New research from Professor Melissa Williams demonstrates how the consistent questioning female surgeons face to their authority increases burnout—and how this could carry over into other male-dominated professions.
When it comes to unhealthy hierarchies in the workplace, almost everyone has a horror story—in some cases, several.
Researchers have long sought to quantify the ways in which power disparities have a profound effect on productivity and worker wellbeing. Professor of Organization & Management Melissa Williams specializes in examining some of those dysfunctional dynamics through the lens of social identity—and gender identity, in particular.
“I’ve long been interested in how the day-to-day or hour-by-hour of women’s and men’s workplace experiences might differ,” says Williams.
But the origin and maintenance of unhealthy workplace hierarchies can be subtle and nuanced.
“As researchers, we tend to get access to workplace experiences only from the outside or in the aggregate, such as looking at turnover numbers or salary data. Workplace dynamics or interpersonal interactions at work are harder to capture.” In other words, it’s often the small, private interactions that fly under the radar of appropriate but nevertheless wear workers down— a kind of war of attrition that is not always perceptible to the outsider, or even to the victim.
What Williams needed was access to such an environment—a traditionally male-dominated environment in which women are abandoning the prestigious and important posts they worked so hard to earn in the first place.
Dissecting the Dynamics of the Operating Room
In a chance conversation with Amy Chen MD 23EMBA, then a cancer surgeon at Emory’s Winship Cancer Center, Williams found the opportunity she’d been looking for. Chen and Williams had already been in one another’s orbit through shared colleagues and collaborators when they landed on the topic of women in surgery.
“Amy and I talked a lot about how surgery differs from other fields, including other fields of medicine,” says Williams. “Many areas of medicine have come close to achieving gender equality, and there are now slightly more women than men who graduate from medical school in the U.S. But surgery remains quite male-dominated and culturally hierarchical.”
Why is this? There is no simple, singular answer.
Compared to many other medical fields, the operating room is a crucible. It requires several people with different roles and hierarchical positions; when a matter of seconds could determine life or death outcomes, keeping roles and hierarchy clearly defined and rigid is needed to save time and keep operations efficient.
“The Operating Room is a high stakes environment with lots of personalities and egos,” Chen confirms. “The responsibility of the patient resides with the surgeon in most situations, and thus there is a lot of pressure on the surgeon.”
It’s not hard to see how such an environment could exacerbate power dynamics that already exist outside the operating room.
At least part of the reason could be reputation: the numbers show that surgery has historically been dominated by men, and being perceived as a male-dominated field may be enough to deter some women from pursuing the calling to begin with. Beyond recruitment, however, attrition in female surgery residents is far higher. There are fewer female mentors available to them, and some hypothesize that surgery’s uniquely demanding, unpredictable conditions punish women – who may be more likely to require flexibility for care-taking responsibilities outside of paid work – more than men. In addition, many medical fields have been facing attrition in recent years as resources dwindle and demands on medical practitioners compound.
And yet Williams wondered: How much of the reason is due simply to discrimination?
Chen was no stranger to the unique hostilities women face in the operating room.
“I could write volumes on what I’ve endured,” says Chen. And while she’d held her own through those trials, she bemoaned the loss of many of her female colleagues.
“I’ve watched talented women reconsider surgery or medicine because the narrative about their performance—or their behavior—gets warped and used against them.”
Amy Chen MD 23EMBA
Chen wanted a way to quantify those experiences and understand them in context. And ultimately, she wanted a way to staunch the bleed of female talent.
“She asked how we can foster a better workplace climate so that women stay and become leaders and mentors in the surgical field,” says Williams.
“Melissa brings a lot of methodological rigor,” says Chen. “And I’d like to think that I bring the ‘real world’ vibe. I share my perspective on what is feasible to do on the project since I am a surgeon, and have been a surgeon in training.”
With the help of fellow researchers including Brandion Esianor, then a surgical resident at Vanderbilt and former Goizueta PhD student Sara Hendrick—as well as many additional surgeons at their four study sites—the pair got to work.
Catching Bias in the Act
The challenge for Williams and Chen was methodological as much as conceptual. If the researchers simply asked female surgeons whether they had experienced sexism, they would run directly into the ambiguity they were trying to understand.
“We are now in a time in which explicit workplace discrimination, whether based on gender or race or another identity, is largely both illegal and socially taboo. But that doesn’t mean these issues have gone away completely—they’ve just become more subtle and perhaps less conscious.”
A patient who assumes a female physician is a nurse, for example, may be expressing a gender stereotype. Or the patient may simply be confused. A staff member who questions a surgeon’s order may be reacting to her gender—or may have a perfectly legitimate medical concern. Even the person on the receiving end may not know which explanation is correct.
“The challenge for women and people of color is that many workplace situations are very ambiguous with regard to their underlying meaning,” says Williams. “People ask themselves, ‘Did they say that because I’m a woman?’ or, ‘Did that happen because I’m Black?’ But the reality is that a person almost never knows for sure. And they have to continue to go through their work day and continue to work with the same coworkers and clients, without being sure. Instead it might come back to them at 2 o’clock in the morning and keep them up for a while. I think it’s that rumination, that uncertainty, that constant trying to figure it out and decide whether to respond or how to respond that is ultimately so draining.”
“If it’s clear that someone in your work life is explicitly sexist or racist, there may be direct avenues to address it with your employer. But when it’s ambiguous, it’s not clear what can be done.”
Melissa Williams, Professor of Organization & Management
So the researchers deliberately avoided asking participants whether they had experienced discrimination.
“We never mentioned discrimination at all,” Williams says. Instead, the team asked surgeons whether specific things had happened to them during the previous week.
That distinction was crucial. Rather than requiring surgeons to interpret an interaction—to decide, in the moment or after the fact, whether someone had been sexist—the researchers could compare the experiences reported by men and women and look for patterns across hundreds of participants. The study followed surgical residents and fellows at four major U.S. academic medical centers. A total of 329 surgeons completed the initial survey; 323 went on to complete at least one weekly report. Fifty-three percent of participants were women, and their average age was about 30.
At the beginning of the project, participants completed a survey measuring factors including burnout, their sense of professional efficacy and their intentions to remain in medicine and surgery. Roughly five months later, researchers measured those outcomes again.
In between came the heart of the study.
For 13 weeks, participants received a text message every Friday asking about their experiences at work that week. The surveys focused on four categories the researchers believed could reveal subtle differences in how male and female surgeons were treated: challenges to their professional role, questioning of their authority, encouragement and positive feedback, and assumptions that they would perform helpful tasks outside their formal role.
A role challenge might mean someone expressed surprise that the participant was a surgeon or mistook the surgeon for someone in a lower-status position. Authority questioning included experiences such as having someone question a medical decision, doubt the surgeon’s expertise or fail to promptly carry out an order.
For one randomly selected event, participants also described who had initiated the interaction and how positive or negative the experience had been.
The design gave Williams something that much of the previous research on workplace discrimination lacked: repeated observations gathered close to when events actually occurred. Instead of asking someone to summarize a year—or an entire career—of workplace experiences from memory, the researchers were sampling those experiences week by week.
More importantly, the surveys did not force participants to assign a motive to what had happened.
“They weren’t being asked to decide whether gender caused their experiences or not,” Williams says. “As researchers, we are able to investigate whether gender is related to the frequency of authority-questioning experiences, because we can look at the data in aggregate.”
Death by a Thousand Doubts
A pattern quickly emerged.
Female surgeons experienced significantly more challenges to their professional role than male surgeons did. They were also significantly more likely to report having their authority or expertise questioned. The difference in role challenges was particularly pronounced: women reported them substantially more often across the study period, and when such incidents occurred, women rated them as more negative.
Importantly, male surgeons experienced these things too. The finding was not that every questioned order directed at a woman constituted sexism, or that men’s authority was never challenged.
It was that, accumulated across hundreds of surgeons and thousands of weekly observations, women encountered these interactions far more frequently.
That distinction goes to the heart of what Williams and her colleagues were trying to measure. Any single encounter could be ambiguous; the aggregate pattern was much harder to dismiss.
“It struck me that many of the events that participants reported were quite benign. No one was saying things like, ‘No way a woman can be a good surgeon.’ More commonly, say, a patient’s family member would talk to the female surgeon as if they were a nurse, asking them to get a meal or change the patient’s sheets. Often the family member would apologize or correct themselves when they realized their mistake.”
“Gender discrimination in today’s workplaces may be subtle, but it still shapes who stays and who leaves, with negative consequences for both women and the professions they leave behind.”
Melissa Williams, Professor of Organization & Management
Problematic Patients
The source of those experiences also complicated the conventional picture of workplace discrimination.
Williams might have expected senior male physicians to play the central role in perpetuating the hierarchy. Instead, the people disproportionately challenging women’s roles and authority tended to occupy nonsupervisory positions—patients in particular, as well as older people.
“We found that the people who were most often questioning the authority of women more than men, and challenging the professional roles of women more than men, were patients,” Williams says.
In retrospect, she says, the result makes sense. Physicians and hospital employees spend their careers watching the composition of medicine change. Even in specialties where women remain underrepresented, colleagues have had repeated opportunities to see women working as surgeons and authority figures.
Patients may not have. Someone who enters a hospital for surgery only once or twice in a lifetime may carry an older mental picture of what a surgeon looks like. The consequences can surface in seemingly innocuous interactions: a patient or family member assumes the female surgeon is a nurse, asks her to perform a task intended for hospital staff or appears surprised when she introduces herself as the physician in charge.
None of those interactions needs to contain an insult to send a message.
“Sexism can still have consequences even in the absence of a direct sexist intention,” says Williams.
The Hidden Cost of Constant Questioning
The longitudinal design allowed the researchers to move beyond documenting different experiences and ask a more consequential question: Did those experiences predict changes in how surgeons felt about their work? The answer was a resounding, “yes.”
Surgeons who encountered more frequent and more negative role challenges showed greater increases in burnout between the beginning and end of the study. The same pattern appeared for authority questioning.
Because women experienced both kinds of interactions more often, statistical mediation analyses showed an indirect path from gender to increased burnout: women were more likely to have their role challenged and their authority questioned, and those experiences in turn predicted greater burnout over time.
Burnout then had consequences beyond well-being.
Greater burnout predicted less certainty about remaining in medicine, less certainty about remaining in surgery and weaker interest in pursuing an academic career. In other words, the interpersonal frictions documented in the weekly surveys were connected to the very attrition problem that had originally concerned Chen.
For Chen, having her anecdotal experiences transformed into quantifiable data was a bittersweet victory.
“I definitely think it was validating, and a bit sobering as well,” she says.
Perhaps most strikingly, the effect did not depend on whether the surgeons themselves thought gender was responsible.
At the end of the study, the researchers asked participants whether they interpreted the questioning of their authority or challenges to their professional role as gender-related. Some did; others did not. But labeling the experience as sexism did not determine whether it was associated with burnout.
“When these things happened to a physician repeatedly, it ultimately didn’t matter whether they labeled them as discrimination,” Williams says. “Either way, these interpersonal experiences had a negative impact on well-being.”
That finding complicates a common way of thinking about discrimination. If researchers count only incidents that employees themselves confidently identify as discriminatory, they may miss some of the experiences through which inequality actually operates.
Praise: An Unexpected Counterweight
Not every difference broke against women.
“We originally predicted that male surgeons would receive more positive feedback and support than female surgeons, because most of their supervisors (the attending physicians) are still male, and we know that mentors are drawn to mentees who are like them,” says Williams. Instead, their research demonstrated the opposite.
“Female surgeons received more everyday positive feedback at work. It wasn’t just from supervisors, but across roles—including peer physicians, hospital staff, and patients. It was consistently women in these other roles who tended to lift up women surgeons in this way. In addition, the female recipients of this encouragement rated that feedback more positively.”
That encouragement mattered. Greater positive feedback predicted increases in surgeons’ sense of professional efficacy—the feeling that they were competent, effective and making a difference—and, through that increased efficacy, stronger intentions to persist in the field.
Williams is careful not to settle too quickly on an explanation. It could be that women surgeons simply earned more positive feedback; some medical research has found better patient outcomes among female physicians and surgeons. Another possibility is less flattering: previous organizational research suggests women sometimes receive more positive but less candid evaluations because supervisors are reluctant to deliver critical feedback. Or, the support may itself reflect an awareness of the obstacles female surgeons face.
“People in the hospital environment, perhaps especially women in that environment, may recognize that the female surgeons they are working with are fighting an extra battle because of their underrepresentation,” Williams says.
Whatever its origin, the finding provides an important counterpoint. The study does not describe women as simply absorbing an uninterrupted stream of hostility. Instead, their working lives contained simultaneous forces: interactions that undermined their professional standing and interactions that reinforced it—and both accumulated in meaningful ways.
Beyond the Operating Room
The study cannot answer every question. Because the researchers relied on participants to report their own experiences, they could not independently verify each interaction. And although the team had hoped to examine whether the patterns differed for surgeons of different racial and ethnic backgrounds, there were too few participants in individual groups to draw statistically reliable conclusions.
Williams would eventually like to get closer still to the interactions themselves, if she can find a way to be a fly on the wall.
“I’d like to actually get in the room, perhaps recording meetings or interviews or water-cooler conversations, to get some real-time data on how the everyday workplace conversation directed at women might differ from the conversation directed at men.”
That is because, for Williams, surgery is not just a story about surgeons.
The operating room offers an unusually vivid example of a broader class of workplaces: high-status professions where authority matters, hierarchy is deeply embedded and women remain underrepresented. The details might differ among airline pilots, police officers, financiers or other traditionally male professions, but Williams suspects the underlying dynamics will look familiar.
“My hope would be that leaders recognize that workplace discrimination doesn’t just manifest in salary or hiring decisions, but also lower-stakes situations like meetings or hallway chats.”
The broader implication is easy to overlook precisely because the incidents themselves are easy to overlook. Modern workplace inequality may not always arrive as an explicitly discriminatory hiring decision, a pay disparity or an openly sexist remark. Sometimes it arrives when an expert has to establish, once again, that she really is the expert. Once might be forgettable. But if unaddressed, week after week, it will eventually take its toll.
“My suggestion is, if a woman in a field like this is feeling like she’s not making an impact after all, or not feeling like she belongs, to interrogate this and try to find out what her female colleagues are experiencing. If it’s happening to all the women, it might still be painful, but at least it’s not just you.”
Melissa Williams, Professor of Organization & Management
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