Leveling the Playing Field: Can We Achieve Gender Equality in Medicine?

When Stephanie Abbuhl, MD, professor of emergency medicine at the University of Pennsylvania Perelman School of Medicine, was growing up in the early 1960s, the women around her – her grandmother, mother, aunts, and friends’ mothers – were either homemakers, teachers, secretaries, or nurses. Then came Title IX in 1972, a civil rights law that amended the Higher Education Act of 1965 and prohibited discrimination on the basis of sex in any federally funded education program or activity.

“I had just started college at the time, and I saw the change happen. It was very exciting, and suddenly, more women were going to medical school,” said Dr. Abbuhl, who also serves as the executive director of the FOCUS on Health & Leadership for Women program at Penn. FOCUS is dedicated to supporting the advancement of female faculty into leadership positions and promoting research into women’s health.

Dr. Abbuhl entered medical school in 1976, when women comprised approximately a quarter of incoming medical school classes. In the first 20 years of her career, she saw that number grow to 50 percent. “It was remarkable – and a complete sea change,” she told ASH Clinical News.

Yet, when she became a faculty member at the University of Pennsylvania, she saw fewer women advancing in academic medicine. Witnessing the difficulties women were having climbing the ranks and attaining leadership roles gave her pause – and ignited her interest in developing initiatives that support and help advance women faculty.

“Women were bringing unbelievable talent to the medical workforce – talent that, frankly, medicine desperately needed,” said Dr. Abbuhl. “But I also saw these women’s struggles, particularly as our society is still structured such that one parent often needs to put more time in at home. That responsibility was falling mainly on women.”

“Women are a powerful force, and as we bring new strengths to medicine, we are also bringing about needed change.”

—Stephanie Abbuhl, MD

Gender inequality has become a frequent topic of discussion, with movements like Time’s Up and #MeToo shining a light on discrimination and harassment against women in the workplace. The movements originated in Hollywood, but no profession was immune, including medicine.

ASH Clinical News spoke with Dr. Abbuhl and others who study the factors that influence gender inequality in medicine and design interventions to correct these imbalances and help women reach the same levels of success as their male counterparts.

Rising Through the Ranks

Molly Carnes, MD, MS, a professor in the Department of Medicine at the University of Wisconsin’s School of Medicine and Public Health and director of the Center for Women’s Health Research, had an experience similar to Dr. Abbuhl’s. When she became a tenured professor, she looked around and saw that, unlike her medical school class, 40 percent of whom had been women, she was the only female tenured faculty member in her department.

“That observation intrigued me, much more so than the benchtop research I was doing,” she said. “So, I redirected my focus to dig into the interventions that could foster better opportunities for women and other underrepresented groups in STEMM [science, technology, engineering, mathematics, and medicine] fields. Particularly, I wanted to help these individuals become leaders in their field,” Dr. Carnes told ASH Clinical News.

Even though one in three physicians are women, a study conducted in 2017 found that female physicians continue to be passed over for recognition awards, which represent access to key resources and participation in leadership activities.1 The disparity was staggering, particularly in the case of the American Academy of Physical Medicine and Rehabilitation, which hadn’t recognized a woman with an achievement award in 40 years.1,2

A recent study that tracked women’s career advancement in academic medicine in Germany found that, even as more women have joined the ranks of clinicians and investigators over the last 20 years, the proportion of female chairs and full professors in academic medicine is staggeringly low.3 The ratio of women to men in medical school was 1.54 in 2013; in the same year, the ratio in specialty chair positions was only about 0.1. This pattern was observed even in subspecialties in which women represent the majority of physicians, such as obstetrics/gynecology.

“It’s concerning to me that, despite more women entering academic medicine, there remains a large gender gap in promotion from junior faculty to senior leadership positions,” said Linda Burns, MD, the vice president and medical director of Health Services Research at the National Marrow Donor Program/Be The Match and former president of the American Society of Hematology (ASH). “I suspect that the reasons are varied, including the need for role models, faculty mentorship programs, and a self-awareness that we must be advocates for our own career advancement.”

Dr. Burns added that, in her experience, “ASH staff and leadership have done a fantastic job of raising awareness about gender imbalances and ensuring diversity throughout the organization – award committees, planning committees, and other groups.” Because the first step to effect change is to raise awareness that the issue exists, she encouraged “academic medical centers and all organizations should be aware of these gender inequality issues within their own institutions.”

The American College of Physicians (ACP) has also taken a proactive role in correcting imbalances: In April 2018, the society published a position paper highlighting the unique challenges faced by female physicians – including discrimination, gender bias, and a culture that does not prioritize work-life balance – as well as recommendations to help close the gender wage gap and promote women’s career advancement in medicine.4 In an accompanying editorial, Dr. Carnes noted that despite 50 years of federal laws mandating that men and women receive equal pay for equal work, physician pay inequalities persist.5 The position paper, she wrote, “validates the lived experiences of women physicians and legitimizes equity efforts.”

“I wrote the editorial because I didn’t want people to think that [the ACP report] was going to solve anything on its own,” Dr. Carnes explained. She drew an analogy between the position paper and the Surgeon General’s report and announcement in 1964 that smoking was harmful to health. “There already was a lot of evidence then that smoking was bad, and the statement was just a pole stuck in the sand that legitimized the real effort and culture transformation that needed to happen for us to shift to a non-smoking norm,” she said. “In the same way, this ACP statement legitimizes the important, scholarly research into gender inequality.”

Correcting Course

Dr. Carnes, for her part, has contributed to the research on gender inequality with one of the first studies in this area.6 At the University of Wisconsin-Madison, Dr. Carnes and researchers offered more than 2,000 faculty members from 92 departments a “gender-bias-habit–changing intervention” in the form of a 2.5-hour workshop.

Based on pre- and post-workshop responses to surveys that measured gender bias awareness and expectations about gender equity action, the researchers found that the intervention could help break conscious and unconscious biases against women. Participants also self-reported a greater perceived value of their own research and better communication with colleagues.

“We gave the participating faculty members specific, research-derived, cognitive behavioral strategies to help them break the bias habit,” she explained. “We found that if you take a motivated group of people and give them tools that work to break the bias habit, you can see changes in behavior.”

In a follow-up study in 2017, Dr. Carnes and her colleagues found that this intervention had long-lasting effects: The proportion of women hired within departments that attended the intervention increased by about 18 percent, while the proportion of women hired in departments that did not have representatives attending the workshop remained the same.7

“Our work suggests that, to have an effective cultural change, we need interventions for senior leadership and all levels below. Just as we finally had enough experts who eventually advocated for no-smoking policies, leaders in academic medicine have to create a sense of urgency,” she said. “And we can change the culture!”

Dr. Burns agreed that the positive cultural shift to promote female academic faculty into leadership roles must be embraced and promoted by existing leadership. “This needs to come from the highest levels – not only division or department heads, but from medical school deans and university presidents,” she noted.

A Cultural Shift

Dr. Abbuhl also conducted a long-term intervention study to understand what elements are necessary to create a work culture “conducive to women’s academic success” and to study whether a multi-part intervention could improve the success of junior women faculty at the University of Pennsylvania Medical School.8 First, the researchers developed a measure of how conducive to women’s success an academic workplace culture was. Then, in a three-year study they tested the measure in half of a sample of 133 participating female assistant professors within 27 departments at the Perelman School of Medicine.

They determined that, to promote a culture conducive to women’s academic success, programs should prioritize four distinct but related dimensions: equal access to resources and opportunities, work-life balance, freedom from gender biases, and supportive leadership.

At the end of the three-year period, academic productivity and work self-efficacy improved in both the intervention and control groups, and the average hours worked per week decreased. Dr. Abbuhl attributed both outcomes to the likely school-wide intervention effects. Because the study was not blinded, Dr. Abbuhl said there was a reported positive improvement in the supportiveness of the work culture among all 27 departments. “Our research provides valuable empirical evidence for the importance of change efforts targeted at the culture at the department/division-level,” the authors concluded. “[Still], it remains to be seen whether improving the [scores on the conducive culture measure] will be associated with enhancing the scholarly success and leadership of women in academic medicine.”

Dr. Abbuhl acknowledged that unconscious or implicit biases – the social stereotypes about certain groups of people that individuals form outside their own conscious awareness – are a pervasive part of gender inequality for both men and women. “That’s a bit hard to swallow because you want to believe that women won’t have any biases that prevent them from viewing other women as not fully capable and successful,” said Dr. Abbuhl. “But we are part of the same society, so we all can internalize the same stereotypes, even if they are at odds with our stated values.”

One way to combat both the explicit and implicit bias is by “witnessing the successful women in medicine who are bringing incredible talent and leadership to our workplaces,” said Dr. Abbuhl. “The more successful women there are in our midst, the more the old stereotypes fade away.”

Mind the (Wage) Gap

In a recent survey report of 36,000 physicians across the U.S. by the social networking site Doximity, pay for female clinicians varied widely geographically, but was always substantially lower than for their male counterparts.9 Even after controlling for hours worked and other factors that might account for variations in pay, female physicians earned about 26.5 percent less, or about $91,000 less, than male physicians.

For Dr. Burns, the question of why this gap exists – and how to close it – is clear. “The leaders are aware of the wage discrepancy, and that’s what is so disappointing,” she said. “There is often a complete lack of transparency to faculty members in how salaries are set.”

She also suggested potential corrections, including mentoring for early-career female trainees and fellows and counseling about the gender wage gap, how to ask for more transparency, and how to negotiate salary and other support during an annual review.

“Women believe that they are being treated fairly and equally, but, unfortunately, that is not always the case,” she observed. “When I speak with female trainees, I always tell them that they need to not assume anything and to speak up for what they feel they will need – not just financially, but in other aspects of support that will be critical to their career success. Think of it as a business in which people expect you to negotiate.”

Of course, she added, “it’s easier to tell someone else to do it than to do it one’s self.”

Reshma Jagsi, MD, DPhil, professor in the department of radiation oncology and director of the Center for Bioethics and Social Sciences in Medicine at the University of Michigan, uncovered a similar gender discrepancy in wages among early-career physician-researchers in a 2013 study.10 The research showed a 17-percent overall disparity between salaries for men and women that could not be explained by factors like specialty, work hours, and productivity.

Gender inequality was an early focus of Dr. Jagsi’s research. While she was a resident at Massachusetts General Hospital, her mentor placed her on a committee of women in medicine, with whom she studied the representation of men and women among authors published in prominent medical journals.11 Her work revealed that, over a 35-year period starting in 1970, the proportion of female physicians who were first or senior authors on research papers in the U.S. increased significantly, from 3.7 percent to 19.3 percent (p<0.001). But, women physician-scientists still made up a minority of authors on original published medical research.

“Leaders in academic medicine have to create a sense of urgency. And we can change the culture!”

—Linda Burns, MD

“The study raised many more questions for me than it answered,” Dr. Jagsi told ASH Clinical News. “I wanted to understand the mechanism of this discrepancy, whether there were differences in outcomes of similarly situated men and women who were entering medicine, or whether the differences were related to women being tracked as clinician-educators rather than as researchers.”

To dig deeper into these questions, Dr. Jagsi analyzed the career paths of early-career clinician-scientists. She observed that, even among high achievers who received prestigious National Institutes of Health K23 and K08 early-career development awards, women were less likely to go on to obtain coveted R01 grants. The results suggested that more men tended to pursue a grant-based medical research career than women.12

#MeToo in Medicine

An element of gender inequality in the workplace that cannot be ignored is sexual harassment. The recent #MeToo movement (spurred by women speaking out about their experiences of sexual harassment in Hollywood) has opened the door for women in other fields to break their silence.

“Sexual harassment is one piece among the causal factors that need to be considered when one is looking at the challenges that face women in their professional careers,” noted Dr. Abbuhl.

Medicine has certainly not been exempt from sexual harassment. A 1995 survey showed that more than half (52%) of women serving as U.S. academic medical faculty reported experiencing harassment in their careers, compared with 5 percent of men.13

In 2015, Dr. Jagsi decided to recreate that 1995 survey, thinking that 20 years later the picture would have improved. What she found was surprising – and disheartening: Of more than 1,000 clinician-researchers surveyed about their career and personal experiences, 70 percent of women, compared with 22 percent of men, experienced gender bias in their careers.14 Thirty percent of women reported a personal sexual harassment experience, compared with 4 percent of men. Among the 150 women who reported harassment, 40 percent classified it as “severe” and 59 percent said that the incident (or incidents) had a negative effect on their personal and professional confidence.

“As we’ve seen disclosures in other fields, we are realizing that this is a far-reaching societal problem,” Dr. Jagsi said. “Perhaps things haven’t changed as much as we might have hoped.”

She reflected on these findings in a recent perspective article published in The New England Journal of Medicine.15 The essay, Dr. Jagsi told ASH Clinical News, was written for the many women who shared accounts of their own harassment following her 2016 study. They never disclosed these incidences publicly because of the stigma of accusing someone of harassment and the career repercussions that could follow.

“When you have devoted your entire life to your career – especially in medicine, where training is arduous and subspecialties create small communities – you worry about your professional identity being threatened by speaking out. Many women decide that the benefits of reporting simply don’t outweigh the risks,” she noted.

The Way Forward

Still, Dr. Jagsi is an eternal optimist. “The conversation has started, and with so much evidence of gender bias, I think right now we need to facilitate the thoughtful implementations of interventions we know work,” she said.

She added that she thinks people generally want to do good by others. “Many people are aware of others’ unconscious biases, but they don’t fully acknowledge their own,” she explained. “I don’t think people wake up in the morning wanting to oppress the women that they employ. We need to make it clear that our gender biases are deeply rooted and not always intentional. We are mostly decent human beings, and we all need to combat these issues together.”

Dr. Abbuhl agreed. “It’s too easy to simplify things and say that this is all about sexual harassment, but that is not the case. We have to collectively look at interventions and solutions that account for the complexity of these multifaceted gender issues,” she said. “We can and should talk about sexual harassment, but we also need to focus on how we can make sustainable careers for women – and men – in this age of dual-career couples who are often stretched thin with increasing demands.”

Like Dr. Jagsi, Dr. Abbuhl is optimistic. The medical field is hierarchical and structured, she noted, but it also continues to cultivate rich opportunities for women. “Women represent 50 percent of the best and brightest going into medicine; we are a huge part of this field, and there is power in numbers,” she said. “Women are a powerful force, and as we bring new strengths to medicine, we are also bringing about needed change.”—By Anna Azvolinsky

References

  1. Association of American Medical Colleges. “2014 Physician Specialty Data Book.” Accessed May 24, 2018, from https://www.aamc.org/download/473260/data/2014physicianspecialtydatabook.pdf.
  2. Silver JK, Bhatnagar S, Blauwet CA, et al. Female physicians are underrepresented in recognition awards from the American Academy of Physical Medicine and Rehabilitation. PM R. 2017;9:976-84.
  3. Brüggmann D, Groneberg DA. An index to characterize female career promotion in academic medicine. J Occup Med Toxicol. 2017;12:18.
  4. Butkus R, Serchen J, Moyer DV, et al. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med. 2018 May 15. [Epub ahead of print]
  5. Carnes M. The American College of Physicians is working hard to achieve gender equity, and everyone will benefit. Ann Intern Med. 2018 May 15. [Epub ahead of print]
  6. Carnes M, Devine PG, Baier Manwell L, et al. The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial. Acad Med. 2015;90:221-30.
  7. Devine PG, Forscher PS, Cox WTL, et al. A gender bias habitbreaking intervention led to increased hiring of female faculty in STEMM departments. J Exp Soc Psychol. 2017;73:211-15.
  8. Westring AF, Speck RM, Sammel, MD, et al. A culture conducive to women’s academic success: development of a measure. Acad Med. 2012;87:1622-31.
  9. Doximity. “Second Annual Physician Compensation Report: March 2018.” Accessed May 23, 2018, from https://www.doximity.com/careers/compensation_report?_csrf_ attempted=yes.
  10. Jagsi R, Griffith KA, Stewart A, et al. Gender differences in salary in a recent cohort of early-career physician-researchers. Acad Med. 2013;88:1689-99.
  11. Jagsi, R, Guancial EA, Worobey CC, et al. The “gender gap” in authorship of academic medical literature — a 35-year perspective. N Engl J Med. 2006;355:281-7.
  12. Jagsi R, Motomura AR, Griffith KA, et al. Sex differences in attainment of independent funding by career development awardees. Ann Intern Med. 2009;151:804-11.
  13. Carr PL, Ash AS, Friedman RH, et al. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Ann Intern Med. 2000;132;889-96.
  14. Jagsi R, Griffith KA, Jones R, et al. Sexual harassment and discrimination experiences of academic medical faculty. JAMA. 2016;315:2120-1.
  15. Jagsi R. Sexual harassment in medicine — #MeToo. N Engl J Med 2018;378:209-11.

About 7 percent of physicians report personally experiencing sexual abuse, harassment, or misconduct, according to Medscape’s recently released “Sexual Harassment of Physicians Report 2018,” which included responses from more than 6,200 U.S. physicians and clinicians – both men and women.

Survey respondents were asked about specific harassing behavior they experienced or witnessed within the past three years, as well as where the harassment occurred, how they reacted, and how it affected them. These behaviors included: deliberately infringing on body space; sexual comments about anatomy or body parts; unwanted physical contact; and offer of a raise, promotion, or other advantage in exchange for “a sexual favor.”

Fourteen percent of respondents reported witnessing these types of behavior, and 2 percent said they had been accused of it. However, more women than men said that they had personally experienced harassment (12% and 4%, respectively), and fewer women than men were accused (0% and 3%).

Together, experiencing those behaviors adversely affected the wellbeing of half of the men and women who reported experiencing sexual harassment at work.

About half of the affected physicians “suffered in silence” and did not report the behavior, according to the survey. Forty percent reported the offensive behavior (typically to colleagues), but the results of the reporting were disheartening: 27 percent said “the perpetrator’s behavior was trivialized” and 16 and 15 percent, respectively, said they were retaliated against by the perpetrator or management.

“[Our] company has a harassment policy, but it’s a joke that anything will be done about it. … When the boss brings millions of dollars to the company, no one cares,” said one female physician. “Those who do report are looked down upon for it.”

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