woman/women.

Counterproductive work behavior (CWB) was measured using the 10-item short version of the CWB Checklist (CWB-C) [43]. Sample items included “Insulted or made fun of someone at work.” The participants rated items on a 5-point Likert scale ranging from 1 = never to 5 = every day. Perceived pay equity and promotion was measured using three items that measured qualifications [44] (e.g., my salary is fair given my qualifications for my position), external equity (e.g., my salary is fair in relation to faculty with comparable qualifications at other institutions), and internal equity (e.g., my salary is fair in relation to all other faculty in my medical school). The participants rated items on a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree. Lastly, patient care practices were measured based on a 5-item patient care practices and attitudes scale [44]. Sample patient care practices item included “I did not fully discuss treatment option or answer a patient’s questions” and sample patient care attitudes was “I had little emotional reaction to the death of one of my patients”. The participants’ responses ranged from 1 (never) to 5 (several times a week), as well as a Not Applicable (N/A) option.

The qualitative study involved one open-ended question (If yes, please provide an example). The participants who answered yes to “have you experienced microaggressions” were then asked to provide an example [4]. The data for both the quantitative (QUAN) and qualitative (QUAL) components were analyzed separately, and the results were later combined. Quantitative demographic data, including age, training level, years since medical school, race, ethnicity, experience with microaggressions (yes/no), and specialty [4], were used to describe the sample and provide context for the qualitative findings, in line with the convergent parallel design approach [35,36,37].

2.3. Participants

Ethical approval was granted by the Northwell Health Institutional Review Board (#20-1152) and approved on 1 December 2020. Participants eligible for the study included residents, fellows, and/or attending physicians who self-identified as female physicians employed by or affiliated with the health system between December 2020 and January 2021 and able to electronically consent for participation. Residents, fellows, and or attending physicians who self-identified as male and individuals who were either unable to provide electronic consent or were not employed or affiliated during the specified time were excluded.

2.4. Data Analysis

In this study, an inductive thematic analysis [37] was used to analyze the examples provided in response to the open-ended question on microaggressions. Two of the authors (M.W. and O.A.) followed Braun and Clarke’s six-phase approach to thematic analysis [38] to refine and validate the themes. In Phase 1, the two researchers independently read through the examples several times to familiarize themselves with the data and understand the content and extent of experiences of microaggressions provided by female physicians. During Phase 2, they identified and documented patterns in the data and generated an initial set of codes based on the experiences of female physicians. This process was guided by the aim of the study. In Phase 3, these codes were grouped and organized into potential themes using Microsoft Excel. In Phase 4, the two researchers reviewed the themes collectively, and in Phase 5, they revised the themes when necessary to ensure coherence and alignment with the study’s specific objectives. When there were disagreements on themes, the rest of the team of researchers was brought in where necessary. Finally, in Phase 6, the wider team of authors reviewed the themes for overall alignment to ensure that all the themes accurately reflected the participants’ experiences and aligned with the study’s goals [38].

During the preparation of this manuscript, the authors used OpenAI’s GPT-4 model for the purposes of text editing (e.g., grammar, structure, and proofreading) to streamline the writing process. The authors have reviewed and edited the output and take full responsibility for the content of this publication. All data analysis and conclusions were independently generated and verified by the authors.

3. Results

3.1. Quantitative Results

A total of 159 female physicians responded to the survey, of whom 133 (84.6%) reported yes to experiencing microaggressions. Of the 133 who responded yes, 104 provided examples of their experiences with microaggressions. The majority of the respondents were white (47.6%), attending physicians (79.4%), aged 45 or younger (62.5%), and had completed medical school within the past 15 years (45.2%). While the quantitative results for the broader sample of female physicians have been reported [4], this analysis focuses on the data from the 133 female physicians who answered the open-ended question.

3.2. Qualitative Results

The experiences of microaggressions faced by the female physicians were categorized into four themes: (1) disregard for professional status, (2) undermining contributions, (3) intersectional experiences, (4) impact on career mobility and professional confidence. While the themes of disrespect, undermining, and intersectionality were significant, the participants also noted that institutional culture and leadership played a crucial role in either perpetuating or addressing these issues; as a result, we will also touch on what we saw emerging from the data in this regard.

3.2.1. Theme 1: Disregard for Professional Status

Most female physicians reported being mistaken for a nurse by other support staff, experiences which were more frequent during patient-facing interactions. These incidents highlight a systemic bias where women, especially in male-dominated spaces, have their professional authority questioned. Such incidents were also common even when the female physicians introduced themselves by their professional title of “Dr”, as indicated by one female physician:

“Being called the physical therapist/nurse/dietician despite introducing myself to the patient. Having the patient complain that no doctor has seen the patient for days.”

Such misattributions were not limited to patients; the female physicians also reported that colleagues, including male doctors and nurses, often referred to them by their first name while addressing male physicians as “Dr.”

“… Nurses who will call me by my first name but call every other attending Dr… I did not train with these nurses so it’s not like I knew them as a resident for them to call me by my first name, nor do I have a personal relationship with them, 2 of them just took it upon themselves to call me by my first name at work.”

Of note, such incidences were even more pronounced with male doctors present. Male physicians were more likely to be addressed as “Dr”, while female physicians would be addressed by their first name. For example, one female physician noted the following:

“When the nurse calls you by first name in front of the patient but your male colleagues get addressed as “doctor.” When you walk into a patient room and introduce yourself as a doctor, but they are on the phone and say, “hold on, the nurse just walked into the room.” When you walk into a patient room with the male medical student and the patient assumes that is the doctor. When your patient demands to see the doctor and you have to repeatedly say, “I am your doctor.” When you’re sitting in the ED writing a consult note and someone walks up to you and assumes you’re the nurse.”

3.2.2. Theme 2: Undermining Contributions

The female physicians also reported having their contributions and ideas dismissed or undermined. This could either happen by their ideas or comments being stated by male colleagues without being given credit, or their comments being dismissed during meetings. One leading female physician stated the following:

“I am a leader in a medical group. On numerous occasions I have explained something to the group only to have a male colleague restate everything I said exactly and then to have everyone respond to him.”

The female physicians often reported that credit for their work would automatically go to their male counterparts. As indicated by one participant,

“Multiple episodes of participating in meetings in which I make an observation or have a solution to a problem that is then repeated by a male colleague as if it was their original idea for which they then accept credit.”

There were multiple sources from which the female physicians reported being undermined, such as from nurses and patients who questioned their treatment plans. As per the experience of one female physician,

“Nurse talking over me to tell me plan of care for a patient she has not seen. Patient telling me I’m not qualified to take care of them. Consultant yelling at me to say I have mismanaged a patient because I called him late at night.”

Similarly, even while in seniority positions, the female physicians reported being undermined by those in less senior positions. One female physician recalled the following:

“In residency by a male medical student who insulted me publicly when I was teaching. As an attending by a male resident who insulted me on rounds not knowing I was an attending. He later apologized.”

There were also recollections of marginalization in decision-making, where female physicians are frequently excluded from meetings, and their input is disregarded or undervalued. For example,

“Having a male colleague continuously try to undermine my authority by excluding me from meetings or going around me to others”

The female physicians also reported that they did not notice such incidents of undermining occurring with male physicians, and that men were most likely to be the perpetrators of the majority of microaggressions. For example, one participant noted her observations by stating the following:

I will be the only person cut off while speaking, or a male colleague will respond to questions directed to me, during a meeting. These are noticeable as behaviors that these same individuals never do to other male colleagues in the room. People constantly “forget” when I am involved or even technically leading a given project or activity, and this only seems to happen with me who happens to be one of the few, or the only, female involved.

3.2.3. Theme 3: Intersectionality

Of note, the female physicians also reported frequently experiencing gendered microaggressions, with many describing comments and behaviors rooted in sexism. Such comments ranged from being called “sweetie,” “honey,” or “dear,” to comments about their husbands or questioning their career motivations because of family responsibilities. One participant indicated,

“Was asked why I was inquiring about a raise—doesn’t your husband make enough money?”

These gendered microaggressions, while painful on their own, became even more pronounced for women of color, particularly Black women and immigrant women, who face compounded challenges brought on by the intersections of their race and national origin. From an intersectionality standpoint, for women with multiple intersecting marginalized identities, the experience of microaggressions is influenced not only by gender but also by racial identity. Hence, female physicians with more than one marginalized identity are simultaneously navigating gendered and other identity-related biases, such as racialized biases in the workplace. One female physician shared the following:

“When giving clinical opinion, I am dismissed by body language, tone of voice, and glazing over of the eyes by (mostly) male attendings, residents, and sometimes male nurses. I don’t know if it’s because of my gender or race or both… but I don’t see this happening nearly as often with my white male counterparts.”

More specifically, there were examples of deeply ingrained racial and gender biases that directly impacted Black female physicians, as well as negative stereotypes and unfairly labeled generalizations about Black patients—such as being late or failing to show up for appointments—being told to Black female physicians that reinforced negative and harmful biases within the healthcare system. Black female physicians reported instances where their authority and expertise were disregarded, with patients and colleagues often assuming they were not the doctors. One poignant example of this is captured in the following quote:

“Patient requested a male doctor—did not want a Black female physician.”

Interestingly, since the data was collected during the COVID-19 pandemic, female physicians with a Chinese background reported being subjected to racially charged comments and questions regarding the COVID-19 virus. One female physician with a Chinese background recalled the following:

“I am often asked what race I am. When I respond Chinese, patients will often make remarks about China, or ask if I do certain Chinese cultural things in a very stereotypical manner. When COVID first appeared I felt that patients asked me often about how China was handling things as if I somehow knew more about those things than other Americans did.”

As mentioned earlier, when multiple intersecting identities are present, this compounds the experiences of microaggressions that go beyond individual biases. As aptly stated by one female physician with intersecting identities,

For example… 1. I would explain it; but you would not understand it… 2. I don’t understand a single word you are saying… (of course I have an accent) 3. Where did you learn English? 4. You are not Hispanic, are you?? (sarcastic tone),

Likewise, female physicians of immigrant backgrounds can also experience microaggressions on the basis of national origin. Such microaggressions can include, but are not limited to, the perceived legitimacy of their medical credentials in comparison with U.S.-trained counterparts; accent and language discrimination, despite being fluent in English; assumptions about cultural practices with comments such as “you must be traditional”; and being othered or treated as a foreigner. One physician from India shared an experience that underscores this:

“Had a new patient scheduled in the office with me who refused to continue the visit with me after finding out that I am Indian and went to medical school in India before moving to the US for residency.”

Additionally, age showed up as another intersecting identity that played a significant role in female physicians experiencing microaggressions. Older female physicians often faced dismissive remarks that infantilized their experiences. One older female physician recalled the following:

“I was told that the reason I was behaving the way I was because I “had empty nest syndrome and was menopausal.”

On the other hand, younger female physicians are often met with skepticism about their competence due to their age, as highlighted by comments said to one female physician:

“You look so young to be a doctor”, “Do you even know how to drive?”

3.2.4. Theme 4: Impact on Career Mobility and Professional Confidence

In addition to listing specific incidences of microaggressions, the participants also provided examples of how those microaggressions impacted their opportunities for professional advancement, such as being left out of committees, leadership development programs, and opportunities for learning and development. For female physicians with caregiving responsibilities, gendered career stagnation was particularly prevalent, as societal expectations and various institutional biases often link women’s professional trajectories and career progress to family responsibilities. One female physician shared the following:

“I was told that my career wasn’t progressing quickly because I am a mother and have young children.”

In addition, gendered expectations led to gender-based disparities in career advancement as well. Despite having similar workloads, qualifications, and seniority as their male counterparts, female physicians were not afforded the same opportunities and support, and at times had their professional needs and time deprioritized. According to one female physician,

“… Not being offered block time due to low case volume when my male partner was and had done equivalent amount of cases over the same time period—Having PAs instruct me to complete the pre-op paperwork on arrival to hospital, while they would arrive early for other surgeons—frequently being asked to modify my clinic schedule to make for other male physician requests for theirs—Having my clinic schedule more frequently disrupted with “X-ray maintenance” and office construction disruptions as I am less likely to complain.”

Moreover, female physicians were also actively excluded from key leadership positions and explicitly denied career advancement opportunities by their leaders. A lack of support from leadership stifles career growth, which in turn impacts the female physician’s self-esteem and sense of belonging in the organization. One female physician shared her experience when looking to advance in her role:

“Not being offered an opportunity to advance in my role as an attending physician by the department head, not being supported by the ancillary staff in my attempt to take on a leadership role.”

These experiences of being overlooked and deprioritized can have a significant emotional and professional toll, which can lead to a sense of professional stagnation as well as reinforce feelings of being undervalued despite working hard and being equally qualified. As a result, the participants reported a lack of confidence and motivation, and questioned their place as physicians. As explained by a female physician,

“I have mostly worked with men in the critical care arena, I have been demoralized and ridiculed for being female, having children, requesting alternate scheduling for childcare needs and ill family members, I was omitted for scholarly activities and salary increases (discovered by chance and after the fact). The list goes on and on. As the breadwinner for my family, I lived in fear of losing my job, and not being believed if I reported. Back then, you did not do such things.”

3.2.5. Emerging Theme 1: Leadership and Culture

Throughout the examples of microaggressions provided by the female physicians, one theme we saw emerge, though not central in the data, was leadership’s role in either perpetuating or addressing microaggressions, both through overt and subtle yet impactful behaviors that shaped the organizational culture. First, the female physicians provided examples of leadership ignoring or failing to accept and implement solutions they had provided to improve workplace issues. One female physician stated the following:

“Superiors ignoring any suggested changes to improve situations,”

There also appeared to be an “Old Boys Club” where the microaggressions were enacted by male leaders, but more specifically, there was gendered treatment by leadership where male physicians were often favored and treated with more respect than women. One female physician indicated the following:

“In my observation, my boss has always favored men in his work environment. Me being the only female, I felt like I was being treated differently. He would often have meetings with my male colleague and not me, whereas we simultaneously worked on the same project. When he is angry, he will slam any words on to you, and you just are supposed to take it with a grain of salt.”

In line with this, the female physicians also reported a lack of recognition for their hard work and skills as physicians, yet being praised for more gender-stereotypical skills in the workplace, such as planning and organizing office events. For example,

“When I saw the head of my department in the elevator (who I don’t see often) after a seminar he didn’t ask me how my work was going or what I thought of the seminar but instead asked what I had organized for the seminar speaker lunch.”

While such microaggressions were overt, there were also subtle examples of microaggressions that reinforce gender stereotypes and the roles and priorities of female physicians. One female physician recalled being told the following:

“When I was a resident the surgical chief told me to go back to the kitchen when he didn’t like my reading” or “Was asked why I was inquiring about a raise—doesn’t your husband make enough money?”

Lastly, the female physicians also reported their authority and credibility being heavily undermined by senior individuals as it relates to making clinical decisions around patient care. One female physician recalled the following:

“An older caucasian male surgeon from XXX refused to speak with me regarding a patient I had seen in consultation and wished only to speak to my older male colleague who had not seen the patient nor reviewed the case. He was told I had seen the patient by my staff and they offered to connect him to me. He did not care about my opinion and only cared what the older male surgeon had to say. (this happened 2 years ago) The head of the surgery department told me and my female partner we should act like the wives of the current division director in my department to help him be a leader.”

3.3. Integration of Quantitative and Qualitative Results

In our qualitative study, 84% of the female physicians reported having experienced microaggressions in the workplace. More specifically, within the past 6 months, the female physicians reported being unable to contribute to workplace conversations and feeling unheard [4]. Additionally, we also found that the female physicians who reported experiencing microaggressions also reported lower perceptions of pay and promotion equity. Of note, this reflects aspects of our themes captured in the qualitative data.

The female physicians reported experiencing microaggressions that resulted in them being undermined, left out of key decision-making processes, and passed over for promotions despite holding the same qualifications, level of experience, and at times, higher credentials than their male counterparts. Our quantitative results did not fully describe the array of microaggressions experienced by female physicians, nor did they describe the sources of those microaggressions, as well as the culture, all of which were uncovered upon further analysis in our qualitative results.

4. Discussion

This study used a mixed methods approach to gain a comprehensive understanding of the experiences and impact of microaggressions faced by female physicians. Our qualitative data gave us a much richer understanding of these experiences and how they may contribute to the challenges related to career advancement, professional identity, and belonging in healthcare settings for female physicians. Taken together, our results indicate that both overt and covert microaggressions continue to reinforce systemic gender inequalities that contribute negatively to the professional experiences of female physicians, a situation that is exacerbated for those with marginalized intersecting identities. The results are more comprehensively understood through the lens of three theoretical frameworks, all of which offer possible explanations that bolster our quantitative data.

Proponents of SIT posit that individuals perceive themselves as belonging to in-groups with others who share similar identities, rather than out-groups. Members of an in-group have a mental representation of a typical group member and tend to have more positive interactions with in-group members compared to out-group members [18]. Similarly, under the umbrella of SIT, individuals categorize others according to their social identity (e.g., race, gender, and profession) based on what social norms have historically considered prototypical [18,45]. In the case of physicians, the prototypical group member is an older white male. As a result, previous research has shown that individuals tend to engage in discriminatory behaviors such as microaggressions because of their in-group biases [18,33,34]. In the current study, SIT explains why female physicians often report being mistaken for non-doctor roles (e.g., nurses and janitors) by their peers, leaders, and patients while also being excluded from the decision-making process and career advancement opportunities, and having their contributions dismissed.

Our results are consistent with other studies that show that female physicians experience microaggressions because they do not belong to the “in-group” in such a male-dominated field like medicine [24,28,30]. Moreover, research shows that the perception of female physicians as the out-group leads to cognitive biases and perpetuates the idea that female physicians do not belong in positions of authority, thereby limiting their professional identity and opportunities for upward mobility [22,23,26]. This also reflects a larger power dynamic within the medical field where male physicians are the ones who dominate leadership positions, further marginalizing female physicians. A recent paper examining trends in senior leadership within medical societies found that between 1974 and 2023, women represented only 4% of professional society presidents in medicine. However, there has been a 32% increase in female representation over the past decade [39]. Data from AAMC show that as of 2022, female physicians were 38% of the physician population, but only 19% held key leadership positions in hospitals [46,47]. Consequently, misidentifying female physicians and undermining their authority diminishes their professional identity, which contributes to their marginalization and sense of belonging within the medical profession. Not surprisingly, our quantitative data indicated that microaggressions increased the risk of imposter phenomenon in female physicians, with at least 38.7% of the respondents reporting that they felt unable to contribute to conversations in the workplace [4].

Notably, female physicians with multiple intersecting identities reported unique forms of microaggressions that are compounded as a result and not fully captured by those with a single marginalized identity. For example, several female physicians reported experiencing microaggressions based on their accent, national origin, and race. More specifically, one female physician of Chinese descent reported being treated with less respect and encountering harmful comments around the COVID-19 virus. This may be because of intersectional invisibility, which states that female physicians who do not look like the prototypical physicians, both in terms of race (white) and gender (male), are rendered invisible and overlooked in the workplace [19,48,49]. Of note, while many females experience microaggressions at some point in their career, white female physicians (the majority of our sample, which was consistent with the physician racial makeup) reported experiencing microaggressions that were typically related to gender (e.g., mistaken for a nurse, told to go back in the kitchen). However, for female physicians of color, the added identity of race and immigration status introduced more nuanced experiences of microaggressions that were compounded because of race, gender, and national origin biases [19].

This point underscores the need for more tailored interventions that are rooted in intersectionality, not simply gender. Research on diversity interventions found that they are ineffective because they fail to consider intra-group differences among women. More specifically, Wong et al. (2022) found that at least 90% of organizations’ diversity interventions focused on agency, a concept that was of priority to white women [50]. Furthermore, organizations broadly mentioned marginalized groups and rarely mentioned intersectionality, indicating a one-size-fits-all approach to solutions around the negative experiences of women in the workplace [50]. Tailoring interventions to target the specific needs of female physicians with intersecting identities can help create more inclusive environments where every physician, regardless of their background, can thrive [22,48,49,50].

Another theme that emerged was the impact of microaggressions on the career advancement of female physicians. Some of the most noticeable examples provided were being passed on for opportunities of advancement, “Old Boys Club”, and a lack of credit/recognition of ideas. We also found that the participants in our study perceived unfairness in decision-making processes, outcome distribution (e.g., pay and promotion), and interpersonal relationships (e.g., male physicians were treated better). Similarly, the findings from our qualitative data revealed similar patterns, in that female physicians who experience microaggressions reported lower levels of pay and promotion equity [4]. The experiences of female physicians in this study align with the components of organizational justice. They perceived that opportunities to advance, be treated fairly, and be recognized for being a physician were unfairly influenced by gendered microaggressions and biases.

Throughout the examples provided, female physicians reported not being offered the same opportunities for respect, access to senior leaders, accountability, and recognition as their male counterparts, despite being equally or more qualified. Furthermore, there were reports of a lack of leadership and organizational support in addressing microaggressions, some of which were perpetuated by senior leaders. Such inaction and lack of accountability further exacerbate perceptions of unfairness in the workplace [31,32,33]. According to Greenberg [20], inaction on the part of leadership creates a sense of procedural injustice. Female physicians perceive inequities in the processes by which outcomes and rewards are distributed. Our results were consistent with previous studies in healthcare settings, which show specific demographic factors (e.g., race and gender) influence perceptions of organizational justice among different populations of healthcare professionals (e.g., male vs. female physicians or physicians vs. nurses) [32,33,37]. Female physicians were more likely to perceive unfairness in systems related to opportunities for mentorship/sponsorship, recognition, pay, access to leadership, flexible work schedules, and the adoption of suggestions for improvement [27,32,33].

In their view such systems are inherently biased and continue to perpetuate gender-based inequities [27,30,51]. Consequently, when healthcare institutions fail to address such inequities and support female physicians, they contribute to their marginalization. Ultimately, female physicians do not feel protected, valued, seen, or that they belong, which undermines their trust in the systems and policies of the organization to be fair. Moreover, this leads to lower job satisfaction, decreased career progression, and high levels of burnout [9,24,26].

Our study has important implications for both practice and future research. First, as medicine moves towards gender parity, it is imperative that healthcare institutions recognize and address the significant role of microaggressions in the professional experiences of female physicians. As mentioned earlier, it is important for diversity initiatives aimed at women to be viewed from an intersectionality lens to address the nuanced and often exacerbated experiences with microaggressions of female physicians of color in the workplace. As we saw from the study, perceptions of procedural injustice are prevalent and rooted in the fabric of the policies and systems of healthcare. It is, therefore, necessary that healthcare institutions actively work to address those system issues through policy changes, training, and leadership development opportunities [10,27,31,49]. Healthcare institutions are tasked with ensuring that all physicians, regardless of their race or gender, receive equitable treatment and have access to the same opportunities that are necessary for career advancement. This is essential in fostering a more inclusive and supportive environment for both physicians and patients [10,24,52].

Second, future research should explore longitudinal studies that examine the prolonged impact of microaggressions on the long-term career trajectory and professional identities of female physicians over time. This research should also take into consideration the leaky pipeline in turnover intentions of female physicians as it relates to their experiences with microaggressions in the workplace. There has been a call for more research to explore intersectional invisibility and how historically marginalized identities create unique challenges for female physicians across diverse specialties and career stages [19,49,50]. Such research will further deepen our understanding of the impact of these complex dynamics and the nuances of microaggressions on the professional outcomes of female physicians with intersecting identities.

5. Limitations

Our study is not without limitations. First, our study primarily focused on the experiences of female physicians within a single healthcare system. This may have introduced selection bias as well as limited generalizability, and may not fully represent the diverse experience across different medical fields and specialties. Future research should ensure equal representation across specialties and geographic regions. Second, while intersectionality did show up as a theme in our results, the sample was predominantly white and included female physicians from specific ethnic backgrounds. As a result, we were limited in the diversity of intersectional identities examined (e.g., LGBTQIA+, religion, neurodiversity, etc.) [19,25,48,50,53]. Also, this study did not account for the identity of being a caregiver, which can limit productivity and opportunities for leadership. Future research should ensure a more representative sample to capture the nuanced experiences of historically marginalized and often overlooked populations [19,25,48,53]. Fourth, we used a cross-sectional design, which hindered our ability to establish causal relationships [4]. While our qualitative study did show significant correlational relationships, the direction of these relationships cannot be definitively determined. Furthermore, data was collected during the COVID-19 pandemic, which can influence the experiences of microaggressions in a unique way (e.g., the experience of the female physician of Chinese descent) and introduce historical effects. As stated earlier, future research should explore longitudinal as well as experimental research to determine causal relationships.

6. Conclusions

This study adds to a growing body of literature on the experiences of female physicians with microaggressions in healthcare settings. The study highlighted the very nuanced and exacerbated effects of microaggressions on female physicians with intersecting marginalized identities (e.g., race, gender, national origin, and age). By exploring the results through the lens of three theoretical frameworks (SIT, organizational justice, and intersectional invisibility), we aimed to gain a more comprehensive understanding of how microaggressions shape the career progression, professional identity, and overall perceptions of female physicians. The results from the study underscore the dire need for addressing systemic gendered inequities within healthcare institutions and the need to revamp and implement fair policies and procedures to ensure equality, equity, inclusion, access, and belonging for all physicians regardless of their background. Such an effort is needed not only to ensure that physicians thrive within their working environment but that patients receive the best care.