Julia Files and Anita Mayer, physicians at the Mayo Clinic, started seeing a pattern: When their male colleagues were introduced at conferences, they were usually called "Doctor." But the men introduced them and other female doctors by their first names.
The pair quickly realized they weren't alone. Sharonne Hayes, another Mayo doctor, had noticed the same thing. While a male colleague would be introduced as "Dr. Joe Smith," for example, the women were often simply called "Julia," "Anita" and "Sharonne."
So the three decided to study speaker introductions at "grand rounds" -- events where doctors, researchers, residents and medical students present medical problems and treatments for discussion. Their research showed that unequal introductions were real -- that women were less likely than men to be introduced by professional title when men did the introducing.
"It gets down to perception of expertise, perception of competence," said Files, an associate professor of medicine at Mayo and the lead author of the study. "We know that in other settings, choices of words really impact women's progress in careers."
The study, published in the Journal of Women's Health, looked at videos of 321 speaker introductions at 124 internal medicine grand rounds from 2012 through 2014 at Mayo Clinic campuses in Arizona and Minnesota. The results showed that male introducers used professional titles for female doctors only 49 percent of the time on first reference, but introduced male doctors by their titles 72 percent of the time.
Female introducers used titles in introductions of both male and female doctors more often than male introducers (96 percent of the time vs. 66 percent of the time).
Hayes, a professor of medicine and cardiovascular diseases, said the form of address wouldn't matter if it were the same for both genders.
"It's the inequity and the context," Hayes said. "I don't mind being called 'Sharonne' -- it's my name -- but if all the men are being called 'Doctor Jones' and all the women by only their first names, that's offensive."
"While I have to assume it's inadvertent, the effect is to put me in my place as 'less than,'" she said.
The unequal introductions can affect a woman's performance, noted Hayes, who directs the Office of Diversity and Inclusion and the Women's Heart Clinic at Mayo's headquarters in Rochester, Minnesota.
"The other thing is, grand rounds is kind of a high-stakes event that is the premier educational venue at academic medical centers," Hayes said. "As the speaker, you've spent hours preparing for it, may be a little nervous in front of the podium, ready as an expert, and then somebody says, "Here's 'Sharonne.' You're immediately put off a bit and may not be at your best performance."
Kim Williams, a professor and the chief of the Division of Cardiology at Rush University Medical Center in Chicago, said male introducers might be using first names for women because they felt more familiarity with them. But he added, "That's not acceptable."
"I doubt that it's purposeful but no doubt that it's dysfunctional and insulting to the people on the other end," said Williams, who was not involved in the research.
While Williams said first-name introductions didn't happen at Rush, female doctors at other institutions said they were all too common.
"My question would be 'Are there any women doctors who have never been introduced by their first names?' " said Esther Choo, an associate professor of emergency medicine at Oregon Health & Science University in Portland. "There are a lot of built-in presumptions about your level of commitment and capability."
Choo, who lectures on gender bias in medicine, said she thought the first-name introductions could reflect unconscious bias but might also be because of familiarity or the introducer's seniority, which the study brings up.
Kim Templeton, a professor of orthopedic surgery at the University of Kansas in Kansas City, said she cringed every time she heard female doctors introduced by their first names and had experienced it plenty of times herself.
"Women don't tend to be thought of as leaders. They're thought of as worker bees and the people who work well together," said Templeton, immediate past president of the American Medical Women's Association. "Talking to us is no different than talking to their wives or daughters at home."
"They just assume, somehow, that they don't warrant the same respect as the men do," she said.
A blog post on the study that appeared on KevinMD.com and GenderAvenger.com drew a flood of positive responses from doctors, clergy members and others, applauding the authors for their study. But several commenters said the women were overreacting, and one posted a message that said, "Boo hoo you weren't called "Dr."! BOO HOO!"
Mayo Clinic administrators have decided to create new speaker guidelines for introductions at grand rounds, stipulating that the title "doctor" should be used on first reference, though a first name or nickname might be used thereafter, if appropriate.
Anupam Jena, an associate professor at Harvard Medical School, said male introducers could be using first names because they felt that "the work done by female colleagues is somehow different than the work done by male colleagues."
"Subconsciously they are not equating the stature of female speakers to be the same as male speakers," he said.
Jena said the introductions might have only a small direct effect on female physicians, but "the general attitude within medicine that drives these differences is probably what's most important." (Jena has studied how sex differences affect faculty rank in medical schools and the effect of sex and race on physician incomes. In both areas, the differences were disadvantageous to female doctors.)
"Once they fix this notion within the department, I would expect there could be spillovers to all sorts of other interactions that would happen in a hospital," Jena said.
For Rachel Allison, an assistant professor of sociology at Mississippi State University, the grand-rounds study showed how even simple words can have a profound effect.
"As sociologists, we know language is very powerful; it both reflects larger social meanings and patterns and can directly contribute to them, in many cases perpetuating social inequality," said Allison, who studies gender equality.
"The words we use can shape how people feel about themselves and others, how they interact and how they make decisions about the distribution of rights and resources," she said.
Allison said changes should eventually go beyond fixing the introductions.
"The question for me is not what women can do to navigate the landscape, although that is an important one, but what we can all do to change it," she said.