Scenario: A third-year student who identifies as a cis-gender woman (she/her) is rotating through a general surgery clerkship. She is a hard-working student on service with another student who identifies as a cis-gender man (he/him). She notices that the other medical student is frequently asked to go to the OR to assist and to see "cool cases," even though he's stated his career interests lie outside of a surgical speciality. She professionally asks the senior resident about the discrepancy and they respond, "I didn't think you'd be interested in extra time in the OR. You were just talking the other day about how you hope to have a good balance of career and family."

Impact: There are numerous potential impacts of a scenario such as this. The educational implications of missing out on opportunities to participate in additional operative experiences are obvious. Understandably, the student feels offended and frustrated that despite her good work on the rotation, she would be denied an opportunity for more OR time simply because she expressed her hope to have a family. She is left wondering if she was left out because of her gender. Although she had been strongly considering a surgical specialty as a career, she wonders if she will continue to experience bias.

Outcome: The student completes the rotation and scores a Pass. She wonders if perhaps she would have received Honors if she hadn't been viewed by her team in the way she was. She writes a lukewarm review of the clerkship, considers filing a Learning Environment Survey, but isn't sure she will be taken seriously.

Takeaways:

• Medical educators should always try to share educational opportunities between all groups of students, whenever feasible.

• Educators must be thoughtful about the words they use, particularly when considering students for opportunities for rewards or training. We must be thougthful about how we discuss families with trainees, especially given the challenging realities for many physicians who build families with children. We should never make the assumption that because someone notes they want to have a family and a work/life balance that they would not be interested or capable of being a specific type of physician.

• This case also demonstrates some of the impacts mistreatment in the learning environment can have on students (such as frustration, humiliation, loss of faith in the accuracy of feedback/evaluations, desire for a different career, etc).

• If we hear of or witness examples such as the above, that may be or are considered learner mistreatment, we should encourage students to bring their concerns forward via the Learning Environment Survey Form. Their concerns will be taken seriously and in this case, if the senior resident had not been involved in previous episodes of learner mistreatment, it's likely they would be asked to meet with the Assistant Dean of Student Affairs, Learning Environment for a non-judgemental reflective conversation.

Scenario: A fourth-year medical student is working in an outpatient office during an elective. Their preceptor, a Professor of Family Medicine who is a well-regarded member of the learning community, frequently refers to the student as, "Dear," "Sweetie" and "Sweetheart." The student also witnesses their preceptor using these words and other "terms of endearment" with nurses and patients.

Impact: As with any case, there are a range of impacts that this scenario may have on a student. In this case, the student describes feeling as though they were not taken seriously as a fourth-year medical student and embarrassed when these terms were used. The student felt unsure about how these comments might impact their final course evaluation. In addition, the student felt concerned that a well-respected member of the school could be allowed to use sexist terms without consequence.

Outcome: The student reported their concerns, appropriately, by completing a Learning Environment Survey. The student was contacted by the Assistant Dean of Student Affairs, Learning Environment (ADSA-LE) for support and further discussion. It was decided, with the support of the student and the Executive Committee on the Learning Environment, to address terms of endearment in a faculty newsletter.

Takeaways:

• Terms of endearment (such as those above) are considered gender-based, offensive and do not have a place in the learning environment

• Offensive sexist remarks or names do not have to be obviously inappropriate to be considered mistreatment

• The impact of terms of endearment can be the receiver feeling condescended to, undermined, and not respected (among many others!) even though the intent may be non-malign

Scenario: A fourth-year student (she/her/hers) on a surgery sub-internship completes her rotation and is committed to becoming a surgeon. The student is thrilled that both her and the surgery clerkship director feels as though she did an excellent job on the rotation. With her passing Step 1 score (recall, Step 1 is now pass/fail), strong preclinical grades, surgical research experience and Honors grades in several required clerkships, this student has an excellent chance of matching into a categorical surgery residency. After reading one of her sub-internship evaluations by a fellow, she felt frustrated and concerned about the content. A representative excerpt of her evaluation is below:

"Mariela was very warm and approachable, especially in her interactions with patients. She has well-organized presentations and is a team-player. Overall, she is a caring student and will be a good doctor."

Impact: The student received slightly less interview offers than average for surgery residencies and wonders how much her evaluations, which likely contained unintentional gender bias, contributed to this. At first pass, a reader might review this evaluation excerpt and think: how could the student possibly be frustrated by this evaluation?

Outcome: The student anonymously reported her concerns via the Learning Environment Survey which did not allow for closed loop communication or further investigation. However, their report was kept on file in order to identify any patterns related to gender bias in feedback within the learning environment.

Takeaways:

• Gender bias can be intentional or unintentional and can be manifested through language; it can (and does) appear in student (and for that matter, faculty) evaluations

• Research suggests that female-identifying students are more likely to be described using words like caring and compassionate while male-identifying students are more likely to be described based on technical abilities

• Male-identifying students are more likely to be positive and contain more superlatives than female-identifying students

• When giving high-quality feedback, focus on observed and/or competency-based behaviors

• Explore gender-bias in feedback using this tool