What do 3D printing, the Hib vaccine, and CAR T-Cell therapy have in common? They were all discovered by women. In the 19th century the role of women in medicine expanded to include physicians, as well as nurses and midwives, allowing them the opportunity to study, conduct research, and provide direct patient care. While this was an exciting milestone, it wasn’t until the feminist movement of the 1970s and the passage of the Equal Opportunity Employment Act when female representation in medicine really began to increase.
In 2019, for the first time, women accounted for more than half of all medical students. With more women attending medical school today than ever before, why is it that they remain underrepresented in the most senior level positions?
The pipeline theory – “you’ll catch up”
The pipeline theory suggests that women will eventually catch up to the same level of achievements in medicine as men, they just entered the field later due to the discrimination in the past.
“The problem with this theory is that it is passive and takes a ‘wait and see’ approach,” says Christina Cutter, MD, Clinical Assistant Professor, Department of Emergency Medicine at the University of Michigan Medical School.
“Even in specialties where women have comprised ≥50% of the physician workforce for the past 25 years, they remain disproportionately underrepresented in leadership positions.”
A study conducted by Nonnemaker in 2000, found that while the number of women in academic medicine was increasing, the number of those advancing into senior level positions was not. Tracking women in academic medicine conducted by the Association of American Medical Colleges (AAMC) in 2020 confirms that the gender gap has not narrowed since then. It would seem as though enough time has passed for the pipeline theory to be an acceptable explanation. If that doesn’t account for such a large gap, what else could it be?
Unconscious bias
While it’s true that some women don’t seek promotions, often many of them are not even considered for a higher position due to preconceived notions about a woman’s domestic responsibilities and role in society. In fact, a 1999 study by Steinpreis concluded these biases toward women exist in females as well as males. In this study, participants were sent one of four versions of a curriculum vitae (i.e., female job applicant, male job applicant, female tenure candidate, and male tenure candidate) along with a self-addressed stamped envelope and questionnaire to fill out. Both men and women were more likely to hire the male job applicant even though the female had identical qualifications. Similar findings of unconscious bias have been discovered in race as well.
It’s not the women, it’s the system
There may be no limit to what women can achieve in medicine if they were not in an unlevel playing field in which numerous systematic disadvantages exist.
Employment negotiations. As aggressiveness is a more socially acceptable trait for men, female physicians are more likely to be penalized for even initiating employment negotiations and tend to negotiate less aggressively than their male counterparts. As a result, they often get less protected time and fewer resources to pursue scholarly work.
Gender bias in compensation. Jagsi et al (2012) study found that gender differences in salaries of physician-scientists persist after accounting for academic rank, leadership positions, research time, and specialty. These differences existed even for women that did not have children and therefore did not need the flexibility for family schedules as did others. An additional study estimated this compensation gap to reach more than $2 million over the course of a physician’s career.
Challenges in research. Women are less likely to receive the funding and protected time they need for research projects. Studies have also suggested that women are less likely to sit on editorial boards, hold leadership positions within medical societies, receive prominent awards, progress in academics, and be listed as senior authors on published manuscripts. Factors leading to these disparities may include fewer opportunities to access mentorship and sponsorship programs and the pressure to contribute to clinical workload.
Domestic responsibilities. Jolly et al (2014) study found that female physician-scientists spent 8.5 hours more time per week on domestic activities than men. They are also the most likely to take time off to care for children when childcare arrangements fall through. In the early career phase among physician-scientists, women are more likely than men to experience burnout.
Gender-neutral policies. What are considered seemingly gender-neutral norms and policies, such as achieving tenure status and qualifying for grants, can have a negative impact on women as they are balancing competing concerns with their biological and professional clocks.
Impact of the COVID-19 pandemic. The pandemic was particularly disruptive for women. As the primary caregivers in most families, women were more likely to experience disruptions to personal life during the pandemic's peak than their male counterparts. This led to amplifying existing gender inequalities in academic medicine, compounding the academic isolation of women in fields in which they are underrepresented.
Closing the gender gap in medicine
For those individuals and institutions who recognize and want to address this issue, the National Academies of Sciences, Engineering, and Medicine commissioned a report in March of 2020 that reviewed [existing research on policies, practices, programs, and other interventions for improving the recruitment, retention, and sustained advancement into leadership roles of women in these disciplines]. Here are the top four recommendations of their study report findings:
- Transparency and accountability. Transparent paths to leadership require open applicant calls for leadership positions and recognition, leadership term limits, investment in leadership, and institutional accountability.
- Targeted data-driven approaches to closing the gender gap. Comprehend and acknowledge differential impacts across specialties, career stage, faculty demographics, and identities.
- Rewarding, recognizing, and resourcing equity, diversity, and inclusion efforts that are often hindered by insufficient resources and “minority tax” expectations (i.e., assuming extra duties without appropriate compensation).
- Filling in knowledge gaps which requires scholarly research.
To really have an impact on change, action must be taken on multiple levels including individual, interpersonal, and institutional. A 2017 study that analyzed programs aimed at recruitment, promotion, and retention of women in academic medicine found that many medical schools have no such programs, and existing programs were inadequate because of a limited focus on the individual.
To be a real catalyst for change we must create a culture of personal responsibility for progress and approach gender equality the same way we do innovation.
