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THE IRON MEN GO TO WAR:

GENDER-BASED COUNTERTACTICS AND SOCIAL MOVEMENT REFORM IN

THREE SURGICAL TEACHING HOSPITALS

Katherine C. Kellogg

MIT Sloan School of Management

50 Memorial Drive (E52-582)

Cambridge, MA 02142

781-771-9753

617-253-2660 (fax)

kkellogg@mit.edu

ABSTRACT

Much of the change that social movements try to accomplish requires male and female reformers

to act collectively for change inside of organizations populated by both reformers and defenders

of the status quo. This comparative case study of three hospitals—QUICKFAIL, SLOWFAIL,

and SUCCEED (pseudonyms)--demonstrates that accomplishing such reform may require

reformers not only to mobilize with one another but also to stand up to defenders‟ gender-based

countertactics in everyday encounters. In organizations where men are dominant, defenders can

try to divide male-female reformer coalitions by labeling reformer practices as feminine,

denigrating the masculinity of male reformers, and recruiting male reformers to the defender

group. I argue that the success of defenders' gender-based countertactics depends on the strength

of the initial gender threat posed by female workers inside the organization. When the initial

gender threat is high, male reformers are more likely to feel concerned about loss of male

privilege in the face of gender-based countertactics and, in turn, to distance themselves from

reformer practices and align with male defenders to protect their masculinity and its rewards.

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Social movements often try to change practices inside organizations. Sometimes they

pressure organizations to alter work practices related to employee equal opportunity, consumer

safety, environmental protection, and the like (e.g. Davis, Morrill, Rao, & Soule, 2008; Zald,

Morrill, & Rao, 2005). Other times, they transform organizations created for other purposes,

such as churches or universities, into sites that press for the changes the social movements

themselves are working to accomplish (e.g. McAdam, 1999 [1982]; McAdam, Tarrow, & Tilly,

2001). Since much important movement activity occurs in informal, face-to-face interactions in

everyday encounters inside organizations (e.g. Gamson, 1992; Gamson, Fireman, & Rytina,

1982; McAdam, 1988b; Morrill, Zald, & Rao, 2003), it is critical to understand what explains

variation in social movement processes and outcomes in these settings.

In this article, I explore such variation through a field study of three U.S. teaching

hospitals. Historically, surgical trainees (also called “residents”) in U.S. hospitals worked 100-

120 hours per week. A social movement composed of patient safety and resident rights activists

fought for and, in 2002, were successful in winning new regulation that would reduce the work

week for residents to 80 hours. Yet the implementation of the regulation was contested inside of

hospitals across the country (e.g. Landrigan, Barger, Cade, Ayas, & Czeisler, 2006) and each of

the three teaching hospitals I studied responded differently to the new public policy. At one

hospital, the reform was quickly defeated. At the second hospital, the reform was defeated after

lengthy struggle. And, at the third hospital, the reform was accomplished.

As I will show below, the outcomes at these hospitals were not different because the three

had different organizational characteristics. To the contrary, the three organizations were

comparable in terms of industry sector, work organization, prior organizational performance, and

other characteristics that have been shown to affect organizational response to external pressure

for change. Nor can the different outcomes be explained by different levels of support by

organizational elites. In all three hospitals, organizational elites created similar programs to help

residents reduce their work hours. How, then, can we explain the differences in reform outcomes

inside the organizations?

According to existing theory, variation in implementation of the same reform inside of

similar organizations depends on differences in the degree of internal reformer mobilization.

Thus, social movement theorists would likely explain the variation in outcomes by suggesting

that internal reformers must have mobilized differently in each hospital. These theorists argue

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that organization members who are connected to outsiders or who hold identities consistent with

reform are critical to accomplishing reform inside organizations because they participate in

everyday organizational practices in ways that external activists cannot (e.g. Binder, 2002;

Katzenstein, 1998; Kellogg, 2009; Lounsbury, 2001; Meyerson, 2003 [2001]; Moore, 2008;

Morrill et al., 2003; Raeburn, 2004; Scully & Segal, 2002; Weber, Thomas, & Rao, 2009; Zald et

al., 2005). In cases where they succeed, these internal reformers have access to resources created

by external activists or to resources available inside their organizations that allow them to

mobilize with one another for change; in cases where they fail, they do not have access to such

resources, they fail to mobilize with one another, and hence they do not accomplish change.

Internal reformer mobilization does explain quite well the different outcomes at two of

the three hospitals—QUICKFAIL and SUCCEED. As I explained in detail in another paper

(self-citation) and as I will summarize here as well, reform at QUICKFAIL failed because

internal reformers did not mobilize with one another and collectively act for change. But the lack

of internal reformer mobilization cannot explain why reform failed at SLOWFAIL. For at both

SLOWFAIL and SUCCEED, internal reformers mobilized and began collectively challenging

defenders of the status quo to change traditional work practices. In fact, SLOWFAIL actually

had both a greater number and a greater percentage of these mobilized internal reformers than

did SUCCEED. And yet, reform was not accomplished at SLOWFAIL while it was at

SUCCEED.

In this article, I argue that, in organizations populated by both reformers and defenders

where reform requires the collaboration of male and female reformers, we must take into account

internal defenders‟ gender-based countertactics to explain movement outcomes. Gender based

countertactics, as I conceive them, are face-to-face tactics that internal defenders use against

mobilized male reformers in everyday workplace interactions to persuade them to abandon their

male-female reformer coalition and stop pressing for change. I find that the effectiveness of

defenders‟ gender-based countertactics depends upon the initial degree of gender threat present

in the organization.

In what follows, I first review the existing literature on social movement reform

implementation inside organizations and describe the research setting and the details of the

research design. I then explain the difference in outcomes at the three hospitals by recounting

how male and female reformers at QUICKFAIL, SLOWFAIL, and SUCCEED mobilized with

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one another (or not) and how defenders undermined the reformers‟ male-female coalitions (or

not). I end by discussing the implications of gender-based countertactics and gender threat for

understanding social movement outcomes and gender in organizations.

SOCIAL MOVEMENT REFORM IMPLEMENTATION IN THE LITERATURE

The Importance of Internal Reformers

Social movement theorists have argued that internal reformers, also called “mediators”

(Moore, 1999), “insiders” (Binder, 2002; Katzenstein, 1998), “employee activists” (Raeburn,

2004; Scully & Segal, 2002; Taylor & Raeburn, 1995) and “tempered radicals” (Meyerson, 2003

[2001]; Meyerson & Scully, 1995), are critical to accomplishing social movement outcomes

inside organizations.

Who are internal reformers? Internal reformers are organizational insiders who join in

collective action for change because they are also members of a social movement (e.g. Creed &

Scully, 2000; Lounsbury, 2001; Moore, 2008; Raeburn, 2004) or because they share a social

identity or reformist goals that coincide with the collective identity or goals of a movement (e.g.

Kellogg, 2009; Meyerson, 2003 [2001]; Meyerson & Scully, 1995; Scully & Segal, 2002; Weber

et al., 2009; Zald et al., 2005). These actors are critical to accomplishing reform inside

organizations because they participate in everyday organizational practices in ways that external

activists cannot (Binder, 2002; Moore, 1999).

How do internal reformers mobilize for change? Internal reformers mobilize for change by

adapting resources created by external activists for use in their local settings and by leveraging

resources available within their organizations. Internal reformers may use frames and identities

created by external activists to demand the transformation of certain aspects of their

organizations and to pursue appropriate lines of action vis-a-vis opponents (e.g. Creed, Scully, &

Austin, 2002; Lounsbury, 2001; Rao, Monin, & Durand, 2003; Weber et al., 2009). Similarly,

they may employ mobilizing structures built by external activists—structures such as social

movement organizations and networks--to create the solidarity with a larger community needed

to launch and effective protest (Moore, 1996; Scully, Creed, & Ventresca, 1999). And they may

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use new regulations or other new organizational requirements to provide them with leverage to

demand change (Binder, 2002; Katzenstein, 1998).

Internal reformers may also draw on resources available to them inside their own

organizations to frame problems, to propose solutions by collective action, to organize with one

another, and to create political opportunities. For example, reformers may persuade supportive

organizational elites to provide them with monies or staffing structures to assist them in their

mobilizing efforts (Kellogg, 2009; Raeburn, 2004; Scully & Segal, 2002). Alternatively, internal

reformers may rework existing identities and beliefs to create a “we” feeling across various

identity groups and to craft arguments for change (Katzenstein, 1998; Kurtz, 2002; Meyerson,

2003 [2001]) . They may utilize pre-existing employee networks or spaces to organize with one

another (Kellogg, 2009; Raeburn, 2004; Scully & Segal, 2002; Zald & Berger, 1978). And, they

may create new political opportunities by using their representation on organizational taskforces

to communicate with organizational elites (Meyerson, 2003 [2001]; Raeburn, 2004).

When do internal reformers successfully implement reform? Success in implementing social

movement reform depends both on the strength of these available external and internal resources

and on the internal reformers‟ connection with those who control these resources. Strong external

resources consist of social movement frames or identities that resonate with the beliefs of those

within the organization (e.g. Creed et al., 2002; Rao et al., 2003), mobilizing structures that allow

reformers to build solidarity with one another (e.g. Clemens, 1993; Moore, 1996), and political

opportunities or threats that lower the costs of collective action (Katzenstein, 1998; King, 2008).

Strong internal resources consist of monies or organizing structures provided by organizational

elites to assist in reform and of pre-existing structures inside the organization, such as networks,

taskforces, or free spaces that reformers can co-opt to mobilize with one another (e.g. Kellogg,

2009; Raeburn, 2004). The more internal reformers are connected to external activists and

supportive organizational elites, the more likely they are to have access to these resources

(Binder, 2002; Katzenstein, 1998; Moore, 1999).

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Bringing Internal Defenders and Gender into our Understanding of Reform

Implementation in Organizations

As I will describe in detail below, the concept of internal reformer mobilization explains

why the reform was quickly defeated at QUICKFAIL—would-be internal reformers there did not

have access to strong external or internal resources and therefore failed to mobilize with one

another. However, although internal reformers at both SLOWFAIL and SUCCEED had access to

strong internal resources and although they mobilized with one another at both hospitals,

SLOWFAIL ultimately rejected reform while SUCCEED embraced it. To understand this

difference in outcomes, we need to bring an understanding of both defender countertactics and

gender into our explanation of social movement reform implementation.

Most social movement theorists studying reform implementation inside organizations

have emphasized the importance of internal reformers, but they have devoted little attention to

internal defenders (see Creed et al., 2002; Katzenstein, 1998; Kellogg, 2009; Taylor & Raeburn,

1995 for exceptions). In addition, few studies have explored the face-to-face dynamics of male-

female reformer coalitions inside organizations (see McAdam, 1988a for an exception). Finally,

to my knowledge, no prior studies have delineated how male-female coalitional dynamics unfold

inside organizations composed of both reformers and defenders. Yet, understanding such

dynamics is critical because many social movement reforms, such as those related to civil rights,

gay rights, environmental protection, or occupational health and safety, depend for their

implementation on the collaboration of male and female reformers inside organizations that are

also populated by defenders.

Gender theorists can provide some help in understanding the kinds of dynamics we might

expect to see in such contexts. They highlight three aspects of “doing gender” (West &

Zimmerman, 1987) that are important to the analysis presented in this paper: 1) hegemonic

masculinity, 2) gender policing and 3) embattled organizational contexts.

Regarding hegemonic masculinity, gender scholars call attention to how, in general,

masculine identities are linked to higher social positions than are feminine identities (e.g.

Ridgeway, 2009; Ridgeway & Correll, 2004). In addition, a particular male identity in any given

culture is associated with the highest status; this male identity is “hegemonic” (Connell, 1987,

1995) in the sense that the values, beliefs, and practices associated with it reinforce the idea that

men have a rightful claim to wealth, strength, and power in society. In modern Western society,

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hegemonic masculinity is associated with the everyday performance of stereotypically masculine

characteristics such as independence, strength, aggressiveness, toughness, competition,

rationality, and confidence and the avoidance of stereotypically feminine characteristics such as

dependence, weakness, passivity, softness, nurturing, emotionality, and timidity (see Ridgeway,

forthcoming for a review).

The privileges that hegemonic masculinity confers are not absolute but must be

negotiated and renegotiated in day-to-day interaction (e.g. Ely & Meyerson, 2009). Men as a

group engage in a particular set of “masculine” cultural practices to distinguish themselves from

women as a group and to justify an unequal distribution of resources on the basis of this

distinction (Martin, 2001; Martin, 2003). To protect hegemonic masculinity and the privileges

associated with it, men “police” (Kimmel, 1994, 1996) each other for signs of femininity and

ostracize and stigmatize those who do not perform masculinity adequately.

For men to conform to the dominant ideals of manliness and to preserve the privilege

they enjoy by so conforming, they must distance themselves from all acts associated with

femininity. This is harder for them to do in some organizational contexts than in others. For

example, men who pursue careers in occupations such as elementary school teaching,

librarianship, nursing, or temporary office work face particular challenges to their masculinity

because these occupations are predominantly populated by women and because they require the

performance of stereotypically feminine acts such as caretaking or deference (Williams, 1993,

1995). Men working in such “embattled” (Dellinger, 2004) organizational contexts have been

shown to be more vulnerable to having their masculinity threatened, and to try to protect their

masculinity (and the power and advantage this identity confers) by engaging in compensatory

manhood acts such as distancing themselves from their female counterparts or resisting demands

to perform traditionally feminine acts (Willer, 2010).

This literature helps us to understand how gendered processes shape the behavior of men

inside organizations. However, to explain the divergence in social movement outcomes I saw at

SLOWFAIL and SUCCEED, it is necessary to reformulate the concepts of “embattled”

organizational contexts and “gender policing” in two ways. First, because those studying

embattled organizational contexts have studied domains populated predominantly by women, we

do not understand the contextual factors that make masculinity more vulnerable to threats in

domains such as surgery that are populated predominantly by men. Second, because those

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studying gender policing have not focused on male-female coalitions, we do not understand the

ways defenders of the status quo can use gender policing to block collective action for change by

dividing and conquering these coalitions.

In this article, I argue that defenders of the status quo may try to divide a male-female

reformer coalition by labeling reform practices as feminine, by denigrating the masculinity of

male reformers, and by recruiting male reformers to the defender group. I demonstrate that, when

gender threat inside the organization is high to begin with, male reformers may be particularly

vulnerable to challenges to their masculinity. They may try to protect their masculinity and the

privileges associated with it by distancing themselves from feminine labels and practices and by

visibly aligning themselves with male defenders. This, in turn, may undermine the male-female

coalition and cause social movement reform implementation to fail.

In what follows, I review the methods used in the study and then describe how reform

implementation unfolded in the three hospitals and why.

METHODS

The methodological strategy employed in this paper draws on qualitative data collection

and historical comparison to generate grounded theory. The three hospitals studied,

QUICKFAIL, SLOWFAIL, and SUCCEED, were selected because they are located in the same

region, they did similar work, and they responded to the same regulation. The sequence of the

research was 1) new regulation was announced; 2) three similar hospitals were studied during the

period just before and one year after the introduction of new formal programs designed to

comply with the regulation; 3) data were examined to determine the process by which reform

was implemented at one hospital and not the other.

Study of Matched Cases

QUICKFAIL, SLOWFAIL, and SUCCEED are remarkably similar on each of the

organizational characteristics that have been shown to affect organizational change in response to

external pressure (Table 1). They are all teaching hospitals associated with major medical

schools in the same urban geographic area. They are each public sector organizations, they share

a positive performance history and image, and they employ residents with similar backgrounds.

The hospitals also are well matched in terms of top manager interests and surgical conditions

treated on the services studied.

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--------------------------Insert Table 1 about here--------------------------------------

Authority relations in the three hospitals were also similar. Indeed, before this regulation,

the structures of surgical residency programs nationwide were remarkably consistent.

Professional training in surgery followed the same widely accepted protocols in the majority of

hospitals, and the work of residents in general surgery was organized similarly. In the

professional bureaucracies of hospitals, directors of the surgery department were surgeons who

managed administrative issues associated with the activities of the other staff surgeons and the

surgical residency program but who had little authority over the day-to-day practices of these

staff surgeons. Staff surgeons brought revenue to the hospitals by bringing in surgical patients.

These staff surgeons were assisted by the surgical residents and, in turn, provided these residents

with hands-on training.

There were several differences among the hospitals, but none can explain why

QUICKFAIL and SLOWFAIL did not implement reform while SUCCEED did. The first is size.

SLOWFAIL is larger than SUCCEED, and SUCCEED is larger than QUICKFAIL. On the one

hand, theorists have hypothesized that larger organizations may be more likely than small ones to

implement change in response to external pressure because they are more visible to governance

bodies. On the other hand, larger organizations may be more difficult to change than smaller

ones. There is no clear size-related pattern in the outcomes. Change was not implemented at

QUICKFAIL (the smallest hospital) nor at SLOWFAIL (the largest hospital) yet it was

implemented at SUCCEED.

Second, differences in the status of the residency programs appear to have had little

effect. There is no clear status pattern in the outcomes at the hospitals. SLOWFAIL and

SUCCEED are high-status residency programs while QUICKFAIL is a middle-status program.

But both SLOWFAIL and QUICKFAIL resisted change while SUCCEED embraced it.

Third, the hospitals experienced slightly different forms of regulatory pressure, yet these

differences cannot explain why SUCCEED reformed while QUICKFAIL and SLOWFAIL did

not. In the Spring of 2002, the American Council for Graduate Medical Education (ACGME)

announced that the new regulation would go into effect in July 2003. Both QUICKFAIL and

SUCCEED experienced additional pressure because the ACGME had scheduled an impending

site visit; they both introduced their compliance programs during the residency year of July,

2002-June, 2003 in order to signal their good intentions to the ACGME. However, SLOWFAIL

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did not introduce their compliance program until the following year, when the regulation actually

went into effect, because they were not up for review from the ACGME until later.

The difference in form of regulatory pressure (ACGME site visit versus regulation

officially in place) cannot explain the difference in change outcomes. In 2002, QUICKFAIL and

SUCCEED both had ACGME site visits, yet only SUCCEED effected change. And,

SLOWFAIL did not accomplish change during the year I studied them even though the

regulation was actually in effect during that year. One might expect that the environmental

pressure that SLOWFAIL faced of officially mandated work hours reduction (and the risk of loss

of accreditation this posed) would be a greater in forcing change than would the environmental

pressure that SUCCEED and QUICKFAIL faced of a site visit (and the risk of new formal

requirements for change this posed) during a time when change was not yet officially mandated.

Yet, SUCCEED effected change and SLOWFAIL and QUICKFAIL did not. Thus, differences in

form of regulatory pressure cannot explain the difference in outcomes.

Finally, resident demographics at the three hospitals also varied. QUICKFAIL had a

higher percentage of female residents than did SLOWFAIL and SLOWFAIL had a greater

percentage of female residents than did SUCCEED. Given the current literature which

emphasizes the importance of internal reformers in effecting change, we might expect that

hospitals with the highest percentage of female residents (QUICKFAIL and SLOWFAIL) would

embrace change since female residents were more avid internal reformers than were male

residents. Yet, I find just the opposite, and will explain this counterintuitive result in further

detail below.

Data Collection

One methodological advantage of a field study is that it provides real-time data that span

the period in which the change happened. At each hospital, I conducted semi-structured

interviews with residents at two different points in time: once before their new compliance

program was introduced and again 12 months later at the end of the residency year (Table 2).

Interviews were performed at the hospital and on average lasted thirty minutes to one hour. I

recorded the interviews, which were transcribed verbatim, and took notes. I also spent time

informally talking to groups of two and three residents in the surgical resident lounge and

hospital cafeteria both before the resident year under study began and at its end. These interviews

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were part of a larger ethnographic study of response to the new regulation in surgery that I

conducted from 2002-2004.

--------------------------Insert Table 2 about here--------------------------------------

I began my study of QUICKFAIL, SLOWFAIL, and SUCCEED by conducting a

“surface analysis” (Spradley, 1979) of the culture and work practices before the initiation of the

change effort. Based on what I learned from my initial interviews, I then made some delimiting

choices about the particular area on which to focus my in-depth analysis (Spradley, 1979).

Because interns (first-year residents) had traditionally worked the longest hours and would

therefore be most affected by the changes and because the actions of the chief residents would be

critical to interns‟ compliance with the new regulation, I focused specifically on the practices

that interns and chiefs would need to change to help the interns comply with the new regulation.

In order to gauge pre-change support for the reform, in my pre-change interviews I asked

respondents questions about how the impending changes would affect patient care, resident

education, and their own quality of life outside the hospital. I also asked them to report their

overall attitude toward the reform. In my post-change interviews, I asked them to explain how

the change process unfolded at the hospital—who was supportive of it, who opposed it, and the

actions related to the reform that were undertaken by both interns and chief residents. I did not

ask any explicit questions about gender. Instead, gender-based themes emerged unsolicited as

respondents discussed the traditional surgical culture in pre-change interviews and answered

questions about how reform unfolded in their post-change interviews.

To measure how everyday practices actually changed in response to the new regulation, I

purposely did not ask interns how many hours per week they were working before and after the

proposed changes, for I was told by the residents that there might be pressure on interns to

misreport their work hours so that the hospitals would not risk sanction from the ACGME in the

event of violations. Instead, I asked interns and chiefs in pre-change interviews which work

practices would be required to enable interns to reduce their work hours to 80 per week in

compliance with the new regulation and how often they currently engaged in these work

practices. In my post-change interviews, I asked interns and chiefs how often they participated in

each of these work practices required for intern compliance.

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Analysis of Contradictory Outcomes

Once I had determined that changes in everyday practice had occurred at SUCCEED and

not at QUICKFAIL and SLOWFAIL (analysis of outcomes explained in further detail below), I

contrasted the three cases to identify the processes associated with the different outcomes. My

inductive analysis (Glaser & Strauss, 1967) consisted of multiple readings of interview

transcripts as well as the tracking of patterned activities and issues related to change in

ATLAS/ti, a qualitative data analysis program. In my coding of the interview transcripts, I

associated virtually every passage with one or more codes that flagged highly specific but

recurring topics related to change in the targeted practice. I provide more information about my

analyses below.

EXTERNAL ACTIVISM

In 2002, a coalition of patient rights‟ and resident rights‟ activists won new regulation

limiting the work hours of medical trainees in U.S. teaching hospitals. Over the prior two

decades, activists had drawn the public‟s attention to the fact that surgical trainees (called

“residents”) were working approximately 120 hours per week during their five-year training

programs (Mukherjee, 2002). In television programs, newspapers, magazine articles, and court

testimony, patient‟s rights and resident‟s rights activists emphasized the dangers that these long

hours posed to patients and to the residents themselves. In the New York Post, a Jacobi Hospital

resident and president of the Committee of Interns and Residents told about a resident nodding

off while assisting in the operating room during a liver transplant: “He was holding a patient‟s

liver and fell asleep, and someone grabbed it before it hit the floor” (Rubinowitz, 1999). An

article in The Washington Post quoted a resident as saying, “You actually start wishing patients

would die so you could get some sleep”(Boodman, 2001).

A countermovement fought back, arguing that although there was much public

skepticism around tired residents and patient safety, the public did not understand that reducing

resident work hours would actually lead to an increase rather than a decrease in the number of

patient errors. They suggested that reducing hours would result in a greater number of handoffs

of patient care between residents and so would be less safe for patients (e.g. Petersen, Brennan,

O'Neil, Cook, & Lee, 1994). But the countermovement failed to persuade the public, and the

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activists successfully pressured the American Council for Graduate Medical Education

(ACGME) to introduce new work hours regulation limiting resident work hours.

SIMILAR INITIAL CONDITIONS AT THE THREE HOSPITALS

Similar Efforts by Organizational Elites

After some initial muddling, directors of the surgery departments at QUICKFAIL,

SLOWFAIL, and SUCCEED all decided to comply with the new regulation by initiating night

float programs. Night float programs, which reduced resident nights on call by adding additional

surgical residents to general surgery services to create teams of residents working overnight each

night, were fairly standard. They had been in place, albeit with mixed results, for over a decade

in New York State, where work hours had been regulated since 1989. The directors at each

hospital successfully secured the resources for new night float programs by negotiating with

hospital top managers and with department directors outside of general surgery to eliminate other

surgical resident rotations (such as those in less busy areas at their own hospitals or at outside

community hospitals) so that their own surgical residents would be freed up to serve on night

float teams that would cover the general surgery services.

Similar Defenders: The Hegemonic Identity of Iron Man

Rather than embracing work-hour reduction and feeling relief at the easing of their work

schedules, some residents at both hospitals expressed moral outrage and resisted the change. To

understand why residents resisted a change that would seem to benefit them, it is necessary to

understand the hegemonic identity of the “iron man” within surgery.

Historical antecedents of the iron man identity. Surgeons and surgical residents have

traditionally described themselves and have been seen by others in and outside of the hospital as

action-oriented male heroes who single-handedly perform death-defying feats and courageously

act with certainty in all situations (Cassell, 1998; Katz, 1999). This image of surgeons as active

heroes originated in the Middle Ages when military surgery was performed amidst perilous

conditions and lives were saved despite hazardous hygienic conditions. It has been perpetuated in

contemporary times (Katz, 1999).

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Iron man demeanor. Residents at QUICKFAIL, SLOWFAIL, and SUCCEED acted out a

masculine “iron man” (their term) identity on a daily basis as they went about their daily work,

dressing and acting in prescribed ways, keeping a rigorous schedule of long hours, and telling

stories to each other that ratified the stereotype of the “iron man.” Iron men at each hospital

aspired to be seen as “go-to guys” with “hairy balls” who could be counted on to singlehandedly

“make it happen,” no matter what the circumstances. Everything about their demeanor was

macho: short haircuts, tucked-in scrubs worn low on the hips, green surgical caps and masks

around necks long after leaving the OR [operating room], and well-toned, muscular bodies

(achieved by male chief and senior residents by a daily regimen of weightlifting at the gym).

The QUICKFAIL, SLOWFAIL, and SUCCEED iron men took the schedule and vacations given

to them with no questions asked, and they rarely mentioned relationships with others outside of

the hospital, except for joking references to “the wife” being irritated at their long hours. Much

of their conversation with other residents involved fantasized or actual sexual exploits of team

members involving conquistador “house calls” and “smokin‟ [hot] interns” whom they ranked

according to desirability. They also used battle and war metaphors repeatedly, talking about

“rescue missions” and “victories” in the OR. Here is a compilation of their favorite sayings,

which emphasized decisive action, risk-taking, and toughness:

Often wrong, but never in doubt.

Always be the go-to-guy; never turn down a case.

If you wanna make an omelet, you gotta break some eggs.

No one is perfect; that‟s why it‟s a 7 year program.

Never let the skin get between you and the diagnosis; jump in there and figure out

what‟s going on.

The only prescription this patient needs is hot lights and cold steel.

You can stand on your head in a bucket of shit for 5 years if you have to--they

can‟t stop the clock; every day you get up is one day less of residency.

Iron man discourses. Iron man discourses in the areas of patient care, education, and work-

personal life integration were widely shared. Iron men believed that patient care should be

provided continuously by one individual who has command of a patient‟s particular history and

surgical needs. In terms of education, they thought that a reduction in hours would mean that

they would participate in surgeries less often and thus their training would be shortchanged.

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Residents, they thought, learned best under pressure. Finally, they suggested that it was not

possible to learn everything they needed to know as residents or to provide good patient care

unless they focused solely on surgical residency.

Iron man hierarchical behaviors. Iron men observed a strict hierarchy and accepted the fact

that tasks and responsibilities should be rigidly prescribed by position. Staff surgeons were the

masters of the residents; they routinely acted out their power by surrounding themselves with

residents whom they expected to revere them for their boldness and deftness in the operating

room. Next in line were the chief residents, “commanders” of the team and molders of the junior

residents. Finally, occupying the lowest rung on the ladder, came the interns, who feverishly

worked to display their potential for iron man prowess.

Iron man work routines. In their daily work routine, residents drew on these demeanors,

discourses, and authority relations as ways of acting out the iron man identity. Of course, in

practice, “total and complete responsibility” was impossible. At the end of a shift, a resident had

little option but to transfer any work not completed during the day to another resident. In order to

keep up the iron man persona in the face of this reality, surgical interns worked long shifts.

Historically, they arrived at the hospital at 4am to pre-round on patients, and often left at about

10pm after all of their routine work on patients was completed. To ensure continuity from the

operative through the post-operative period, interns waited for their chiefs to be out of the OR at

night before engaging in afternoon rounds, even though that often meant they needed to stay long

past when they had any work to do at the hospital. They also rounded on patients in the ICU even

though a separate ICU team existed, and they did not hand off work to physician assistants

(PAs).

In the minds of many interns, the iron man identity was justified on the grounds that it

underwrote a good education. There was little formal teaching except in conferences, which

interns seldom attended or, if they did, usually slept through. Real teaching, they felt, took place

in the OR and on the floors, or else it occurred at night, when they learned by making decisions

on their own (so as not to wake up more senior surgeons with questions). And, finally, interns

learned when their chiefs “pimped” them by aggressively asking them rapid-fire questions about

how they would manage particular patients or situations.

Iron man status. In the U.S., surgeons have traditionally occupied a high position in the status

hierarchy of the medical profession and in society as a whole. At the three hospitals studied here,

16

surgical residents derived their status from conforming to iron man discourses and actions that

distinguished them from workers in other professions and from doctors in non-surgical

disciplines. One SLOWFAIL iron man said:

It‟s not like being an airline pilot…I can tell you personally, from having been up

several days in a row, and someone unwell that comes in, you know exactly what

to do and what needs to be done and I‟ll guarantee you that at the same post-

graduate year of training that I could outthink or outperform any of our colleagues

in other disciplines if a crisis came around. Because that‟s what we‟re trained for.

Similarly, a QUICKFAIL defender related: “Supposedly the director of the medical residents

told them that now that the surgical residents are going to the 80-hour workweek, the medical

residents will now be the workers in the hospital. And everyone will take surgery down off their

pedestal.”

Finally, iron men derived their status from belonging to a predominantly male profession.

Historically, many female medical students had avoided choosing to pursue careers in surgery

because becoming a surgeon required committing to 5-7 years of 120-hour workweeks (Zinner,

2002). A reduction in weekly work hours would make the surgical career more amenable to

women.

At the time of my study, the power and prestige of surgery had already begun to erode

(e.g. Cassell, 1998). The 80-hour workweek was just one more in a series of changes that

threatened the iron man and his status. One SUCCEED defender explained:

When I first started, surgery ruled the roost. It was testosterone city… The chief

resident was the boss of the hospital. When the chief spoke, that was it. I don't care

if there were machine guns in the way, it got done. The chief was king and the

residents were his army…. It was a battlefield mentality. Stuff hitting the fan,

boom, boom, boom. It was like the Wild West. You just did everything. If

someone got in your way, you let them know it. Now you would end up in

[Director‟s] office with a letter in your file. One of my chiefs told the MICU

[medical intensive care unit], “you assholes are killing this patient.” If you say that

now you are dead….

Every surgery resident used to be at codes [emergency surgeries]. Now it is a

special code team and if it is a medical patient, the meddies are in charge. Now you

have to watch them fiddle around. In the old days the chief would walk in and say,

“I'm running this code.”

Now there‟s a lot more malpractice suits going on. And we have to be much more

political with the other services. We used to run the ICU with an iron fist. Now we

are neutered there.

17

Once we understand the iron man identity and the power and prestige that had historically been

associated with it, it is easier to comprehend why some residents resisted a change that seemed to

be designed to benefit them. At each hospital, defenders of the status quo were composed

primarily of chief and senior male residents who were able to accomplish most of the actions

required to live up to the iron man ideal. Because they were single or had wives or girlfriends

who were willing to cook for them, do shopping and housecleaning, provide childcare, and put

up with frequent last minute cancellations of social plans, these high-status residents were able to

demonstrate iron man demeanors and engage in iron man work practices on most occasions.

More Internal Reformers at SLOWFAIL than at QUICKFAIL and SUCCEED

But not all residents at the three hospitals were comfortable with the iron man identity,

and those who were not became advocates of reform. Reformers fell into four groups: 1) male

chief residents who could not live up to the iron man ideal because they had significant others

who expected them to take on personal life responsibilities outside the hospital; 2) male interns

who did not want to live up to the iron man ideal because they wanted to continue to participate

in personal life activities they had been engaged in before residency; 3) female chief residents

who could not live up to the iron man ideal because they wanted to meet gender-based personal

life responsibilities outside of the hospital or because they were sanctioned when they tried to act

like iron men while doing their work within the hospital; and 4) female interns who could not

live up to the iron man ideal and who wanted to continue to participate in personal life activities

they had been engaged in before residency (Table 3).

Before the new programs were introduced, the beliefs of defenders and reformers at

QUICKFAIL, SLOWFAIL, and SUCCEED were similar to one another. Based on the interviews

I conducted before the night float programs were established, there were a higher number of

reformers at SLOWFAIL than at either QUICKFAIL or SUCCEED (Table 3).

--------------------------------------Insert Table 3 about here-------------------------------------

Weak External Resources for Internal Reformers at QUICKFAIL, SLOWFAIL, and

SUCCEED

Once the new night float programs were introduced at the beginning of the residency

year, male and female reformers at the three hospitals tried to mobilize for change. They did so

18

by co-opting internal resources rather than by leveraging external resources. The frames and

identities developed by the external activists were not helpful to the internal reformers at

QUICKFAIL, SLOWFAIL, and SUCCEED. For example, while external activists had framed

current practices as unsafe for patients and harmful to residents, internal reformers had a vested

interest in not conceding that patient care and their own education may have been diminished by

past practices. Similarly, the identity that the movement had provided of the overtired and

overworked resident who was dangerous to patients was not attractive to residents who would

sometimes be working overnight when they joined the profession as staff surgeons.

The mobilizing structures provided by external activists were not helpful to internal

reformers either. Internal reformers‟ efforts were limited by their desire to protect their own

professional status even as they attempted to enact changes in work practices. Therefore, these

reformers eschewed association with external activists who could have afforded them a

collective sense of agency and solidarity and informed them of tactics that had been used

successfully in other hospitals. One reformer noted, “As a surgical resident, I‟m not going to join

a union. That would be the death of your career.”

DIFFERENCE IN INTERNAL REFORMER MOBILIZATION AT QUICKFAIL

VERSUS AT SLOWFAIL AND SUCCEED

QUICKFAIL: Weak Internal Resources and No Internal Reformer Mobilization

Differences in internal resources available to reformers explains why QUICKFAIL so

speedily rejected reform while SLOWFAIL and SUCCEED did not. At QUICKFAIL, there were

no spaces available where reformers with diverse identities and work positions could interact

with one another apart from defenders while at SLOWFAIL and SUCCEED there were. In the

absence of relational spaces, QUICKFAIL reformers did not develop an assurance that reformers

from different subgroups would each complete the diverse tasks required to successfully

accomplish reform. They did not develop new role expectations for reformers from different

subgroups. And they did not create justifications for a new task allocation and role expectations.

Without building a new relational efficacy or new identities, and frames, they were not able to

create a unified collective with one another across subgroups.

Instead, individual reformers attempted individual change, and defenders pushed back by

using countermovement frames suggesting that reform would be harmful to both patient care and

19

resident education. Individual reformers quickly capitulated in the face of these arguments and

QUICKFAIL rejected reform.

SLOWFAIL and SUCCEED: Strong Internal Resources and Strong Internal Reformer

Mobilization

In contrast, at both SLOWFAIL and SUCCEED, spaces existed apart from defenders that

allowed male and female reformers from different work positions to mobilize with one another.

In these spaces, reformers built a set of common reformer identity claims, frames, and practices

that represented all reformer subgroups and that unified these subgroups against a common

defender adversary.

Male and female reformers across subgroups defined themselves in opposition to

defenders by referring to themselves as “progressive residents,” “team players,” “complete

doctors,” and “surgeons with a life.” They used a common set of frames that ran counter to

defenders‟ frames -- that both men and women could be good surgeons, that it was possible to

achieve continuity of care in the team, that it was important to learn by reading and working in

the clinic in addition to learning by operating, and that residents learned better when they were

well rested.

In addition, they used a common set of oppositional practices. Reformer chiefs

introduced three practices to help interns comply with the new rules. First, at the end of the day

after afternoon rounds, they helped the interns finish their “scutlist” (a list of tasks that their chief

resident had told them to complete during the meeting where each patient on the team was

reviewed). This was important to accomplishing change because it was easier for the on-call

intern if the departing interns implemented “ordered” from afternoon rounds before leaving the

hospital. Second, reformer chiefs encouraged interns to hand off uncompleted work to the night

float resident and leave the hospital. To encourage interns to hand of their work, they refrained

from punishing them if they handed off work and the night float was not able to complete it. This

was important because interns would have been hesitant to hand off routine work to the on-call

intern if they were reprimanded if the work was not completed by the night float. Thirdly,

reformer chiefs did not have the interns come in on weekends when they were supposed to be

off.

20

For their part, interns at both hospitals initially acted for change by handing off two kinds

of routine work to the night float residents— “admits” (patients newly arriving in the hospital

who needed to be checked-in) and “post ops” (patients in the post-operative care unit who

needed to be checked on 4 hours after they had come out of surgery).

Reformers‟ identity claims, frames, and practices were inclusive of the key concerns of

each of the reformer subgroups—male chiefs, male interns, female chiefs, and female interns—

so they allowed reformers to build a “we” feeling across groups. In addition, they enabled

reformers to see themselves as a unified group in contrast to a common adversary of “old school”

residents.

SIMILAR DEFENDER GENDER-BASED COUNTERTACTICS AT SLOWFAIL AND

SUCCEED

At QUICKFAIL,in the absence of spaces apart from defenders to coordinate their efforts,

internal reformers had individually attempted change and defenders had pushed back on handoffs

by warning interns about how handoffs led to poor patient care and inadequate resident

education. At SLOWFAIL and SUCCEED, in contrast, internal reformers collectively

challenged defenders. By organizing with one another to attempt handoffs in the face of

resistance, reformers struck at the very heart of the iron man‟s world. Handoffs challenged not

only the traditional practices the defenders were skilled in using but challenged, too, the

hegemonic iron man identity they had perfected and that afforded them high status in the

profession and in society-at-large. This was all-out war.

In response, defenders at both SLOWFAIL and SUCCEED turned to harsher strategies of

retaliation. They began to label their enemies “weak,” “softies,” “part-timers,” “wusses,” “panty-

waists,” “girls”--in short, females. Their countertactics involved a three-pronged attack, all

designed to divide the reformer coalitions at their hospitals: 1) labeling reformer practices as

feminine, 2) denigrating the masculinity of particular male reformers and 3) recruiting male

reformers into the defender group (Table 4).

--------------------------Insert Table 4 about here--------------------------------------

Labeling Reformer Practices as Feminine and Traditional Practices as Masculine

As noted above, gender scholars have demonstrated that men who exhibit stereotypically

masculine characteristics and avoid exhibiting stereotypically feminine characteristics enjoy the

21

highest status in any given the social system (e.g. Connell, 1987). In the United States,

stereotypical masculine characteristics have been shown to include forcefulness, intensity,

aggressiveness, willingness to take risks, competitiveness, rationality, decisiveness,

assertiveness, ambition, leadership ability, athleticism, independence, and individualism (see

Ridgeway, forthcoming for a review). Stereotypical feminine characteristics have been shown to

include weakness, yielding, warmth, understanding, tenderness, sympathy, softness, shyness,

sensitivity to the needs of others, loyalty, loving of children, gentleness, eagerness to sooth hurt

feelings, avoidance of the use of harsh language, compassion, cheerfulness, and affectionate

behavior (Ridgeway, forthcoming).

Defenders at SLOWFAIL and SUCCEED labeled the reform as feminine by using

gender-based language to describe reform practices and reformers. For example, they suggested

that the work-hours reform had made surgical residents “soft” and “weak.” A SUCCEED

defender said:

When you think of surgeons, they are rough around the edges. They are hard core

spitting and swearing and burping. Lots of flexing of muscles. Now the interns are

a bunch of softies.

Defenders also used gender-based intonation that emphasized the stereotypical female

characteristic of emotionality, helpfulness, and sensitivity to the needs of others. In talking about

reform at the end of the year, one SLOWFAIL chief asserted, “All of this stuff about [and here

he imitated a high female voice] „Ooooh I‟ll do this for you. Ooooh, let me help you get out of

here.‟ It‟s bullshit. The interns need to learn to do it themselves.”

In contrast, they labeled traditional practice as masculine. One SUCCEED defender said:

I came here because in elite surgical residencies you get trained to do anything at

anytime. You can do anything. That's what it is all about. It's about feats of

strength. We are the strongest in the hospital. We'll be there anytime to do

anything. We work the hardest. We're here the most. We have the most grueling

hours. I like doing it. To me that is what surgery is.

The interns from day 1 hit the ground in a different light. Their expectations of

when and how it needs to get done are different. They think about hours and

responsibility differently than we did. This perspective of being the marines, of

being unbreakable, isn‟t there for them.

Similarly, one SLOWFAIL defender said:

The interns are a bunch of panty waists. When I was an intern on cardiac, I never

left (the hospital). Two of us covered it all. Now they have 32 residents, a (staff

surgeon) in the cardiac ICU and 6 PAs (physician‟s assistants) on the floor. I took

22

vein all the time [harvested veins in vascular surgery]. They never do…(with

disgust) It‟s all part of the kinder, gentler residency.

Denigrating the Masculinity of Male Reformers

In addition to labeling reformer practices as feminine and traditional practices as

masculine, defenders denigrated the masculinity of particular male reformers. Sometimes, they

directly told male reformers that they were acting feminine. For example, one SUCCEED male

intern said: “My first chief told me that, even though the official rules required us to leave at

6pm, if I handed off, I‟d get a reputation for being weak.” A SLOWFAIL female reformer

recounted, “If the interns said, ‟I‟m going to head out,‟ the old school chiefs would ridicule them

and say „You‟re so weak. Don‟t be a wuss.‟ They do it to the guys, not the women.”

At other times, defenders denigrated the masculinity of male reformers indirectly,

gossiping about their femininity behind their backs. They told stories about particular male

reformers in which they referred to them as “weak,” “softies,” “part-timers,” “wusses,” “namby-

pamby,” and “girls.” For example, one SUCCEED defender talked with evident distaste about an

intern who had tried to comply with the new rules about less overnight call:

One of the interns, Clark [male intern] didn't want to take call on a Sunday. The

night float wasn‟t here on Memorial Day weekend, so Clark had to take call and

wanted a day off to make it up. So the third years and others on for the weekend

had one less person on call during the day, and everyone else had to split Clark‟s

work. In the old Iron Man weekend system we had a three week cycle. And the

intern often had back-to-back power weekends because when we'd switch rotations

that's how we'd come into the cycle. That was just the way it was. We were like,

“Clark is making such a big deal over one day of call. Are we really that soft? Oh

man.”

A SLOWFAIL defender denigrated an intern who had left at the end of a work shift to go to a

picnic:

I had one intern who [at the end of his shift] was like, „Gotta go. I have to leave, I

have a picnic.‟ I kid you not, that‟s what he said, „I have a picnic to go to. I‟m

going to stay for a little and then I have to go.‟

While going to a picnic may not seem like a feminine act to a layperson, to defenders, “going to

a picnic” was beyond the pale, a clear sign of softness, of prioritizing the feminine domain of

home and hearth over the masculine domain of the organization. That another would put his

personal life ahead of work was a breach of some magnitude.

23

Recruiting Male Reformers into the Defender Group

The third countertactic the defenders used was to try to recruit reformers by letting it be

known that if a male reformer would change his ways, he would be re-integrated into the

defender group. Defenders shamed reformers and then told them specifically what they would

need to do to be forgiven. One defender chief related how he had handled a male intern who was

engaging in the reformer practice of leaving the hospital at the end of his work shift as the formal

rules required:

I had one intern who, when he first got onto the service, was weak…He was trying

to leave at 6:00 and get other people to do his work. So I beat on him. I would quiz

him in front of a group on the patients. I would put him on the spot and say, so

what did the CT show on Mr. Jennings… I was pissed off. I wanted (intern) to

understand with some negative reinforcement that it wasn‟t acceptable…. In two

days, he started to get it. He cracked. It was like an epiphany. Then he said, „I‟m

worried that I am not doing a good job” which for a guy who has gotten all As

through (elite university) and has never been told that he has done a bad job at

anything in his life, was intensely gratifying and he said, „What am I doing

wrong?‟ and I told him in pretty clear terms what I wanted him to do and for the

last week that I had him he started to do it.

Defenders also recruited male reformers to the defender group by visibly rewarding members of

their group with male camaraderie and games and by excluding those who persisted in reform

from the boys‟ club. For example, at SUCCEED, defenders paged one another to take a break

each day to “make rounds” or “go to the office.” “Making rounds” consisted of going by to

check out newly hired nurses or physical therapists who were judged particularly attractive.

“Going to the office” consisted of going to the front lobby of the hospital to rate the

attractiveness of women coming in and out. Male reformer chiefs were not invited on these daily

trips to “the office.” At SLOWFAIL, one male defender chief noted how he excluded male

interns who attempted reform practices by limiting interaction to “taking care of business” rather

than “joking around”:

If they kept doing it (attempting to hand off work), I just started telling them “Do

this, do this, do this...” I gave orders like they are a secretary, “Do these five

things.” I just took care of the business and that is bad. That is bad. When it gets

to that point, they know that you‟ve written them off.

24

SUBSEQUENT DIVERGENCE AT SLOWFAIL AND SUCCEED

Different Outcomes

While internal reformer mobilization was similar at SLOWFAIL and SUCCEED,

member action in the two hospitals diverged during the year. At SLOWFAIL, defenders divided

the reformer coalition and blocked reform implementation while at SUCCEED they did not.

In my pre-change interviews, residents at SLOWFAIL and SUCCEED had reported that,

to comply with the new regulation, interns would need to hand off routine work to the on-call

intern and that chiefs would need to encourage them to do so. There were two key practices that

interns would need to engage in to comply with the regulation and three key practices that chiefs

would need to engage in. By 6pm, interns would need to hand off any incomplete post ops

(checks on patients after they came out of the operating room) and any incomplete admits (new

patient admissions to the hospital). Chiefs would need to help interns with post-round to-dos

(new tasks that emerged in afternoon rounds), to not punish them for handing off work

uncompleted by 6pm, and to tell them not to come in on Saturdays when they were not scheduled

to do so.

To measure end-of-year intern actions, I gathered both intern self-reports and chief

reports about the interns. Similarly, to measure end-of-year chief actions, I gathered chief self-

reports and intern reports about the chiefs. Self-reports and other-reports were consistent with

one another unless otherwise indicated.

SLOWFAIL residents needed to falsify the time sheets they submitted to the ACGME in

order to refrain from using these work practices. One intern at SLOWFAIL related:

The suggestion that we are working 80 hours is farcical…It‟s not worth it to fill

out the timesheets correctly…You would be shunned publicly if you filled out

timesheets accurately.

Another commented:

The only way the outside knows if we do is by what residents report. And I would

be a fool to report SLOWFAIL and ruin my own training.

So, at SLOWFAIL, despite their initial support for change, in the end, most residents reversed

their early practices and resisted it.

At SUCCEED, my post-round interviews showed that interns had engaged in reform

practices early on as they had at SLOWFAIL but, unlike at SLOWFAIL, they also engaged in

25

reform practices at end-of-year. Interns handed off work to the on-call intern whenever they had

such work left to do at 6pm and chiefs supported them in their efforts. In addition, chiefs who

had been defenders at the beginning of the year by the end of the year had begun to use these

reformer practices, too (Table 5).

--------------------------Insert Table 5 about here--------------------------------------

Thus, we have two cases where internal reformers mobilized with one another and collectively

acted for change, but in one case reform was not implemente and in the other case it was. How

do we account for this difference in outcomes in organizations with similar internal reformer

mobilization?

Strong Gender Threat at SLOWFAIL but not at SUCCEED

I argue that the difference in outcomes at the two hospitals was associated with different

degrees of gender threat posed by female residents at the two hospitals even before the new night

float programs were introduced. As noted earlier, male residents in surgery historically had

maintained career dominance over female residents by occupying the highest positions in the

surgical hierarchy. In addition, male residents in surgery historically had maintained symbolic

dominance over female residents by using a set of masculine practices--demeanors, discourses,

positional behaviors, and work routines—as they went about their day-to-day work. This

combination of career and symbolic dominance had enabled male residents to maintain the

unequal distribution of resources (such as teaching by staff surgeons and recommendations for

further training) between male and female residents.

The dominance of male over female residents was important not only to the high-status

iron men but also to the lower status men who had enacted alternative masculinities even before

the introduction of the new night float programs (and who later became male reformers when the

night float program was introduced). Such dominance enabled all male residents to claim

membership in the highest status group and maintain privileges vis-à-vis female residents. Yet,

this dominance not equally strong at both hospitals. At SLOWFAIL, the career and identity

threats posed by female residents were strong, while at SUCCEED they were weak (Table 6).

--------------------------Insert Table 6 about here--------------------------------------

26

Strong Career Threat Posed by Female Residents at SLOWFAIL AND NOT SUCCEED.

Traditionally, residencies have been dominated by men, and male residents have occupied the

highest positions of the surgical hierarchy. As in hospitals across the country, at both

SLOWFAIL and SUCCEED, most years there were a much smaller number of female chief

residents than male chief residents. While female residents composed about a third of all

residents at each hospital, female residents tended to be clustered at the bottom of the surgical

hierarchy. On average, only about 10-15% of the chief resident classes were composed of female

residents. While about 45% of the intern classes were historically composed of female residents,

female residents exited the residency program at a greater rate than male residents, so there were

much fewer female residents at the top of the hierarchy than at the bottom.

But, as chance would have it, during the year the night float program was introduced at

the two hospitals, there was a much higher percentage of female chiefs at SLOWFAIL-- four

female chiefs out of ten total chiefs (40% female chiefs)--than at SUCCEED , where there was

only one female chief out of seven total chiefs (14% female chiefs). Because men had

historically been dominant, increasing numbers of women in high status positions at SLOWFAIL

led female residents to be perceived as a career threat by the male residents while they were not

perceived as a threat at SUCCEED.

Strong Masculinity Threat Posed by Female Residents at SLOWFAIL AND NOT

SUCCEED. In addition to seeing female residents as a threat to their careers, male residents at

SLOWFAIL saw female residents as a threat to their masculine identity and the high status

associated with it. At both hospitals, female residents challenged the historical symbolic

boundaries between male and female residents in some ways. For example, at both places,

female residents wore the same surgical scrubs as did the male residents and, like the male

residents, female residents in both hospitals told stories of idiotic medical residents, unflappable

staff surgeons, annoying nurses, and “trainwreck” patients (patients who were seen to have no

chance of living when they arrived). Female residents strode rather than walked through the

hospital, paged jokes back and forth to other residents, and lobbied their chief residents for more

difficult cases.

Yet, I was also struck by the fact that female residents at SLOWFAIL used a wider range

of masculine practices than did those at SUCCEED. In terms of dress, in the important space of

27

the operating room, SLOWFAIL female residents wore surgical caps like the ones worn by male

residents (and like those shown on TV) while at SUCCEED the female residents wore “shower

caps” like the lower-status nurses. Similarly, SLOWFAIL female residents, in my observations,

did not wear any jewelry or makeup while SUCCEED female residents did wear subtle jewelry

and makeup. In terms of demeanor, SLOWFAIL female chiefs told about giving their interns

nicknames, while at SUCCEED, it was the male chiefs who had the prerogative to award

nicknames. SLOWFAIL female residents told of going out drinking while SUCCEED female

residents told me they rarely did so. SLOWFAIL female chiefs told of “throwing bones”

(assigning cases that were officially above the required resident year) to their interns, while

SUCCEED female chiefs did not. Finally, SLOWFAIL female residents recounted episodes

where they had aggressively “told a staff surgeon to move over” in the operating room so that

they could take charge in the operation, while SUCCEED female residents reported avoiding

even being suspected of doing this.

There were certain masculine acts that even SLOWFAIL female residents did not engage

in. For example, SLOWFAIL female residents reported that they did not tell war stories of OR

prowess the way the male residents did nor did they aggressively pimp [rapidly quiz] interns or

lose their tempers. However, overall, SLOWFAIL female residents appeared to engage in many

more masculine acts than did SUCCEED female residents. Because they acted masculine in so

many ways, there was less of a distinction to begin with between female residents and male

residents at SLOWFAIL than at SUCCEED.

CAPITULATING TO GENDER-BASED COUNTERTACTICS AT SLOWFAIL

The differences in gender threat at the two hospitals led male reformers at SLOWFAIL to

be more vulnerable to masculinity taunts than those at SUCCEED. As a consequence of being

concerned about the loss of male privilege, male reformers at SLOWFAIL capitulated to

defender countertactics, engaging in compensatory acts and abandoning the reformer cause

(Table 7).

--------------------------Insert Table 7 about here--------------------------------------

28

SLOWFAIL Male Reformers Concerned about Loss of Male Privilege

Concerned about being seen as feminine. Though I did not ask any specific questions about

gender, when I asked about barriers to change, male interns at SLOWFAIL expressed concerns

about being seen as feminine. One said:

You hear all the time that “You don‟t work as hard as me. You don‟t operate as

much. You‟re weak.” You know the whole “back in the day” argument, and the

thing is you do get concerned about are you tough enough.

Another male intern related:

I think you end up feeling inadequate because of the level of expectations from the

old school chiefs. Because, historically, the intern always showed up at 4am and

basically pre-rounded. Now, it‟s supposed to be working rounds, so no pre-

rounding, and we are all supposed to get the numbers together. But, with the old

school guys, the few times I haven‟t come in early, it hasn‟t been

acceptable…They are obviously pissed off, you know, rolling their eyes and

calling you weak. It would also happen in the evenings, if you signed something

out …They make you feel like you‟re a wuss with an easy life. That you‟re not

man enough to be a surgeon. You know, like “When I was a kid I had to walk to

school in five feet of snow without my shoes on!”

Male reformer chiefs also expressed concerns about being seen as feminine. One noted:

I just wish these guys would stop making comments about 80 hour work week…I

think that it is very undermining to the interns, to the junior residents, and to all of

us, to make us feel like we‟re any less of a surgeon because of the new rules…I

think it‟s destructive always being like, “When I was a resident…When I was in

the Cardiac ICU, it was every other night post-call taking vein.” …They just like to

say how tough they were when they did it.

Concerned about being excluded from male club. Male reformers also expressed concerns

about not being accepted by the male defenders. One male intern said:

You want to be respected by these guys. There‟s a lot of joking around in surgery,

and when you‟re accepted by them, it‟s really fun…And, if you‟re not, they can

make your life miserable.

Similarly, a male reformer chief said:

There is a lot of machismo in surgery. It is a pissing contest. Who is the slickest?

It‟s like the Army. Very hierarchical, don‟t be weak. You fell asleep in your 60th

hour? You‟re so weak! The culture and that kind of thinking is barbarous. But I

would never say that in front of a staff surgeon or another resident. I‟m telling you

because this is anonymous…Everyone wants to be the last to leave. [Otherwise] it

would be like: “See, he left at 6:30.” That kind of thing isn‟t forgiven by these

guys.

29

SLOWFAIL Male Reformers Engage in Compensatory Manhood Acts

Male reformers at SLOWFAIL adopted two strategies to deal with the discomfort

associated with loss of male privilege: distancing themselves from feminine labels and aligning

themselves with defender males.

Distancing themselves from feminine labels. One way that male interns at SLOWFAIL

distanced themselves from feminine labels was by insisting that they were not really weak even

though they were often called so. For example, one male intern told me how interns now didn‟t

really have it much easier than those who had come before:

So obviously there are a lot of little jokes about you know, well with the 80 work

week you guys have it easy. I think there have been some cases of where or maybe

we feel it a little less, I don‟t know if respected is the right word, because of an

easier lifestyle-quality of life as an intern…When, in fact, I don‟t think that‟s at all

true. What‟s different is the on-call time is cut out, but otherwise, when you‟re

here you‟re probably here the same amount of hours as people used to be. You

know what I mean, you‟re getting in early, you‟re leaving late, in fact we don‟t

really have it that easy.

Similarly, a male reformer chief pointed out that it was ridiculous to suggest that people working

so many hours a week were weak:

The big thing is “you‟re so weak.” But, surgical residents work a lot. We get

worked unbelievably, for many many hours… We used to work iron man

weekends from Saturday at 6am to Monday night. That is more than many people

work in a month…For all other people, even 80 hours is twice as long as their

regular workweek…And 80 is really 90 or 100 and 100 is a lot. It is not like all of

a sudden I‟m playing tennis and sitting in Starbucks in the middle of the day. I‟m

now able to do the basic activities of daily living and bodily fluids.

Aligning themselves with male defenders. In addition to distancing themselves from female

reformers, SLOWFAIL prior male reformers aligned themselves with male defenders. Male

interns did this by telling about how male defenders had taught them the correct way to behave.

For example, one SLOWFAIL male intern described how he had worked with chiefs who were

proponents of the new system for the first part of the year. Then, he was assigned to a team with

a defender chief who taught him the error of his ways:

Then, I worked with [defender chief] who is old school, hard core. He has a

reputation for breaking down the interns and toughening them up…I‟d come in at

4:30[am] and we‟d round at 5:30[am]. We decided we wouldn‟t follow the rules

and we worked on Saturdays. He was never trying to get me out [at the end of the

day]. He told me that a certain amount of stuff is expected. Since then, I never

leave at 6pm, ever.

30

Reformer male chiefs aligned themselves with male defenders by publicly declaring their

allegiance to them. For example, as the end of the resident year approached, chiefs voted on

teaching awards for the staff surgeons. The three female chiefs and the male chief who had

initially been the most vocal male reformer all voted for one staff surgeon who was known to

take time with the residents, teaching both during surgery and outside the OR. The remaining

four male chiefs voted for another “very macho” staff surgeon. The male chief who initially had

voted for the first surgeon sent an e-mail to all of the chiefs saying that he had changed his vote.

In his email, he noted specifically that he did this so that “the women wouldn‟t win.” The female

chiefs were outraged. One female chief described the incident to me in this fashion:

So the one guy who was on our side said verbatim, over email, „Well I don‟t like

him either but I‟d rather see the girls suffer. Women shouldn‟t be in surgery

anyway.‟ So he changed his vote and made it 5 -3. And then that email was

followed by the other guys saying „ha-ha we won‟ or whatever. Eight people all

emailing and the final email was from one of the guys who wrote and said: „You

women, you lost, and let‟s face it - surgery is a man‟s sport.‟ Which was the last

line of his email. And not a single one of the guys, in my class or any other class,

because of course everybody heard about it, said that it was unacceptable. Not a

single person stood up and said „That‟s not right.‟ It was just accepted.

SLOWFAIL Male Reformers Refrain from Reformer Practices

By the end of the year at SLOWFAIL, male interns had begun to stay on past the end of

their shifts and male chiefs had begun to stop volunteering to share scutwork with them and to

stop encouraging them to hand off work to the night float resident. Several of these male interns

reported to me that when they stayed late in the hospital, rarely were they involved in patient

care that the night float could not handle. Instead, they told me, they were in the hospital doing

paperwork to maintain their reputations as “strong” residents who did not hand off work. They

simply gave up. A male intern aptly summed up the rule that governed the work life of residents

at SLOWFAIL:

Even though the female chiefs told me to go home and not to come in on Saturday,

I still came in…Reputation is everything in this program, and everyone knows

who‟s here and who isn‟t.

STANDING UP TO GENDER-BASED COUNTERTACTICS AT SUCCEED

As they had at SLOWFAIL, defenders at SUCCEED attempted to divide the reformer

coalition by labeling reformer practices as feminine, denigrating the masculinity of particular

31

male reformers and recruiting male reformers into the defender group, yet male reformers at

SUUCCEED did not capitulate to these countertactics. I argue that, because the gender threat at

SUCCEED was low, male reformers at SUCCEED did not experience concerns about loss of

male privilege, so did they respond to gender-based countertactics by capitulating to defenders.

Male reformers at SUCCEED were less concerned than they had been at SLOWFAIL

about being seen as feminine or being left out of the boys‟ club. One male reformer chief said:

“The old school guys like to say that handoffs are weak, that we are all becoming soft. I don‟t

buy it. Unless we do things differently, surgery is never going to change.”

Because male reformers at SUCCEED were not concerned about loss of male privilege,

they did not engage in compensatory manhood acts such as distancing themselves from feminine

labels aligning themselves with defender males. One male intern explained:

One time at afternoon rounds, I hadn't checked the film and the [defender] chief

went off on me. It was totally inappropriate. It was in front of everyone on the

team. He was like, „You look like you're gonna cry. Are you gonna cry?‟ He did it

because earlier they had been making [derogatory] comments about female

residents and I didn't join in…I refused to participate in that kind of crap just so I

could be accepted by them.

Male reformers at SUCCEED maintained their coalition with female reformers and

continued to put pressure on defenders to change. The continual lack of cooperation between

defenders and reformers led to breakdowns in everyday working procedures—handoffs were

fumbled, orders were ignored, instructions were stonewalled—and defender chiefs found

themselves trying to manage a system that was rapidly falling into disarray. While defender

chiefs had originally attempted to resist change in scutwork practices, these continual

breakdowns forced them to deal with the problem of scutwork that was not completed. They

began to think that it was necessary to change tactics and began to help interns with scutwork

during the day and allow handoffs of scutwork between interns and night float residents.

DISCUSSION

This article demonstrates how internal defenders of the status quo can use gender-based

countertactics in everyday interactions to divide male-female reformer coalitions and block

social movement reform implementation inside organizations. These findings contribute to social

movement theory and gender theory in several ways.

32

Contributions to Social Movement Theory

Social movement theorists suggest that understanding how social movements change

practices in informal processes inside organizations is critical because social movement

outcomes depend on such intra-organizational processes (e.g. McAdam, 1999 [1982]; McAdam

et al., 2001; Morrill et al., 2003; Zald et al., 2005). They have demonstrated that internal

reformers are key players in reform implementation because they participate in everyday

organizational practices in ways that external activists cannot (e.g. Binder, 2002; Katzenstein,

1998; Kellogg, 2009; Lounsbury, 2001; Meyerson, 2003 [2001]; Moore, 2008; Morrill et al.,

2003; Raeburn, 2004; Scully & Segal, 2002; Weber et al., 2009; Zald et al., 2005).

However, by focusing predominantly on the actions of internal reformers, these scholars

may overestimate the likelihood of social change. Indeed, SLOWFAIL had a greater number of

internal reformers than SUCCEED did, but reform was implemented at SUCCEED and not at

SLOWFAIL. This suggests that internal reformers may not be able to implement reform solely

by mobilizing with one another.

Many sites of reform, such as churches, universities, and workplaces, are populated by

both reformers and defenders. In addition, many reforms, such as those related to civil rights,

gay rights, environmental protection, or occupational health and safety, to name but a few,

require male-female reformer collaboration to accomplish social change. I find that to implement

such reforms in these kinds of settings, internal reformers may need to stand up to defenders‟

gender-based countertactics in everyday encounters.

Internal defenders can try to demobilize male reformers in everyday encounters by 1)

labeling reformer practices as feminine, 2) denigrating the masculinity of particular male

reformers and 3) recruiting male reformers into the defender group. By using such countertactics

internal defenders can threaten male reformers‟ distinction between themselves and female

reformers, and persuade male reformers to try to protect their masculinity and the privileges

associated with it by distancing themselves from female reformers. In this way, defenders can

divide male-female reformer coalitions and block collective action for change.

In addition to explaining the importance of gender-based countertactics, these findings

add to social movement theory by illuminating when such tactics may be successful. I

demonstrate that the strength of initial gender threat may be particularly important to the

33

outcome of defenders‟ use of gender-based countertactics against male-female reformer

coalitions in contexts where males are privileged over females. When the initial gender threat is

high, male reformers may be more likely to experience concerns about loss of male privilege in

the face of defenders‟ gender-based countertactics and to try distance themselves from reform

practices and female reformers to protect their status and the rewards associated with it.

Contributions to Gender Theory

These findings also contribute to our understanding of gender in organizations. Gender

theorists have elaborated the ways that high-status men can enact hegemonic masculinity in

organizations in ways that disadvantage women (e.g. Martin, 2001; Williams, 1995) and how

men can enact alternative masculinities (Connell, 1995). Because these scholars have not

detailed how high-status men can use gender-based countertactics to divide male-female

reformer coalitions, they have not addressed how high status male defenders can use

masculinities to block coalitional action by male reformers for change. Understanding such

gender-based countertactics is critical to understanding how actors in organizations can

accomplish gender equity because since women, in general, occupy lower status positions in

organizations, they often depend on the help of male reformers to accomplish change.

Our understanding of gender in organizations is also deepened by an elaboration of the

importance of gender threat. Because gender theorists studying embattled organizational contexts

have studied domains predominantly populated by women (e.g. Dellinger, 2004; Williams, 1993,

1995), we do not understand the factors that contribute to embattled organizations in domains

such as surgery which are predominantly populated by men. Here, I find that two factors—the

strength of career threat posed by female workers and the strength of masculinity threat posed by

female workers—contribute to embattled organizational contexts in primarily male domains.

When gender threat is high, men may feel anxiety about engaging in reformer practices if these

practices further blur the differences between themselves and their female counterparts. In such

situations, we may see men engage in the kind of compensatory manhood acts that gender

theorists have seen in other, primarily female, domains.

34

Future Research

This analysis raises several questions for future research. First, social movement theorists

have previously shown that interaction between external and internal reformers is critical to

reform implementation inside of organizations. But reformers at all three hospitals eschewed

direct interaction with external activists to protect their professional privilege. This raises the

question of whether SLOWFAIL reformers could have accomplished change if they had pursued

rather than avoided interaction with external activists. If this were true, then a mismatch between

resources provided by external activists, on the one hand, and internal reformer motivations, on

the other, rather than internal defender gender-based countertactics would explain failure to

implement reform. Because the mismatch was present at all three hospitals, my study cannot rule

out this explanation. Future research could investigate this explanation by studying organizations

with similar defender countertactics but different levels of match between external resources and

internal reformer motivations.

Second, in considering the boundary conditions of this theory, it is useful to contemplate

the subset of situations in which male-female reformer coalitions would be less vulnerable to

gender-based countertactics. In the case of resident work-hours reform, accomplishing reform

required male reformers in organizations where female characteristics had historically been

devalued to engage in stereotypically feminine behaviors such as limiting hours at work and

helping one another. One could imagine that gender-based countertactics would be less effective

in leading male reformers to abandon reform in settings where female characteristics had

historically been more highly valued than male characteristics (e.g. elementary school teaching).

One could also imagine that gender-based countertactics would be less effective in settings

where reform required male reformers to engage in stereotypically masculine behaviors, such as

buying market credits for environmental emissions. Future research could explore the ways in

which the historical gender status hierarchy in the organization and the requirements of the

reform itself are related to reformer vulnerability to gender-based countertactics.

Finally, the practical implications of these finding are complicated. On the one hand, the

findings suggest that female reformers would do well to respect traditional gender hierarchies

and behaviors to minimize defenders‟ ability to threaten the masculinity of male reformers and

divide the reformer coalition. On the other hand, such gender hierarchies and behaviors are often

precisely the problem that female reformers are interested in remedying. Future research could

35

investigate the kinds of tactics that male and female reformers can use to deal with this difficult

dilemma.

In sum, this study demonstrates that implementing reform inside of organizations may

require male and female reformers not only to mobilize with one another across diverse interests

but also to stand up to defenders‟ gender-based countertactics in everyday organization

encounters. The success of the defenders' gender-based tactics may depend on the initial gender

threat posed by female workers in the organization. When the gender threat is high, defenders

who label reformer practices as feminine, denigrate the masculinity of particular male reformers,

and recruit male reformers into the defender group may be more successful in their attempts to

raise male reformer concerns about the loss of male privilege and lead male reformers to

dissociate themselves from female reformers. When the initial gender threat is weak, male

reformers may be able to more successfully resist defenders' gender-based countertactics. An

understanding of defenders‟ countertactics and the organizational context within which they

occur is critical to understanding when actors can successfully transform organizations created

for other purposes into sites of social change.

36

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39

Table 1: A Comparison of the Three Hospitals

QUICKFAIL SLOWFAIL SUCCEED

Similarities

Location U.S. urban center U.S. urban center U.S. urban center

Size of surgical residency

program

2 directors

23 staff surgeons

10 general surgical chief

residents and interns

2 directors

33 general surgeons

18 general surgical chief

residents and interns

2 directors

32 general surgeons

14 general surgical chief

residents and interns

Alignment with public

sector

High Same

Same

Existence of personnel

office

Yes Same Same

Prior organizational

performance

Full accreditation every

year for which data are

available

Same Same

Organization type Teaching hospital Same Same

Authority relations Residents subordinate to

surgeons

Same Same

Union status No surgical residents in

union

Same Same

Director background Career in academic

surgery

Same Same

Resident background 4 years of medical school Same Same

Training period 5 clinical years; 2 lab

years

Same Same

Work organization 4 teams of residents

provide care for

approximately 15 patients

on a service

Tasks assigned according

to year of resident

Residents rotate onto a

new service every 4-8

weeks

Same Same

Conditions treated Colorectal, GI, Vascular,

Oncology

Same Same

Differences

Size of hospital .75xbeds 1.2x beds x beds*

Resident demographics 61% Male, 39% Female

71% White, 27% Asian,

2% Black

68% Male, 32% Female

70% White, 26% Asian, 4%

Black

77% Male, 23% Female

60% White, 33% Asian, 7%

Black

Status of residency

program

Middle status: Affiliated

with very good medical

school

High status: Affiliated with

elite medical school

High status: Affiliated with

elite medical school

External Pressure Year Studied:2002-2003

Pressure from ACGME

visit; regulation

announced but not in

effect

Year Studied: 2003-2004

Regulation in effect

Year Studied:2002-2003

Pressure from ACGME

visit; regulation announced

but not in effect

*To disguise which hospitals are studied here, actual number of beds is not recorded.

40

Table 2: Residents Interviewed at the Three Hospitals

Residents QUICKFAIL SLOWFAIL SUCCEED

Male Chiefs 3 6 6

Male Interns 3 5 4

Female Chiefs 2 4 1

Female Interns 2 3 3

Total Residents 10 18 14

Total Interviews

(pre and post)

20 36 27

*1 male chief at SUCCEED out of 7 not interviewed pre-change effort

Table 3: Defenders and Reformers

Residents Reasons for Stance on

Change in Signout Practice

Number at

QUICKFAIL

Number at

SLOWFAIL

Number at

SUCCEED

Defenders 2 4 4

--Male Chiefs Change violates traditional

surgical identity, beliefs,

hierarchy and the

professional power and

privilege associated with

these

2

4

4

Reformers 8 14 10

--Male Chiefs Interested in creating more

time for personal life

responsibilities

1

2

2

--Male Interns Interested in continuing to

have time for personal life

responsibilities

3

5

4

--Female

Chiefs

Interested in creating more

time for personal life

responsibilities and in

changing the traditional “iron

man” identity and practices

2

4

1

--Female

Interns

Interested in continuing to

have time for personal life

responsibilities and in

changing the traditional “iron

man” identity and practices

2

3

3

41

Table 4: Similar Use of Gender-based Countertactics at SLOWFAIL and SUCCEED

Gender-based Countertactics Associated Practices

Defenders label reform

practices as feminine Use stereotypically feminine labels to describe

reform practices (soft, weak, wusses)

Use stereotypically masculine labels to describe

traditional practices (tough, strong, iron men)

Defenders denigrate

masculinity of particular male

reformers

Directly tell male reformers that they are acting

feminine

Indirectly gossip about femininity of male reformers

not present

Defenders recruit male

reformers to the defender

group

Communicate femininity of reformer past actions and

specifying gender-based solutions for reintegration

Include converts in and exclude persistent male

reformers from boys‟ club

42

Table 5: Divergence in End-of-Year Outcomes at SLOWFAIL and SUCCEED

Name

Hospital Sex Position

Beginning of

Year Use of

Reformer

Practices

End of Year Use

of Reformer

Practices

Total Consistently

Using Reformer

Practices

SLOWFAIL

78%

N= 18

22%

N= 18

Kapila SLOWFAIL M Chief No No

Perry SLOWFAIL M Chief No No

Mugford SLOWFAIL M Chief No No

Koon SLOWFAIL M Chief No No

Lucas SLOWFAIL M Chief Yes No

Anand SLOWFAIL M Chief Yes No

Ciappenelli SLOWFAIL M Intern Yes No

Bussema SLOWFAIL M Intern Yes No

Nast SLOWFAIL M Intern Yes No

Cerulle SLOWFAIL M Intern Yes No

Campbell SLOWFAIL M Intern Yes No

Lucarelli SLOWFAIL F Chief Yes Yes

Sanchez SLOWFAIL F Chief Yes Yes

Nicol SLOWFAIL F Chief Yes Yes

Shea SLOWFAIL F Chief Yes Yes

Hsaio SLOWFAIL F Intern Yes Tailored to chief

DiLascia SLOWFAIL F Intern Yes Tailored to chief

Davies SLOWFAIL F Intern Yes Tailored to chief

Total Consistently

Using Reformer

Practices

SUCCEED

71%

N= 14

100%

N= 14

Cleary SUCCEED M Chief No Yes

Baker SUCCEED M Chief No Yes

Robertson SUCCEED M Chief No Yes

Agarwal SUCCEED M Chief No Yes

Gupta SUCCEED M Chief Yes Yes

Lewis SUCCEED M Chief Yes Yes

Chopra SUCCEED M Intern Yes Yes

Ruiz SUCCEED M Intern Yes Yes

Mehra SUCCEED M Intern Yes Yes

Clark SUCCEED M Intern Yes Yes

Scott SUCCEED F Chief Yes Yes

Hwang SUCCEED F Intern Yes Yes

Morris SUCCEED F Intern Yes Yes

Radan SUCCEED F Intern Yes Yes

43

Table 6: Initial Gender Threat at SLOWFAIL and SUCCEED

Gender Threat SLOWFAIL

Strong Gender Threat

SUCCEED

Weak Gender Threat

Career Threat Yes

40% of chiefs are female

No

14% of chiefs are female

Identity Threat Yes

Female residents enact most

elements of hegemonic iron

man identity

No

Female residents enact fewer

aspects of hegemonic iron

man identity

Table 7: Effects of Initial Male-Female Boundaries on Response to Gender-based

Countertactics Response to Gender-

based Countertactics

Associated Practices SLOWFAIL

Unclear

Boundaries

SUCCEED

Clear

Boundaries

Male Reformers

N=7

N=6

Experience Concerns

about Loss of Male

Privilege

--Express concerns about being seen as

feminine

7 0

--Express concerns about being left out of

boys‟ club

6 0

Engage in Compensatory

Acts

--Distance themselves from feminine labels 6 0

--Align with male defenders 6 0

--Refrain from reformer practices 7 0

Female Reformers

N=7

N=4

Experience Identity

Threat

--Express concerns about being seen as

feminine

0 0

--Express concerns about being left out of

boys‟ club

0 0

Engage in Compensatory

Acts

--Distance themselves from feminine labels 0 0

--Align with male defenders 0 0

--Refrain from reformer practices 0 0

44

SLOWFAIL

SUCCEED

STRONG GENDER

THREAT

WEAK GENDER

THREAT

MALE

REFORMERS

ENGAGE IN

COMPENSATORY

MANHOOD ACTS

MALE

REFORMERS

STOP ENGAGING

IN REFORM

PRACTICES AND

REFORM FAILS

MALE

REFORMERS DO

NOT ENGAGE IN

COMPENSATORY

MANHOOD ACTS

MALE

REFORMERS

CONTINUE TO

FIGHT FOR

CAUSE AND

REFORM

SUCCEEDS

MALE

REFORMERS

EXERIENCE

CONCERNS

ABOUT LOSS

OF MALE

PRIVILEGE

Gender-Based Countertactics and Social Movement Reform

Implementation at SLOWFAIL and SUCCEED

•SIMILAR

RESOURCES

FROM EXTERNAL

REFORMERS

•SIMILAR

INTERNAL

REFORMER

MOBILIZATION

•SIMILAR TOP

MANAGER

SUPPORT

•SIMILAR

GENDERED

COUNTERTACTICS

MALE

REFORMERS

DO NOT

EXERIENCE

CONCERNS

ABOUT LOSS

OF MALE

PRIVILEGE