Who is a “Kingmaker”?

This term was first coined long ago in 16th century England. It is used to describe someone who himself cannot become a king because he is not of royal blood but has enough financial and social power to create circumstances and events that can affect positively or negatively, royalty’s political climb to the throne and ability to stay on the throne.

Empowerment starts with Words

Google (AKA Stanford/NSA/CIA) in its efforts to organize online neurolinguistics and coalesce it into some sort of collective consciousness, has yet to associate the term kingmaker with medical residency training. In turn, part of the purpose of this blog post is to do just that. Empowerment and social awareness starts with translating abstracted ideas and non linguistic observations into the limits of linguistic language and shifting linguistic meaning through the contextual use of words. This is how patriarchal systems of thinking, spirituality and power formed in history. This is how these systems can also be dramatically reshaped.

Why is Kingmaker an important term?

Kingmaker gives a concise word for a diverse, complex and common set of power dynamics experienced by, in particular, female residents in the patriarchy of medical training. It’s important to bring the word kingmaker into the discussion of medical residency training as there are many types of kingmakers in academic medicine. In the teaching hospital setting, the hierarchical lay of the land is one where already established or known people can put themselves in the position of a kingmaker. It can be an upper level resident, attending physician, a nurse, a physician extender, an administrator or a patient.

Doctors in training are portrayed in the media and perceived by the general public as professionals who have the ultimate form of job security and a great income. This is despite the personal costs, risks and responsibilities doctors take on which most people are not aware of. When comparing the investment and responsibility to income ratio of doctors to other careers of similar income potential, one realizes that doctors are grossly underpaid for the type of work they do. Nevertheless, an intern coming into an academic center will easily be seen by many as a person who has the opportunity to achieve economic agency that most could not. If that doctor is a woman, that can be viewed by both men and women in a competitive workplace as a greater threat because women are typically seen as being reliant on men for their income. The more conservative a culture’s value system is, the more professional women will be viewed through this lens.

How does kingmaking accurately describe a female physician’s experience of residency?

It means that in order for her to survive politically, socially, clinically and professionally she has to make the assumption that anyone she works with could play a kingmaker move on her. This is particularly true in the beginning of her training, when she is not known by most people at the institution. Unfortunately, it will also continue throughout the rest of her career beyond residency. Many women physicians in major medical centers feel their career is not secure and constantly under the microscope.

What are the sociologic mechanisms behind this dynamic? Most are subconscious assumptions people make about women and the social obligations women have in a society’s fabric. Motherhood is regarded by many, even in progressive cultures, as a social obligation. Without women reproducing, there would be no society at least for now. Ex-vivo artificial uteruses are on the list of reproductive technologies currently being developed. These technologies will shape the female gender role lens at work as a function of change in women’s reproductive power at home. Institutions make the assumption that all women have the same priorities and that is to be mothers. Kingmaking is just one of many strategies patriarchal societies use to limit what women can and cannot do outside unpaid domestic labor.

What is not given to the goose is given to the gander

In the early 1970’s, a former nephrology chair of an Ivy League medical center had a position in residency admissions. They were faced with unique economic challenges of letting in the first female residents into their surgery program. He said that these women were married to much less educated men with less earning power. In order to have the female resident be economically sustained during her training, the admissions committees helped their husbands find new jobs at the new location. This was not done for the wives of the incoming male surgery residents. At that time women were not expected to have any economic upward mobility. The assumption was the wives of male medical residents would want their husbands as doctors to give them the financial security to not have to work so they could stay at home to raise a family. But these assumptions are still present today subconsciously in the minds of both men and other women who work in the patriarchal hierarchy of academic medicine.

Kingmakers see the world through specific social lenses

Women residents have to read a lot of egos and feed them in the ways those different egos need to be fed. Women do this to avoid being attacked by others, especially when they do not adhere to gender roles. When men do the same thing, they are given social leverage. Women medical residents and attendings still have to identify and manage the economic and reproductive gender role lenses they are viewed through. These lenses protect the egos of the people who wear them because these social glasses define the kingmaker’s world view. Triggering a person’s ego either positively or negatively in the hierarchy of the medical profession will either aid or demote a resident’s social influence. It will also influence access to reliable clinical information and foresight.

Metaphorically speaking, if a female resident inadvertently removes the gender role glasses of her viewer by doing something outside the accepted female gender role, two things will happen. She will at best be ignored or at worst be black balled and defamed because she has disrupted her viewer’s perspective on the world. The closest term to describe this psychological response is cognitive dissonance. Cognitive dissonance fuels misogyny and kingmaking/queenmaking power moves are just one of the social symptoms of those suffering from cognitive dissonance. One way female physicians avoid triggering cognitive dissonance is they give off the impression they are adhering to gender roles. Then they gradually let others learn their uniqueness over time by developing trusting relationships with those they work with. Men are not expected to do the same interpersonal investment of their time and energy. Men are granted authority and respect without this investment.

Knowledge is Power, but so is Time

Entering residents initially have less experience and are for the short term in a position of vulnerability to kingmaking power plays. As an example, interns can start rotations in an ICU setting where clinical data changes fast. Gathering information from nurses and physician extenders, who have had more experience, becomes very important. The intern’s initial learning curve and long term learning curve are greater with expectations for faster acquisition of knowledge. This places the intern, for the short term, in a vulnerable position if lower ranking professionals decide they do not like an intern. Undermining an intern can take the form of omitting, delaying or changing information which the intern is ultimately held accountable. One way junior levels try to mitigate this position of vulnerability is to not ask too many questions, not give the impression they do not know enough or soothe the kingmaker. Female physicians in training are faced with the additional challenge of being viewed through gender role lenses in this power dynamic. They are seen as women with potential for significant economic self agency. This can be a source of resentment not only in men but also other women with less economic agency and who have internalized the female gender role paradigm of financial dependence on men.

Different Kingmakers in Different Kingdoms

It is important to separate the kingmaker power dynamics between female residents and physician extenders in a patriarchal hierarchy from those between themselves and other residents and attendings. This is because each person’s ascent to a position of political and financial authority has to be taken into consideration as this will affect the lens through which a growing female physician in training will be viewed. Anyone in medicine will attest to the importance of having access to a mentor but many physicians did not have this resource. Learning amounted to absorbing as much information by osmosis, by asking colleagues about topics indirectly and pattern recognition of patient clinical data. While some more senior residents would have had access to support from their colleagues, many are thrown under the bus by their upper levels and what was passed down to them, they will pass on to those below them in rank. This is even more a truth for older surgical attendings who think they had it much harder than the younger ones coming in.

Different Ego Exchange Rates

In order to overcome this ego block to the sharing of knowledge from higher ranking physicians, many female residents will date and/or marry more powerful male residents or attendings. This exchange of sexual/reproductive currency for insights and career protection is commonplace in all academic medicine whether in a liberal or conservative state. Male residents also do the same thing with higher ranking female residents and attendings but it is not as common today. There are less female physicians in academic faculty positions. Women have not been socialized as men have to be incentivized to take sexual currency from men to protect men in their careers. Women carry more biological risks with sexual relationships due to anatomy and in turn, there is less advantage for them to accept sexual currency from a lower ranking male in his objective to protect his career. Normally he would have to feign some sort of emotional attachment to get her to think its safe for her to take on that biological risk, be really good in bed or both.

Other Kinds of Payments 

Beyond sexual currency exchanges, female residents navigate the patriarchy through use of self deprecating humor, humility, graciousness, exuding gratitude, emotional intelligence and outperforming their male peers. The attitude female medical residents have to manage is that they must “make their bones”. Women physicians have to prove they should be given an ascent to power like their male peers over the heads of fellow women who made a decision to invest in men rather than themselves. It could be argued that sexism against women is itself created by other women and carried out by the men who benefit from it. Kingmaking is just one of many examples of power dynamics women residents have to manage in their upward mobility to economic self sufficiency in medicine.