Bolstering gender equity in academic medicine

Women and men enter the physician pipeline at about the same rates, but the female-to-male ratio in academic medicine drops off after residency.


There's a gender gap in academic medicine, according to recent studies that have looked at issues from pay to leadership to scholarly publication.

Women and men enter the physician pipeline at about the same rates—medical students and residents were 46% and 47% female, respectively, according to 2013 and 2014 statistics from the Association of American Medical Colleges (AAMC).

Illustration by Sarah Ferone
Illustration by Sarah Ferone

But the female-to-male ratio in academic medicine drops off after residency, with women making up 38% of full-time faculty, 21% of full professors, 24% of division chiefs, and 15% of department chairs, according to the same AAMC data. Other recent research has shown gaps in pay, speaking gigs, and research authorship for female academic hospitalists.

Keenly acknowledging these disparities, female leaders in academic medicine offered insight on what's causing this gap and how individuals and institutions can compress it.

Compensation

Female hospitalists earned $14,581 less annually than their male colleagues in 2010 (after adjustment for several variables), according to a study published in the August 2015 Journal of Hospital Medicine (JHM). This is an improvement over the estimated $24,000 wage gap noted in a 1999 study published in Inquiry, although differences between the studies make comparison difficult.

“We could make the argument that the earnings gap is decreasing, which is good, but it's difficult to compare 2 different studies with 2 different methodologies and convincingly say that the earnings gap is improving,” said A. Charlotta Weaver, MD, lead author of the JHM study. “Optimistically, it is, but I think only longitudinal studies will help us determine that. It's still there, and it's still significant.”

Fewer women than men in her study reported prioritizing substantial pay when choosing a job, but that only partly accounts for the disparity. The study also found that women were more likely than men to work nights. “I do find it surprising and a little bit upsetting that despite the fact that women are working nights, they're still earning less, because traditionally, nights are paid much better than daytime jobs are,” said Dr. Weaver, a hospitalist and assistant professor at Northwestern University Feinberg School of Medicine in Chicago.

Possible explanations for the pay gap include differences between men and women in terms of money-related behaviors, according to Dr. Weaver. “Women don't negotiate as much, as often, or in the same way that men do, partly because that's not been part of their upbringing, partly because they've not been taught how to negotiate, and partly because there are messages that society gives to women that it's not OK to negotiate—that women should prioritize preserving their relationships instead,” she said.

Research confirms that women are less likely than men to ask for higher salaries and negotiate their first or subsequent jobs, which puts them further behind, said Michele G. Cyr, MD, MACP, associate dean for academic affairs in the division of biology and medicine at Brown University in Providence, R.I. “Certainly there are skills and ways that women can approach this and maybe improve some of this,” she said. “But I think we also need to look at what the institutions can do to close the gender pay gap.”

Employers can tackle the problem by embracing and adopting salary transparency, a policy in which hospitalists' salaries are easily visible and comparable, suggested Dr. Cyr, who presents sessions on negotiation at national physician meetings. For instance, a transparent academic department would make clear the differences in pay between a full-time assistant professor and a full-time associate professor.

“Salaries are very much still a taboo topic in the medical field, and I think that increasing transparency is 1 thing that could change and mitigate disparities for the better,” agreed Dr. Weaver. Colleagues should talk to each other about how much they make, and employer groups can also do their part, she suggested. “Having not only transparent numbers but also a transparent methodology for determining the pay scale for their employees is essential if we want to eventually develop parity in pay between men and women.”

Hospitalist groups could also hold annual salary equity reviews for all faculty to make sure compensation is evenly distributed, Dr. Cyr recommended. Beyond an overall review, individual reviews are also integral to ensuring equity, she said. “Women—all faculty—need to have an annual review at which time they can review their salary with a supervisor on an individual basis.... Ask the question, ‘Am I in line with the other members of this group?’ and force that supervisor to look at the pay range and who's getting paid more.”

To make their own assessments of the pay scale, hospitalists can gather data from faculty salary reports from the AAMC or Medical Group Management Association. “It's evidence-based negotiation. I think it helps to have objective data because studies suggest that women don't ask because they're fearful of being rejected, they'll seem greedy, and they won't be likeable,” said Dr. Cyr.

Leadership

Female hospitalists are also less likely than male hospitalists to lead divisions or sections of hospital medicine, according to another study published in the same issue of JHM. The study compared academic hospitalists to general internists. Both groups had about the same proportion of women overall, but female hospitalists lagged behind female general internists as heads of divisions or sections (16% vs. 35%).

Dr. Cyr was “somewhat perplexed” at the differences between hospital medicine and general internal medicine. “On the face of it, you would think that it should be somewhat the same: Hospitalists should have the same disadvantage for being women as general internists,” she said.

One possible explanation is that hospital medicine and the women who practice it are younger, experts said. It could also boil down to choice, according to hospitalist Vineet Arora, MD, FACP, associate professor of medicine and assistant dean for scholarship and discovery at The University of Chicago Medicine. “Of course, there is a glass ceiling, so there are women that try to lead but can't—but I think there may also be women who could lead but choose not to,” she said.

Dr. Cyr said plenty of women want to lead, noting that a climate survey at Brown indicated that the female faculty members were just as interested in advancing their careers as the men. “We do have that bias that there may be more women who aren't interested because we suppose that they have more demands on their time, but that doesn't bear out in the data,” she said. The GRACE (Generating Respect for All in a Climate of academic Excellence)Project, a survey conducted in 2000 at the University of Arizona in Tucson, also found that female professors within the college of medicine were just as interested as the men in advancement and attaining positions of leadership.

To get ahead, female hospitalists could seek connections with people in positions of authority, such as the hospitalist group director, who can identify leadership positions or opportunities for career advancement, suggested Dr. Cyr.

“When that person's asked to give a talk at a national meeting, they may not have the time or the inclination to do it, so they could then give that opportunity to 1 of their faculty members. I always encourage women to have meetings with people who might be potential sponsors....It's amazing how much of a difference that can make, just having that conversation with somebody who maybe has never thought of you as being interested,” she said.

There are also local opportunities for leadership. After having her child in 2014, Dr. Arora said she became more cautious about the travel she accepted. “I let go of 3 national, high-profile opportunities, and I took on some things that were more based in Chicago that I knew I could do,” she said. “So it's not necessarily that I stopped leading; I just lead in a different way.”

Scholarly productivity

There are also gender differences in speaking opportunities at national meetings and publications for academic hospitalists, according to the leadership study, which found that female academic hospitalists were less likely than female general internists to be listed as speakers at national meetings from 2006 to 2012 (26% vs. 50%), first authors of publications (33% vs. 47%), and senior authors (21% vs. 34%).

The study was inspired by the anecdotal observations of lead author Marisha A. Burden, MD, FACP, chief of hospital medicine at Denver Health Medical Center in Colorado. “I just kept going to conference after conference, and in my mind, my question was, ‘Where are all the women speakers?’” she said.

Among the study results, 1 number struck her in particular: Female hospitalists made up only 9% of the featured or plenary speakers at national meetings, compared to female general internists, who claimed 45% of featured spots. “I thought that number was fairly shocking,” Dr. Burden said. “The other interesting surprise was that general internists, at least when it came to speakers, were fairly equal.”

At the annual meeting of the Society of General Internal Medicine (SGIM), balanced gender distribution is no accident, said Jean S. Kutner, MD, MSPH, FACP, president of the Association of Chiefs and Leaders of General Internal Medicine and an ex officio member of SGIM's Council. While serving on the planning committee for the society's Distinguished Professor in Geriatrics Program, which is held at each annual meeting, she made a point to invite women to speak.

“We kept track of who our speakers had been, and we would deliberately say, ‘Hey, we had a male speaker last year or the last 2 years. There are plenty of highly qualified geriatrics professors out there who would be of interest to this audience—let's specifically and deliberately think about who the woman would be that would be a good candidate for this.’ With that, we ended up with a very balanced speaker profile,” said Dr. Kutner, chief medical officer of the University of Colorado Hospital and a professor of medicine and associate dean for clinical affairs at University of Colorado Medical School.

Similarly, ACP's annual Internal Medicine Meetings are planned so that faculty reflects the College's membership, which is about one-third women, said Barbara Licht, director of educational meetings and conferences. “When the...Scientific Program Committee begins planning the program, it is made aware of the College's priority to have a diverse faculty both in terms of gender and ethnicity,” she said. For the past several years, women have comprised about one-third of meeting faculty, which includes all speakers and those teaching at the Herbert S. Waxman Clinical Skills Center, according to Ms. Licht.

The Society of Hospital Medicine (SHM) has an estimated membership ratio of 60% men and 40% women, according to Ethan Gray, vice president of membership. Of all speakers at SHM's 2016 meeting (not including workshops), about 36% were female, and the breakdown was about the same the year prior, said Leonard Feldman, MD, FACP, chair of the 2017 annual meeting committee.

“It's clear that we do have a gap between the number of male and female presenters, and it is something that we'll have at the forefront of our minds as we plan the annual meeting,” he said. The committee plans to invite more female hospitalists to present at next year's meeting, with big-picture goals of facilitating the promotion of more female academic hospitalists and encouraging more women to get involved, said Dr. Feldman, a hospitalist and associate professor of internal medicine and pediatrics at Johns Hopkins Medicine in Baltimore. “We would at the very least want it to be 40% to reflect our membership, but I think we can do better, given all of the talented members we have,” he said. “We would love to have a 50-50 split.”

There has been a noticeable change in the percentage of female speakers in the past several years, according to Dr. Burden, “But I would also say that aiming for a gender distribution that reflects an organization's membership may not be the correct goal. If this is an organization's goal, then it is likely that it will continue to perpetuate the status quo and thus will not continue to make strides forward when it comes to representation of women and minorities,” she said.

Getting female hospitalists their share of speaking opportunities is absolutely possible, said Dr. Arora. “The low-hanging fruit, like speaker opportunities, we should fix immediately because those women are out there.”

Challenges and solutions

Networking with both male and female hospitalists may be a key to getting more women the academic exposure they seek, but some obstacles currently exist, the experts noted.

“There's the phenomenon where women might put down other women, and women are women's worst critics. That's got to go,” Dr. Arora said. “A lot of times, it's the insecurity where a woman who's made it to the top in a man's world is harsher on the younger women because she thinks that they need to pay their dues, so to speak. Women should nurture other women, and that's the way that we'll be able to move forward.”

Men should also be more inclusive of women when it comes to networking and cultivating mentoring relationships, Dr. Weaver said. “Women shouldn't be the only ones mentoring women. I think men in leadership positions also need to mentor women, and men also need to be inclusive of women in their social networks.”

Another challenge can involve female hospitalists' home lives. A 2014 study in Annals of Internal Medicine found that female academic physicians spent 8.5 more hours per week on domestic activities compared to their male counterparts. “I do think that makes it a little bit harder for women to volunteer to travel or be a clinical leader because obviously, leading a clinical group means that you're on call for all sorts of crisis issues,” said Dr. Arora.

But it's not an insurmountable barrier, experts said. “Some of the most successful women I have known are women who are very strategic with regard to how much travel they do away from home because of family responsibilities,” Dr. Cyr said. “They may go to only part of the meeting where they can get the most bang for their buck [e.g., networking or presenting their work], the buck being their time away from home.” Some institutions provide child care support for faculty who are traveling to meetings to present their work, she added.

The choice to raise a family should not be a disqualifier for female hospitalists who want to advance their careers, Dr. Arora said. “It's not necessarily an either/or, like ‘You've chosen the mommy track, so you're done.’ I would never want anyone to have that impression of hospital medicine.”

Women hospitalists may, however, prioritize family over career advancement at points in their careers. “There may be women who can enter a research career later, traveling as their kids get older....There may be a time where we need to be sensitive to the idea that, in order for people's work-life balance to work, there are going to be times tilted more toward life, less toward work,” Dr. Arora said.

She offered this advice to hospitalist group leaders: “First of all, try to diversify your group. And then, for the women you've hired, [think about] how you can make working in the group sustainable so they can be present for their families but also continue in a career that's professionally and personally rewarding at a level they can manage until they are ready to assume leadership positions.”

Overcoming bias

Although all these tips can help even the playing field, a remaining challenge is implicit gender bias in the minds of both men and women. Molly Carnes, MD, MS, a geriatrician who researches women's issues, contrasted implicit bias with the explicit bias that bombarded her when she first got her start in medicine. “I had attendings come up to me and say, ‘I just want you to know that I don't think women should be doctors,’ or ‘You're taking the place of a man,’” she recalled. “That would never happen now.”

However, women in medicine today face a different, possibly more difficult obstacle in implicit bias. “It's funny: That kind of overt bias, the research suggests, can actually be less damaging because it's so overt it triggers what's called a reactance, where you say ‘Well, I'll show him—I'm going to work so hard, and I'm going to make it,’” said Dr. Carnes, who directs the Center for Women's Health Research at the University of Wisconsin in Madison.

Dr. Cyr offered an example of the implicit bias that exists today. “It may be that some of the leaders, and they may be men, just assume that women with families or other responsibilities outside of work will not be interested in taking on more,” she said.

Dr. Carnes was dismayed at the results of the compensation study because hospital medicine is a new field—a tabula rasa. “It does show that these gender biases are so deeply rooted in the way we make decisions and judgments and process information that, however unintentionally, they just continue to play out over and over again—even in brand-new fields,” she said.

There are several possible ways to mitigate implicit bias, the experts said. “The first thing you have to do is acknowledge the humbling possibility that you could be biased in your judgment,” said Dr. Carnes, “because physicians...we like facts, we like data, we like to think we're objective. So the first thing is to actually acknowledge that, in spite of all this data that you know, you could be biased when you evaluate an individual person.”

Another tactic is to recognize stereotypes, which society constantly reinforces, she noted. “So for a woman in a hospital medicine leadership position, she might walk into a room and, without meaning it, there might be the assumption that she's not the director of the program or the physician or the expert,” Dr. Carnes said. “If you can fill in real information [like stating your name and position], you can prevent the assumptions from coming to mind.”

Female hospitalists can also overcome assumptions about their lack of interest in advancement opportunities by actively expressing their wishes, whether for a raise, a promotion, or a publication or lecture opportunity. “I think making it clear that you are interested is critical because those biases may be operating,” said Dr. Cyr.