Speaker Introductions at Grand Rounds: Differences in Formality of Address by Gender and Specialty

Introduction

The representation of women in academia and in medicine has steadily increased over time, with the representation of women as authors of original research significantly higher in recent years than decades ago. ^1,2 However, gender biases still exist in society and within medicine specifically, as comprehensively detailed in repeated reports of the National Academies. ^3,4 The bias that has been convincingly demonstrated in experimental study designs ^5,6 may influence the outcomes of unblinded review of grants ^7,8 and publications, ⁹ and ultimately is likely to explain at least in part the persistent observations of inequitable pay for women ^{10 –12} and their underrepresentation in the most senior positions of academic medicine. ^{13 –16}

Recent attention has focused on how bias can manifest insidiously even at the level of forms of address used in professional settings. Previous work has shown that women are not only less likely to be invited as grand rounds speakers ^17,18 but also less likely to be introduced by their formal titles when invited to deliver grand rounds in medicine at a prominent institution. ¹⁹ This is important because the systematic use of less formal forms of address for women in academic medicine reinforces stereotypes of women having lower status and expertise in ways that can influence the perceptions of the audience.

Moreover, the same study by Files et al. showed that women serving as introducers use formal titles almost exclusively, regardless of speaker gender, so the difference observed is likely related primarily to differences in the behaviors of male introducers. ¹⁹ Other studies have focused on introductions at major professional society meetings. Analyses of annual meeting introductions in the fields of oncology ²⁰ and colorectal surgery ²¹ have also suggested that the gender of both speaker and introducer are associated with formality of introduction. By contrast, analyses of radiation oncology ²² and urology ²³ annual meetings suggested that differences were limited to introducer gender, with women favoring greater formality, and a study of a surgical oncology meeting detected no gender differences at all. ²⁴ Culture—specifically the customs and social norms of professionals—may differ across specialties. Additional research is needed to reconcile and synthesize these observations. Given possible differences in culture and women's representation at different academic institutions and across different medical specialties, we sought to build on this work by investigating speaker introductions in the grand rounds of five departments at a single large Midwestern academic center.

Materials and Methods

Results

A total of 922 grand rounds recordings were reviewed, of which 615 were eligible for analysis. Recordings were excluded from the analysis due to the lack of available videos (n = 54), audio difficulties (n = 109), lack of an introduction included in the recording (n = 121), or lack of a doctorate degree for the speaker (n = 23); Supplementary Table S1 provides their distribution by department. Of the 615 eligible videos, 89 were from family medicine (14.5%), 66 from general surgery (10.7%), 235 from internal medicine (38.2%), 75 from obstetrics (12.2%), and 150 from pediatrics (24.4%).

As detailed in Table 1, 162 of the introducers were female (26.3%) and 297 of the speakers were female (48.3%). Speakers were largely internal to the institution, with 70.4% (n = 433) from within the university. Most speakers had MD or equivalent degrees only (80.3%, n = 494), 11.2% (n = 69) had MD or equivalent degrees and another doctorate, and 8.5% (n = 52) had a non-MD doctorate only. The mean H-index of invited speakers was 21.5 (standard deviation: 24.5, range: 0–141). The most common academic rank was full professor (34.5%, n = 212). Gender of the total faculty by academic rank and overall in the five departments is available in Supplementary Table S2.

Overall, speakers were introduced professionally in 56.3% (n = 346) of grand rounds presentations: 59.3% (n = 176) for female speakers versus 53.5% (n = 170, p = 0.17) for male speakers. The proportion of professional introductions was higher for women introducing women (67.7%, n = 69) and women introducing men (73.3%, n = 44) and lower for men introducing women (54.9%, n = 107) and men introducing men (48.8%, n = 126; Table 2). Women were more likely to introduce speakers professionally than men introducing men (odds ratio [OR]: 2.67, p = 0.003, for women introducing women, and OR: 2.76, p = 0.006, for women introducing men, both compared with men introducing men). Men were not more likely to use professional introduction for one gender over another (men introducing women vs. men introducing men, OR: 1.28, p = 0.28).

Use of formal introduction varied by specialty, with the rate of professional introductions higher than average for family medicine (83.2%, n = 74), general surgery (75.8%, n = 50), and pediatrics (64.0%, n = 96). The percentage of professional introduction was lower than average for internal medicine (37.5%, n = 88) and obstetrics and gynecology (50.7%, n = 38; Table 1).

Bivariable analyses investigating first professional introduction are presented in Supplementary Table S3. On multivariable analysis, female introducers were more likely to introduce speakers professionally (OR: 2.52, p < 0.001). Department was significantly associated with the use of formal introduction, as speakers giving grand rounds in the departments of family medicine, general surgery, or pediatrics were more likely to be introduced professionally compared with internal medicine (OR: 12.79, p < 0.001; OR: 8.83, p < 0.001; OR: 2.02, p = 0.007, respectively). Higher academic rank of the speaker was associated with more formal introduction (group p = 0.02). A statistically significant interaction existed between speaker's gender and externality of the speaker (p = 0.003). External female speakers were less likely (OR: 0.49), and internal female speakers were more likely (OR: 1.75), to be introduced professionally compared with external and internal male speakers, respectively (Fig. 1; Supplementary Table S4). A secondary analysis assessing the use of a professional title at any point in the introduction was performed and was consistent with the previous analysis (Supplementary Table S5).

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FIG. 1.

Forest plot of multivariable analysis for factors related to first professional introduction. This figure depicts the associations observed in a multivariable logistic regression model of use of a professional title at time of first introduction of speakers presenting in 615 grand rounds in five departments at an academic medical center in the United States between 2014 and 2019.

Discussion

This study builds on existing research studying the formality of speaker introductions by gender in academic medicine. In our analysis of grand rounds speaker introductions in the five largest departments at an academic teaching hospital, we found significant differences in professional introduction by introducer gender and department. We also found a significant interaction between speaker gender and whether the speaker was internal or external to the institution. Female speakers external to the institution were less likely to be introduced professionally than male external speakers, but female speakers internal to the institution were more likely to be introduced professionally than male internal speakers. The reasons for this interesting finding in this study, which is the first to our knowledge to have evaluated this possibility, merit further reflection.

Files et al. previously conducted a rigorous evaluation of forms of address in 124 internal medicine grand rounds conducted in 2012–2014 at the Mayo Clinic that first documented gender differences in speaker introductions in academic medicine. ¹⁹ The most striking finding of their study was that women speakers were substantially less likely to be introduced by their professional titles. This was driven by low rates of use of titles when their introducers were men (49.2%) compared with 72.4% use of formal titles when men introduced men. As in the present study, female introducers in the Mayo Clinic study were overall more likely to use professional titles as the first form of address compared with male introducers (96.2% vs. 65.6%; p < 0.001).

Of note, several more recent studies have considered introductions at national specialty society meetings. Two studies have yielded results consistent with the study of Files et al. Duma et al. analyzed 781 videos from the 2017 and 2018 annual meetings of the American Society of Clinical Oncology and found that 62% of female speakers received a professional form of address versus 81% of male speakers (p < 0.001). ²⁰ They also documented a significant interaction between speaker and introducer gender, with the difference again driven by differences in the behavior of male introducers, who used a professional form of address 53% of the time when introducing female speakers versus 80% of the time when introducing male speakers. Similarly, Davids et al. evaluated speakers and moderators of the formal program from the 2017 annual meeting of the American Society of Colon and Rectal Surgeons and also found female moderators to be more likely than male moderators to use formal introductions (68.7% vs. 54.0%; p = 0.02) and male moderators to be less likely to formally introduce a female speaker versus a male speaker (36.4% vs. 59.2%; p = 0.003) in the 47 sessions they evaluated. ²¹ More recent single-specialty analyses have also shown that women are more likely to use professional address, for example, in radiation oncology ²² and urology, ²³ although differences by speaker gender were not observed in those studies. One single-specialty analysis of surgical oncologists showed no difference in introduction by gender, ²⁴ although it did detect differences by seniority of both the introducer and the speaker.

Interestingly, in the current study, which focused on institutional grand rounds like Files et al. but in multiple specialties, there was no difference in the likelihood of professional introduction by speaker gender overall. However, a significant interaction existed, whereby there was indeed an effect of speaker gender on professional introduction that differed in direction depending on whether the speaker was internal or external to the institution. It is unknown whether the speakers invited to those grand rounds talks at the Mayo Clinic in the study by Files et al. were primarily internal or external; it is possible that a greater proportion of the speakers at that institution were external to the institution and that might explain the differences seen in the current study and the Files et al.'s study. Specifically, a higher proportion of external speakers may result in the overall observation of greater use of professional introduction for male speakers than female speakers.

Another key contribution of the present study is the observation of large differences in the use of professional address during introductions across departments. Introductions in the Department of Family Medicine, for example, had nearly 13 times the odds of using a professional title as an introduction in the Department of Internal Medicine. Differing norms across different departments are likely reflective of specialty-specific differences in culture that are consistent with the differences observed in the various single-specialty studies of annual meeting introductions. These specialty-specific differences in culture are then, of course, shaped by the larger institution in which each is housed. Understanding the elements of culture that lead to varying behaviors, which have a disproportionate impact on one gender, may provide further insight into modifiable factors that may help to eliminate subtle biases. For example, specialties with higher numbers of women faculty (such as obstetrics and gynecology) may have differing norms. Additional research to elucidate the specific aspects of culture in different departments that could help address disparities is needed. Such studies should utilize validated measures to assess whether a department's culture is conducive to women's success. ²⁵

Similar to prior work, we observed gender differences in behavior on the part of introducers, with female introducers more likely to introduce all speakers professionally. Although some might believe that women's tendency to utilize formal titles when introducing others relates to the typically more junior standing of women faculty compared with men, ²⁶ we believe that it may also reflect their “out-group” status in academic medicine. This concept refers to the perception of women as not being members of an insider group of privileged individuals, usually white men, holding greater power and status. ²⁷ Given the importance of professional titles in medicine for conveying both authority and expertise, when external female speakers are introduced less formally than their male peers, they may be perceived as less competent, ²⁸ and gender stereotypes, bias, ²⁹ and discrimination may all be reinforced by this behavior in a vicious cycle. When internal female speakers are introduced formally, this may be a pernicious sign that they are less well integrated into the culture of a department, ³⁰ although it could also potentially represent an institution's efforts to ensure respectful treatment of women in medicine. Therefore, an important direction for further research is to obtain a deeper understanding of what features, actions, and policies can create a culture truly conducive to women's academic success. Ultimately, it is critical to identify best practices to eliminate the association between speaker gender and formality of introduction, as deviations in either direction may be signs of bias.

This work builds on important prior studies that have assessed the use of formal address in introductions and yields insights to guide efforts to address gender inequity in academia. Female faculty continue to hold only a minority of influential positions across medicine, such as serving as authors, ^{1,2,31 –33} leaders of medical specialty societies, ²⁶ speakers at professional conferences, award recipients, ^{34 –36} and editorial board members. ³⁷ The systematic gender differences in formality of address documented in this study and others indicate that these disparities may develop, in part, due to unconscious bias and the ongoing marginalization of women within the culture of the field. Future work on best practices in individual specialties, implementation of formal procedures for selection of speakers and introducers alike, guidelines to promote the consistent introduction of speakers, ³⁸ mitigation of unconscious bias, ³⁹ and wider initiatives to promote women into leadership positions are needed as a comprehensive approach to promote gender equity. ⁴⁰ Guidelines specific to grand rounds might promote universal use of professional address, as well as other items beyond the scope of the current study, such as uniform descriptions of speakers' backgrounds, requesting that speakers offer small introductions that highlight past research, and guides for respectful methods for audience members to ask questions.

Limitations of this study include its single-institution retrospective nature. There was limited information on the introducer as the introducer rarely self-identified during the introduction process, and information about repetition of introducer (e.g., the same person introducing multiple speakers) could not reliably be analyzed. Due to the lack of information about introducer identity, there was an inability to discern pre-existing relationships between the introducer and speaker or to cluster analyses if a single individual introduced more than one of the speakers. As there may be greater informality with greater familiarity, and understanding whether familiarity between introducer and speaker mediated some of the gender differences observed would be illuminating if possible in future studies. Gender was assigned by the authors as a binary variable in this study and thus might in some cases have been misassigned and did not account for individuals with nonbinary gender; the experiences of nonbinary individuals are a particularly important subject for future research using alternative designs. The study design also limited the ability to investigate other important questions that should be the subject of future research. For example, although we observed no clear patterns with respect to the proportion of women faculty in a department and the formality of introductions in that department in the five departments we studied, future research with different methods may help to explore that question better than the current study could. Additionally, there are no institution-wide established policies for selection and introduction of speakers, and thus differing department norms may influence the results of this study. Strengths of this study include its large size and inclusion of a diverse set of specialties, as well as analysis of the interaction between the speaker's institutional affiliation and gender in determining formality of introduction.

Conclusions

At one large Midwestern academic medical center, women remain more likely to use professional address when introducing grand rounds speakers compared with men, and female external speakers were less likely to be introduced formally than male external speakers. The novel finding that the formality of introduction varied in the opposite direction when speakers were internal, and the large variations in the use of professional address by specialty detected in the present study should motivate further research to identify ways to level the playing field and ensure environments conducive to the success, inclusion, and respect of men and women alike in academic medicine.