Three previous single institutional studies used the same outcome measure, the Sexist MESS, to explore gender bias experiences in female surgeons [19, 27, 28]. The first Barnes et al. study of female surgical trainees had 33/50 participants (response rate 66%) [27]. They divided the trainees into female-dominate field (obstetrics/gynecology) and male-dominate fields (all other surgical specialties). Female trainees in male-dominant fields reported more frequent, severe, and stressful microaggression experiences than female trainees in female-dominant fields. Their study had five items in the Sexist MESS that scored over 2, indicating a more severe or significant result, in comparison to our study that only identified one item (Table 2). The second Barens et al. study of female surgeons of all specialties had 65/101 participants (response rate 64%) [19]. The frequency and severity of Sexist MESS scores were higher for trainees than attendings. The variables of non-White ethnicity, having children under 18, and fellowship training were not associated with the Sexist MESS scores. The third Sudol et al. study’s objective was to determine the prevalence of sexist and racial/ethnic microaggressions against female surgeons and anesthesiologists and to assess its’ association with burnout [28]. Using the Sexist MESS, they defined the prevalence of microaggressions as at least 1 mean subscale score for frequency. They also employed the Racial Microaggression Scale and Maslach Burnout Inventory. With a sample size of 652/1609 (response rate 41%) conducted at a single health maintenance organization, they reported that 94% of female respondents reported sexist microaggression and 81% of racial/ethnic minority physicians reported racial/ethnic microaggression. Microaggression was significantly associated with physician burnout, an important mental health and human resource issue in the health care system. This study was able to study the intersectionality of gender and race/ethnicity with microaggression.

This current study reinforces the previous literature that trainees are more at risk for gender bias and microaggressions [27, 36,37,38]. In the domain analysis of the current study, the frequency severity, and total MESS score was higher for trainees than attendings in the domain of sexual objectification. In the second Barnes et al. study, trainees had higher frequency MESS scores in six of the seven domains and higher severity MESS scores in three of the seven domains [27]. A recent multi-institutional, national survey of American general surgery and surgical specialty residents revealed that the majority (72.2%) of residents had experienced microaggression, most commonly from patients (64.1%) [36]. Only 7% reported these events and nearly one-third (30.8%) of residents experienced retaliation due to reporting of microaggressions [36]. Further studies in plastic surgery and emergency medicine confirmed these results [37, 38]. For example, misidentification as a non-clinician staff, the most common form of microaggression in the emergency medicine study, occurred more commonly with trainees than attendings, more commonly with women than men, and more commonly with non-White than White respondents [38].

In the medical hierarchy, attending physicians may have more authority and power than trainees, who are more vulnerable in experiencing and addressing microaggressions. Attending physicians may be bystanders when these microaggressions occur to trainees. Bystanders are defined as “anyone who becomes aware of and/or witnesses unjust behavior or practices that are worthy of comment or action” [39, 40]. Education and faculty development on how to manage these experiences are crucial and the goal is to support bystanders to become “upstanders”. “Upstanders” are those who take action, intervene, and speak up for trainees/colleagues who are experiencing microaggressions [37, 40]. Universities and teaching faculty members have an ethical and legal obligation to provide a safe learning environment for their trainees. Speaking up for trainees in the face of microaggressions is one aspect of advocating of them.

The current study also investigated the concept of self-efficacy. Self-efficacy has been studied in surgical trainees in relation to well-being and burn out [30,31,32]. A large cross-sectional survey of all surgical residents at Stanford reported that high self-efficacy was predictive of well-being [30]. Another multicenter study of general surgery residents reported that lower burnout was associated with higher self-efficacy and lower perceived stress scores [31]. A third multicenter study of vascular surgery residents reported that burnout was associated with lower self-efficacy and higher levels of depression [32]. Higher levels of self-efficacy were also found to prevent burnout in other first line responders, like nurses and firefighters [41, 42].

Our study showed that female otolaryngologists have high degrees of self-efficacy, but there was no significant association between GSES and Sexist MESS scores. There may be several explanations for the lack of statistical significance. First, there was a narrow range of GSES scores, so it may be difficult to show a statistical association with another variable. Second, there may be survivorship bias in this study [43]. Female otolaryngologists who survived the rigours of surgical training and stayed practicing in this field were surveyed. Those with lower self-efficacy may have left the field and not been eligible for the study. We do not know the self-efficacy of women who did not complete the study. Lastly, there were no senior full professors who completed the study; albeit, women comprise a very small proportion of full professors in academic medicine [6].

Figure 1 showed that the top source of microaggressions experienced by female otolaryngologists was patients (90%). This was confirmed in three previous studies, which rated patients as the top source of microaggressions experienced by 94% of female surgical residents [27], 80% of all female surgeons [19], and 64.1% of all American surgical residents [36]. Addressing microaggressions that were perpetrated by patients is problematic on multiple levels. Although the conduct of health care providers is directly regulated by industry and hospital standards of professionalism, the conduct of patients is not regulated. Furthermore, patients seek care when they or their loved ones are ill and at their most vulnerable state. Patients and their caregivers often feel they need to advocate for themselves or their loved ones, and they may strike out against health care providers. Health care professionals may feel an ethical obligation to maintain the physician–patient relationship, even in the face of gender bias and microaggressions, and even more egregious behaviour.

Addressing microaggressions and managing gender bias can be challenging. Barriers for physicians to address these issues include fear of retaliation, fear of situational escalation, further discrimination, jeopardizing personal/physical safety, and exclusion by coworkers [44, 45]. Some advocate that the first step to addressing microaggressions is recognizing it [44]. The perpetrator may not be aware of the transgression and may not have had any malicious intent. On a system level, implicit bias and diversity training have been implemented by multiple institutions to reduce these biases. Evidence of successful changes in the workplace, unfortunately, are slow, as it takes a long time to change organizational culture [46, 47].

Figure 2 shows that these microaggressions caused negative feelings and responses in about half of respondents. About half of female otolaryngologists felt offended, got angry, or frustrated. About half of respondents ignored the microaggressions, which is an unhealthy response as it does not address the issue and builds up negative emotions in the victims. Instead, ignoring the microaggressions enables the perpetrator to continue the inappropriate behaviour. Only about one fifth of respondents were empowered to confront the perpetrator. This may educate the perpetrator about the transgression and hopefully break the cycle. Previous qualitative studies have reported that female surgeons have developed resilience—“toughness” or “thick skin” [19, 27]. Some developed coping strategies like using humour; others used increased effort to adapt [19, 27].

One study recommended that future directions should explore how to address these microaggressions in a healthy and productive manner [19]. The Mayo Clinic has developed the GRIT (Gather, Restate, Inquire, Talk It Out) Framework for Addressing Microaggressions: [48] 1. Gather your thoughts. Do not overreact with anger. Decide if it is the appropriate juncture to address the perceived microaggression. 2. Restate the comment or ask the speaker to restate it. Allow the person to clarify or realize the potential negative impact of the comment. 3. Inquire. Dig deeper and seek clarification: Be nonjudgmental. Address the comment rather than making it personal. 4. Talk it out. Discuss the potential impact on others and your own perception. This framework aims to promote open, productive communication between all parties, recognizing that we may all be recipients, witnesses, and perpetrators of microaggression.

Gender bias can have potential impact on the hiring process of potential candidates. These unconscious stereotypes have been found to have negative consequences for women who apply for jobs traditionally held by men [49,50,51]. For example, a systematic review of reference letters for residency and academic medicine faculty positions reported that reference letters for female applicants had more frequent use of doubt raisers and mentions of applicant’s personal life and/or physical appearance [50]. Women were more likely to be described with communal adjectives, like “compassionate”, while men were more likely to be described with agentic adjectives, like “leader”. During interviews, applicants who displayed gender incongruent behaviours (e.g. women who were self-promoting) were rated lower than applicants who behaved in a more gender-congruent manner [51]. Employers are becoming aware of this gender bias and a systematic review discussed interventions to mitigate this [49]. Interventions included providing only job relevant information to raters (e.g. not including parental or marital status), being aware of gender stereotyped behaviour and appearances, and instituting explicit employment equity policies.

We recognize some limitations in this study. Gender is a fluid concept and some otolaryngologists may not fully identify with the binary distinction of cis-man or cis-woman. The authors attempted to build a comprehensive mailing list of all practicing female otolaryngologists by contacting the 17 otolaryngology departments across Canada and the Canadian Society of Otolaryngology Women in Otolaryngology group. Some private practice or community otolaryngologists may have been inadvertently left off the distribution list. Although Table 1 reports that 50.0% (30/60) of the respondents were fellowship trained, the study population included trainees (19 residents and 6 fellows); thus, only 35 respondents were attending surgeons who would have been eligible for completing fellowship training. The proportion of fellowship trained attending surgeons (30/35 = 85.7%) was much higher, so there may have been a higher representation of academic surgeons who have completed a fellowship. Despite employing the Dillman’s Tailored Design Method [34] for survey distribution, the response rate of 30% could be improved upon. The previous studies were all single institution studies [19, 27, 28]. Our sample size of 60 was larger than the first Barnes et al. study (n = 33) and comparable to the second Barnes et al. study (n = 65) [19, 27]. The response rate of 30% is less than the previous two studies’ response rates of 64–66% and the third study’s response rate of 41%, which likely reflects the challenges of a multi-institution study [19, 27, 28]. There may have been a selection bias in which female otolaryngologists who felt strongly about the topic decided to complete the survey. The opinions of those who did not participate were unknown. Since there were no senior full professors who answered this survey, we were unable to comment if more senior female otolaryngologists experienced microaggressions differently than junior female otolaryngologists. About one third of participants felt that men were also subject to gender bias, and this would be an area for future research. Studying the intersectionality of gender with race/ethnicity, religion, and sexual orientation and its effect on microaggression was outside of scope of this current study.