Zoe Stewart: Crisis of confidence

FEMALE medical students are less confident than their male counterparts, yet they are more competent, according to recent research.

The authors of the research, published in a letter to the Annals of Internal Medicine, analysed the responses of 1021 medical students who were asked to rate their confidence level before answering 50 questions on a mobile web-based medical education platform. Female students were less likely to say they were sure of an answer, yet more likely to answer the questions correctly, even when they were unsure.

Sadly, these results are not surprising and certainly not unique. Women quite consistently lack confidence, even when their performance is equal to, or better than, that of men.

In fact, one study found that confidence was inversely proportional to competence — the higher a person’s confidence in their ability to perform a simple surgical task, the lower the standard to which they were likely to perform it. Those with higher confidence levels tended to be men.

Outside of medicine, the story is the same. The term “confidence gap” has even been coined to describe the relatively consistent difference in self-assuredness between the sexes.

Of course, men are not always self-assured and I have many male colleagues with poor self-confidence. However, broadly speaking, men tend to be more confident than women.

People often adjust their self-confidence according to the expectations placed on them. If women are expected to be less competent leaders, professionals or doctors, they will tend to have less confidence in their abilities in these areas.

Naturally, patients — and, indeed, allied health staff, nurses, medical students, and other doctors — are likely to have more faith in a doctor who seems confident in their decisions. These doctors are, in turn, likely to receive a confidence boost from such positive feedback, while negative feedback can have the opposite effect. Hence initial differences are intensified.

These feedback loops partly help to explain why differences between men’s and women’s experiences can be so difficult to change.

There is a multitude of factors contributing to the confidence gap. Just a couple of months ago, there was a major media focus on sexual harassment in the medical profession, and rightly so. The plethora of stories that emerged from female doctors about harassment and bullying provides a small insight into this pervasive problem within the culture of our profession.

However, more subtle differences in expectations can have just as powerful an effect on women’s confidence in the workplace.

As a female doctor I am expected to be kinder to and better at communicating with patients. Nurses will be less intimidated by me and will therefore interact differently with me than with my male counterparts — they will be less likely to defer to me in the decision-making process.

Patients and colleagues think I would make a great paediatrician or GP but not as good a professor or surgeon. I am likely to earn a lot less than my male colleagues.

All of these expectations will take a toll on my confidence and make it more likely that I will fulfil the low expectations that have been laid out for me.

Clearly, stereotypes and expectations do not just influence women. Members of any social minority will experience a variation of this.

Medical student Hui Ling Yeoh recently wrote about the assumptions made about her as a result of her Asian heritage.

Stereotype threat is real. People do not want to confirm negative stereotypes associated with their race or sex, so they second-guess themselves and their confidence drops.

To truly combat these problems, we need significant sociocultural shifts. We need to change assumptions that form from inaccurate stereotypes and educate future generations to look beyond gender, race, religion, sexual orientation, or any other label, and to make judgements of people’s character and ability based on behaviour and performance. Although ambitious, this seems to me the only way to truly close the confidence gap.

Until then, perhaps we should follow the suggestion of the authors of the Annals of Internal Medicine study to promote a medical education system that results in more accurate alignment between self-confidence and performance.

We should strive for income equality and an equal balance of women and men in senior clinical, academic and management positions in all medical and surgical specialities.

In this way, we can make it clear that female and male medical students and doctors are equally competent.
 

Dr Zoe Stewart is an Australian junior doctor and a clinical research fellow in metabolic medicine at the University of Cambridge. She has an interest in medical research and its translation into policy and clinical practice and is supported by the Gates Cambridge Trust and Jean Hailes for Women’s Health.