the income , prestige , and authority of doctors in most western countries reflects their omnipotence amongst health care professionals and their power within our society .
however , concurrent with the increasing number of women entering medicine , there has been a recent decrease in that power .
for example , a significant proportion of female family physicians reports being sexually harassed by male patients .
sexual harassment is an abusive behaviour perpetrated by those with power on the more vulnerable .
the victimization of female doctors could only occur if the offending male patients saw their physicians as vulnerable women rather than powerful professionals , that is , if gender rather than professional role was the primary determinant of power in the relationship .
if female physicians are " women first " in the eyes of some male patients , do their overwhelmingly female nurse colleagues also view them through a gender lens ?
how will the increasing percentage of women in medicine change professional relationships between doctors and nurses ?
this study examines whether the traditional authority of doctors over nurses is eroded when that authority arises solely from profession and not from gender .
historically both the gendered role of nursing and the sex of nurses was almost exclusively female .
the profession primarily attracted working class or immigrant women whose background fostered unquestioning obedience to authority .  
the " doctor  nurse " game described by stein ( 1967 ) indicated that despite the passage of time , roles had not changed substantially . by showing initiative and making important recommendations , while appearing to defer passively to the doctor 's authority
stein revisited the nurse - doctor game in 1990 and argued that nurses had unilaterally decided to stop playing .
the change was , in part , attributed to an increasing number of female physicians and male nurses , both of whom were unable to play .  
nurses ' recent overt refusal to be dominated by physicians is also a reflection of the decrease in power differentials between men and women in western society at large .
in contrast to nursing , the gender role and the practitioners of medicine one hundred years ago were male .
many nurses and physicians still overtly and covertly resist the equalization of power that true teamwork requires .
salvage and smith argue that while assertive nurses resent being put down by doctors , physicians resent being challenged by nurses .
obstacles to collaboration include gendered thinking , different styles of learning , models of working , regulatory mechanisms , role ambiguity , and incongruent expectations .
nurses generally experience greater satisfaction when communicating with female rather than male physicians   and prefer a female managerial style .
nurses doubt that physicians ' sex affects their behaviour , although some admit anger or disappointment when female physicians do not exceed the standards nurses set for male physicians .
they deny any sexual chemistry that favours male physicians , despite the female doctors ' impression to the contrary .
some female nurses describe female doctors in stereotypic terms such as " demanding " , " domineering " , and " bitchy " .
female physicians , on the other hand , resent both having to make extra efforts to be nice to nurses , and devising conscious strategies to cultivate egalitarianism and friendship .
more than 80% feel that at some time in their careers they have experienced unequal treatment , more intense scrutiny , or a lack of respect   from nurses because they ( the doctors ) were female .
a recent norwegian study examined the physician 's perspective on what happens to the doctor - nurse relationship when both are women .
both male and female physicians thought the relationship was influenced by the doctor 's gender .
female doctors perceived that they received less respect or help than did their male colleagues .
the physicians interpreted this in two ways , thinking that either nurses ' wishes to reduce status differences between nurses and physicians affect female doctors more than male , or that there is an " erotic game " taking place between male doctors and female nurses .
hypothesizing that the sex of the physician could affect nurses ' behaviour , we examined differences in the interaction between female nurses and female and male physicians . a self selected population of nurses working in an urban , university based hospital was asked to complete one of two forms of a three page questionnaire in jan . 2000 .
the questionnaire included four clinical vignettes reflecting some previously identified areas of strain in the doctor nurse relationship . in form 1 of the questionnaire the physicians described were female , male , female , and male . in form 2
participants were asked five point likert type questions about nurse physician interactions , their expectations , probable actions , and feelings about the physicians .
the questionnaire was pre - tested amongst a small group of hospital nurses to assess face and content validity .
letters explaining that the accompanying study 's aim was to examine teamwork in a hospital setting , that participation was voluntary , and that responses would be confidential were left at all patient care planning areas ( nursing desks ) of the hospital .
all surveys left at a specific patient care planning area were of the same form .
nurses were asked to return questionnaires , whether completed or not , to an identified collection envelope , and to complete only one questionnaire . following the final collection date , letters explaining that responses to the two forms of the questionnaire would be compared to identify differences in interactions between nurses and physicians based on the doctor 's sex , and describing the " nurse - doctor game " were distributed .
the analysis compared the responses to each question based on the sex of the physician in the particular vignette ( ie responses to form 1 and form 2 of the questionnaire ) .
pearson chi - square analysis was used to test for statistical significance ( p < 0.05 ) .
of the three hundred surveys printed , 265 were taken , 197 were returned completed , 2 were returned with no responses , and 66 were not returned .
the overall response was 74% ( 199 of 265 taken ) and included approximately 22% of the 900 nurses employed by the hospital .
the inpatient nursing specialties were broadly represented amongst the 95% ( n = 177 ) who indicated they were female , the 5% ( n = 9 ) who were male , and the 11 respondents who did not specify . based on the overall sex ratio of respondents these
11 were assumed to be female and included in the analysis .. responses from men were excluded , leaving 188 surveys for inclusion ( 95 surveys of form 1 and 93 of form 2 ) . in the first vignette a physician leaves a suture tray with needles at the bedside , despite a department policy assigning cleanup responsibility to the user of any " sharps " .
female nurses expected physicians of either sex , to dispose of the needles ( 85.3%  female physician , 86.0%  male physician , p = 0.97 ) but were significantly less likely to remove the needles for female physicians ( p < 0.05 ) . nurses expectations of , and conflicts with physicians varied by sex .
those surveyed were more likely to feel indifferent about a male physician , and negative about a female physician when the nurse ultimately removed the needles herself ( p < 0.01 ) . in vignette two ,
the nurse was interrupted while checking a patient 's vital signs and asked to do the same check on the doctor 's patient .
nurses were equally unlikely to immediately stop and help a female or male physician ( p = 0.69 ) .
however assertive requests by physicians were more likely to be acted upon if the physician were male ( p < 0.03 ) despite near universal resentment of this aggression ( 80% toward females , and 77% toward males , p = 0.89 ) .
when physician requests for help were polite , nurses felt positive toward both male and female physicians ( 68.5% toward females , and 65.1% toward males , p = 0.33 ) but , as in vignette 1 , were less likely to help the female physician ( p = 0.17 ) .
the nurse wonders if the physician remembers that the mother received meperidine ( a medication that could depress the baby 's breathing and that could be reversed by giving the baby naloxone ) two hours previously .
nurses were more likely to suggest to the physician that the newborn needed naloxone , ( 99% were likely or very likely to suggest to female physicians and 97.8% for male physicians , p = 0.24 ) , than they were to tell the physician that the newborn needed naloxone ( 31.8% were likely or very likely to tell a female physician and 26.1% for a male physician , p = 0.21 ) . again , though not statistically significant in this case , there was a trend for nurses to be more forward with female doctors .
they were less likely to wait for a female doctor to make her own decision about giving naloxone ( p = 0.15 ) , and more likely to suggest ( p = 0.21 ) or tell ( p = 0.20 ) the female doctor to give the medication .
nurses also expected female doctors would respond more positively to their suggestions ( p < 0.04 ) . in the final vignette
a doctor on call has just gone to sleep in her / his call room .
nurses were asked if they would call the physician for an acetaminophen ( an analgesic ) order .
there was , however , a consistent and contrary trend to that observed in the other scenarios .
nurses were less likely to call a female physician than a male , regardless of whether the physician had given the nurse a complement earlier in the day ( p = 0.24 ) , or had been rude earlier on ( p = 0.63 ) .
nurses were more likely to feel that a male physician 's anger was inappropriate ( p = 0.39 ) .
they were less comfortable approaching a female doctor to discuss her anger ( p = 0.38 ) . in this vignette
our findings suggest , however , that the process of , and feelings around nurse physician interactions are informed by gender stereotypes . in addition to professional hierarchy , gender appears to account for physicians ' perceived power over nurses .
although physicians may well reinforce these same stereotypes this study did not examine their beliefs .
overall , nurses ' behaviour was influenced by the sex of the physician . in vignette 1 , those surveyed expected both male and female physicians to remove needles left on a suture tray .
they were , however , more willing to clean up after male physicians , and to do so with indifference rather than with the hostility they directed toward female doctors .
findings that nurses are statistically less likely to remove needles for female doctors , and to feel somewhat more resentful toward female doctors for whom they have cleaned up , speaks to the primacy of sex over hierarchy in defining the doctor nurse relationship .
perhaps nurses feel role confusion because female physicians do not fit into their learned male stereotypes , and instead better fit into traditionally female roles such as " cleaner " .
these results corroborate pringle 's subjective findings that nurses do more for male physicians and expect more of female physicians . that nurses were unlikely to drop everything to assist either a male or female physician take a blood pressure is consistent with the increasing autonomy of the nursing profession .
assertive physician requests met with resistance from these increasingly confident nurses who commented , " many times doctors feel they have the right to interrupt with little to no consideration for the rns .
they feel their job is more important ! " and , " she is perfectly capable of doing vital signs .
" pleasant requests for nursing help were more effective . again , however , sex role stereotypes appeared to enter the relationship as nurses accepted aggressive male behaviour and acquiesced more readily to male requests for help .
responses to the third scenario suggest that the ' doctor - nurse game '   is alive and well .
nurses deferred to the physicians ' status despite knowing what was medically necessary , and would suggest , but not dictate , treatment for the unresponsive baby .
as one respondent wrote , " i would be more likely to phrase it in a way that would make him feel in control .
" nevertheless , there was again more deference to the authority of male doctors . in the final vignette
, respondents showed a non - significant trend toward a more kindly association with female than male physicians . at first this
this vignette , however was the only one of the four requiring a nurse to initiate , rather than respond to an action .
perhaps nurses are hostile and reactive to female physicians in situations where their expectations ( often based on sex stereotypes ) are not met , such as when women fail to clean up after themselves . however
, when the nurse is in control , her less hierarchical relationship with another female , despite the power differential of profession , may foster collegiality . when doctors and nurses are both female , elimination of the power differential of gender diminishes nurses ' perceptions of professional power inequalities .
as a result , female nurses appear more comfortable approaching and communicating with female doctors , but are also more hostile toward female physicians ' use of medical authority .
these paradoxical behaviours will confuse female physicians if they view themselves as doctors first , rather than as women , and expect nurses to interact with all physicians equally . as females
these same physicians may anticipate appreciation for their increased collaboration and egalitarianism , and not understand the nurses ' confusion at the lack of traditional professional hierarchy .
perhaps the perception that female physicians are more caring and compassionate than their male counterparts creates conflicts with nurses , who define caring as their function , and may feel their role in health care delivery is threatened by women physicians . in general , the nurses surveyed said they would resist being controlled by physicians .
this decrease in the power of medicine over nursing is concurrent with an increase in the number of women physicians in north america .
although the feminization of medicine could diminish the power and prestige of all physicians within the health care system , our findings suggest that nurses are more resistant to domination by female , rather than male doctors .
changes in power differentials between medicine and nursing appear to be shaped by gender , suggesting that the traditional omnipotence of physicians in the health care hierarchy arose from gender roles , and not solely from profession .
written responses may define socially desirable values rather than actual behaviours in clinical situations , however the hostility toward physicians expressed in many of the nurses ' written comments ( not reported here ) mitigates against this concern . because the study was limited to hospital nurses and the scenarios were hospital based
as with any study in which participants are self - selected rather than randomly surveyed , selection bias is possible .
our relatively high response rate ( 74% ) minimizes , but does not preclude this limitation .
written responses may define socially desirable values rather than actual behaviours in clinical situations , however the hostility toward physicians expressed in many of the nurses ' written comments ( not reported here ) mitigates against this concern . because the study was limited to hospital nurses and the scenarios were hospital based
as with any study in which participants are self - selected rather than randomly surveyed , selection bias is possible .
our relatively high response rate ( 74% ) minimizes , but does not preclude this limitation .
historically , the power held by a predominantly male medical profession may have arisen primarily from gender rather than from hierarchical position .
current relationships between doctors and nurses appear to be shaped by gender as well as by profession . when nurses and doctors are female the traditional power imbalance between the two diminishes .
the effects of this change on the authority of the medical profession , the role of nurses , and on patient care remain undefined .
 backgroundthe nurse - doctor relationship is historically one of female nurse deference to male physician authority . 
 we investigated the effects of physicians ' sex on female nurses ' behaviour.methodsnurses at an urban , university based hospital completed one of two forms of a vignette - based survey in january , 2000 . 
 each survey included four clinical scenarios . in form 1 of the questionnaire 
 the physicians described were female , male , female , and male . in form 2 , vignettes were identical but the physician sex was changed to male , female , male , and female . 
 differences in responses to questions based on the sex of the physician in each vignette were studiedresults199 self - selected nurses completed the survey . 
 the responses of 177 female respondents and 11 respondents who did not specifiy their sex , and were assumed to be female based on the overall sex ratio of respondents , were analysed . 
 persistent sex - role stereotypes influenced the relationship between female nurses and physicians . 
 nurses were more willing to serve and defer to male physicians . 
 they approached female physicians on a more egalitarian basis , were more comfortable communicating with them , yet more hostile toward them.conclusionwhen nurses and doctors are female , traditional power imbalances in their relationship diminish , suggesting that these imbalances are based as much on gender as on professional hierarchy . 
 the effects of this change on the authority of the medical profession , the role of nurses , and on patient care merit further exploration . 
Background
Method
Results
Discussion
Study Limitations
Conclusion