Abstract
Introduction: Although women now comprise most U.S. medical students, male physicians continue to dominate leadership roles, earn higher salaries, and hold more full professorships. These disparities suggest that cultural dynamics contributing to gender inequities may emerge early in medical training. This mixed-methods study investigated gender differences in perceived and actual participation in mandatory educational sessions during the first two years of medical school. Methods: First, a survey assessed student perceptions of gendered participation across mandatory first- and second-year educational sessions. Subsequently, these sessions were observed for eight weeks at a single institution. Observed sessions included full-class Didactic and Social/Ethical sessions (120 students) and smaller Clinical sessions (30 students). For each participation instance (asking or answering a question), the gender of the student and instructor was recorded. Students could opt out. Results: Survey responses indicated that most students perceived no gender-based differences in Social/Ethical or Clinical sessions. Female students, however, reported that men participated more frequently in Didactic sessions, while male students perceived no disparity (p = 0.001). Observational data showed male students accounted for 72.4% of 311 participation events (p < 0.001). Men contributed significantly more in Didactic (81.2%) and Social/Ethical sessions (67.1%; both p < 0.001), with no significant difference in Clinical sessions (54% male; p = 0.19). Male participation decreased in sessions led by female instructors compared with male (p = 0.036) or mixed-gender faculty (p = 0.023). Discussion: Despite objective gender disparities in participation, most first- and second-year students did not perceive differences. Notably, only female students perceived this discrepancy in their pre-observation surveys, and only in the context of didactic sessions. This imbalance may reinforce early professional norms favoring male visibility and engagement, perpetuating gender inequities in academic medicine. Addressing these dynamics is essential for fostering equitable learning environments and promoting diverse leadership in medicine.