Pushing toward gender equity in medicine

Women in medicine are leading on all fronts of the COVID-19 pandemic. In addition to holding 76% of all health care jobs, as the U.S. Census Bureau reported in 2019, women are holding the line at home, managing child care, elder care, social relationships, and household responsibilities.

Despite these efforts, the pandemic might adversely impact women's careers by exacerbating existing gender gaps in pay and promotions, said Shikha Jain, MD, FACP, a medical oncologist at the University of Illinois Cancer Center in Chicago and founder and chair of the Women in Medicine Summit, held virtually last October. For instance, such journals as JAMA Surgery have reported a decline in manuscript submissions from female authors since the start of the pandemic. “In academics especially, that directly impacts the ability to be promoted and to climb to leadership positions,” she said.

One reason behind such gender inequities is the fact that women's environments often fail to account for their different needs versus men, said ACP's Executive Vice President and Chief Executive Officer, Darilyn V. Moyer, MD, FACP, during her keynote on promoting justice, equity, diversity, and inclusion (JEDI). “It's important to emphasize that we need to fix the systems, not the women, to get to a more JEDI environment in health care,” she said.

While the overall impact of COVID-19 on physical and mental health is concerning for all, women may ultimately be most affected because of their increasing demands at home, said Nancy Spector, MD, executive director of the Executive Leadership in Academic Medicine program and associate dean for faculty development at Drexel University College of Medicine in Philadelphia. “That's going to potentially impact the issues of scholarship for women [and] being promoted.”

Anecdotally, she said many leaders in medicine have reported that fewer women are applying for higher-level positions during the pandemic because they are busy leading COVID-19 efforts and taking care of their home institutions and families. “Women are just stepping into those crisis management roles, so what happens later and how we give credit for that and reward that is important,” Dr. Spector said.

During the conference, experts offered strategies to help support women in medicine during the pandemic and beyond, such as strengthening collaborations in academic medicine and shoring up financial gaps. A session on male allyship, as well as a separate HeForShe track, also explained how men can help. As Dr. Jain put it, “Let's make sure it's not just the people who are affected by the disparities [who] are doing the work.”

Advancing academic medicine

As women clinicians work to stay afloat during COVID-19, their academic productivity appears to have suffered, Dr. Moyer said. “Fewer projects now result in fewer publications later,” she said. “It's been documented that there are fewer projects that are being introduced by women during the time of COVID in terms of grant proposals and fewer publications—16% fewer first authorships for women in their publications.”

Women in academic medicine may be submitting fewer manuscripts during the pandemic, but factors outside their control may also stall their careers.

For instance, a 2011 study published by Gender Medicine found that 10 of 63 (15.9%) editors-in-chief of top-ranked medical journals in various specialties were women. (Christine Laine, MD, MPH, FACP, is in the minority as Editor-in-Chief of Annals of Internal Medicine.) In addition, most editorial boards have a mismatch of men versus women, with a particularly substantial gap in women from underrepresented groups, said Dr. Spector.

“In a structure like that, there is likely to be bias,” she said. “We all try our best, of course, when we're reviewing, but there's downstream effects [as] to who is going to end up being accepted into the journal and who is going to be invited for commentaries. … These are really important issues because we can't be promoted unless we publish and have first and last author credit.”

There has been some progress regarding women's promotions in academic medicine. From 2009 to 2018, the percentage of promoted faculty who were women increased from 28% to 35% for full professors and from 35% to 41% for associate professors, according to data published last year by the Association of American Medical Colleges (AAMC). In addition, the proportion of women who were section chiefs, division chiefs, or both has nearly doubled since 2004, although fewer than one-third of all chiefs were women in 2018, according to the AAMC report.

A recent study raised questions about that progress, however. Among medical students who graduated between 1979 and 2013, women physicians in academic medical centers were less likely than men to be promoted to the rank of associate or full professor or to be appointed to department chair, according to results published in November 2020 by the New England Journal of Medicine. There was no narrowing in these gaps over the 35-year study period.

In terms of senior leadership, 18% of medical school deans were women in 2018, and the number of female deans has increased by about one per year on average since 2009, the AAMC report said. However, medical schools and departments where women do lead tend to be lower-margined and/or safety-net institutions, which typically have lower endowments, Dr. Moyer noted, adding that women have also endured job losses due to the pandemic. “Many more women have lost their jobs in health care due to the disproportionate burden on home fronts falling squarely into women's laps.”

In 2018, women represented far more administrative faculty leadership—52% of assistant deans and 47% of associate deans—while 34% of senior associate/vice deans were women. Dr. Spector noted that many of those supportive roles, although very important for achieving the missions of medical schools, are service oriented. In contrast, “At the senior associate/vice dean level, that's when those deans have resource allocation abilities … so in effect, they have power,” she said. “What we would like to do is get women into those positions as well in equal numbers.”

At this current rate, academic medicine won't reach gender parity in leadership until around 2070, when even today's medical students will be past retirement age, according to a perspective published in October 2019 by the New England Journal of Medicine that suggested establishing term limits for senior leaders (who remain disproportionately White and male). “We believe that enacting term limits is an important and underused mechanism for increasing diversity, equity, and inclusion within academic medicine,” the authors wrote.

Collaborations are another way to advance women in academic medicine. During Dr. Spector's session on collaborations to promote gender equity, she said organizations and societies can pool resources and intellectual capital to support women in leadership and address barriers to progress.

“I have to give a lot of kudos to the American College of Physicians. … Dr. Darilyn Moyer, their CEO, has created a task force to see how we can gather experts from around the country to think about these ideas together,” she said. (See sidebar on previous page for more on ACP's efforts and resources.)

In addition, the Women's Wellness through Equity and Leadership collaborative includes ACP and five other major medical organizations, such as the American Academy of Family Physicians and the American Academy of Pediatrics. The organizations are each sponsoring three female members' participation in the leadership course, which aims to develop a set of guiding principles on equitable work environments for female physicians.

Fixing financial gaps

Gaps in compensation for women in medicine are well established. Despite data suggesting that female physicians may have better patient outcomes than male physicians, such as an analysis of elderly hospitalized patients published in February 2017 by JAMA Internal Medicine, studies have estimated that female physicians earn 8% to 29% less than their male counterparts. In addition, a study of ACP members, published in November 2018 by Annals of Internal Medicine, found that female internists earn less than men regardless of whether they are generalists, hospitalists, or subspecialists.

A potential contributor to the gender pay gap is the amount of time women spend with patients, according to a study published in October 2020 by the New England Journal of Medicine. In 2017, female primary care physicians generated about 11% less revenue from office visits than their male counterparts (owing to a lower volume of visits), yet spent nearly 3% more observed time in visits. After adjustment for physician, patient, and visit characteristics, women generated equal revenue compared with men but spent about 16% more time with each patient.

Yet another financial gap between male and female physicians lies in their retirement accounts, ACP Member Disha Spath, MD, said during her session on improving financial health. In the Medscape Physician Debt and Net Worth Report 2020, 61% of women reported a net worth less than $1 million, compared with 44% of men. “Most physicians will need about three to five million dollars to retire, and if 61% of females are at less than one million, we've got a big problem,” she said.

Some physicians may believe they don't need to worry about finances, said Dr. Spath, an internal medicine physician for Dartmouth-Hitchcock Putnam Physicians in New York and the founder of The Frugal Physician. “A lot of people believe that once we start making a high salary, we'll be set for life. But unfortunately, it's not about how much we make; it's about how much we keep.”

Dr. Spath outlined four major steps to financial health: Protect loved ones, invest money, get out of debt, and grow investments. To protect loved ones, engage in estate planning, consider life and disability insurance coverage, and keep an easily accessible emergency fund equal to three to six months of basic expenses (or up to 12 months in the era of COVID-19), she recommended.

When investing, start with contributing to tax-advantaged accounts, and remember that compound interest is an exponential formula, Dr. Spath said. Using an average investment return of 7% and an average inflation rate of 3%, the “4% rule” established by the 1998 Trinity study states that one's portfolio of stocks and bonds should last at least 30 years with a withdrawal rate of 4% or less per year. Assuming this rule of thumb, the amount of money needed for an investor to retire equals roughly 25 times her yearly spending, she noted.

Another rule of thumb is to allocate the same percentage of investments to bonds as your age, Dr. Spath said. She added that a simple yet effective way to invest is through a “lazy” three-fund portfolio that includes one total domestic stock market index fund, one international index fund, and one total bond market index fund.

Ultimately, the biggest part of investing is having a plan and writing it down, especially if you are early on in your career, Dr. Spath said. “As you've seen during this COVID crisis, people freak out when the market starts going down, and it's a completely normal thing to do. The best thing you can do is not pay attention at all. … Write down your investment plan and stick to it, keep doing it no matter what the market does, and you'll come out ahead, most of the time.”

Another way to increase your net worth is to slash debt. Dr. Spath, who with her husband paid off more than $200,000 of student loans in a year and a half, suggested avoiding throwing extra money at all debts at the same time. “That's what we call a debt flood,” she said, adding that picking either the snowball method (pay off debts from smallest to largest) or avalanche method (prioritize highest-interest debt first) is more effective, although it's still important to make minimum payments on all debt.

A visual representation of debt can also increase motivation to pay off debt. “We wanted to pay off my student loans, and we represented it in this macaroni jar where each macaroni was $1,000,” said Dr. Spath.

The final step is to grow investments over time by tracking expenses in a written budget and by maximizing the gap between spending and income, she said. “The whole basis of frugality is that you make financially healthy substitutions without affecting your quality of life. So it's not about going for the thing that's cheapest; it's about going for the thing you value the most while spending the least amount of money.”

Lifting each other up

Women can't fix gender inequities alone. During their session on allyship, David G. Smith, PhD, and W. Brad Johnson, PhD, explained what men can do to get engaged.

Across all specialties in medicine, women report far less mentoring and sponsoring than men, and men have myriad reasons for not mentoring women, said Dr. Johnson, a clinical psychologist and professor at the U.S. Naval Academy in Annapolis, Md. “There were so many that we actually gave this syndrome a name: reluctant male syndrome.”

Up to 60% of men report feel uncomfortable having interactions in the workplace with women, perhaps due to false narratives about women, Dr. Johnson reported. But men should become more comfortable establishing trusting relationships with female coworkers, he said. “If they genuinely have anxiety about interacting with women, as a clinical psychologist, I'll just remind you: Exposure therapy is the only treatment,” Dr. Johnson said. “So more coffees, more lunches, more mentoring conversations is really the only solution to this.”

Male allyship encompasses both interpersonal allyship (i.e., one's relationships with women) and the more difficult task of public or systemic allyship: holding other men or the system accountable, said Dr. Smith, a sociologist and professor at the U.S. Naval War College in Newport, R.I. “Without that, we're going to continue to deal with the reoccurring and recreating of the culture that leads to sexism.”

As a man, it's important to be an ally at home first because even before the pandemic, women did 50% more of the domestic work and/or child care, Dr. Johnson noted. “Women are actually doing a lot more now than they were already doing. So men, we have got to start here. … If you think you're doing well in this area and you're not sure, go home and ask for a domestic audit today. And then, when you get the feedback, don't get defensive. You probably have some work to do to make it more fair.”

In addition to mentoring and sponsoring women at work, men can hold others accountable through a “watchdog” set of skills, Dr. Johnson said. For instance, the “Ouch!” technique can come in handy when one hears a sexist or biased comment or joke. “If I'm a guy at that moment, I can just say, ‘Ouch!’ Actually, anyone can say this,” he said. “The beauty of this is that it buys me another two or three seconds when every head in the room turns toward me, and then I can explain what didn't land the right way.”

Finally, workplace policies can make a difference. For instance, Dr. Johnson noted that a policy at J.P. Morgan asked men to take a “30-5-1” pledge because the company was not retaining and promoting enough women. The 36-minutes-a-week pledge involved 30 minutes having mentoring conversations with a junior woman, five minutes pointing out a woman's achievement or congratulating her, and one minute telling everyone else, especially senior leadership, he said.

“We love this because it empowers men to get busy engaging with women in the workplace, and we would love to see this implemented in medical communities,” he said.