Women and Academic Medicine, 2020

A full century after the passing of the 19th amendment, the composition of today’s medical school classes reflects the gender balance of the U. S. population. Of the country’s 92, 733 medical students in 2019, 46, 878 were women. 1 In that year, women comprised nearly half of residents and fellows in training, and most graduate students enrolled in doctoral programs in the biological and medical sciences in the United States were women. 2 The proportions of women faculty in clinical and basic science academic departments have grown steadily over the past decade, and as of 2019, nearly half of new faculty hires across all of academic medicine were women. 2 In that year, some primary care and specialty fields had more female faculty and residents than male faculty and residents. 2 Given these promising observations, one might ask whether the challenges associated with gender in academic medicine have been overcome. And the answer would still be no. Evidence and Experience Why not? Consider the data. Women continue to be underrepresented in top leadership roles in academic medicine. 3 Last year, 18% of U. S. medical school deans and 19% of clinical department chairs were women, with only small increases in the past decade. 4, 5 That same year, fewer than 15% of academic departments of anesthesiology, emergency medicine, neurology, otolaryngology, and surgery were led by women, despite far greater proportions of senior women faculty, 6 and, in 2018, one-third or fewer of senior associate deans, center directors, division chiefs, and section chiefs were women. 2 Women increasingly served as assistant and associate deans in 2018—commonly working with portfolios in education, student or faculty affairs, and diversity—but were rarely appointed to oversee high-stakes and highly influential clinical or research missions. 2 Recent data indicate that a smaller proportion of women attain senior rank in academic medicine compared with men, and men are more commonly promoted in 7 years in both clinical and basic sciences. 3 Also, women have been less likely to successfully apply for National Institutes of Health (NIH) R01 grant renewals for many years, and a 2017 study7 found that gender stereotypes may impact the R01 renewal peer review process. In one 2015 study, 8 female early-career researchers reported significantly lower institutional support than did their male counterparts (median 350, 000 versus 889, 000) for all strata of NIH funding. Few editors of journals in education and in scientific disciplines are women. 9, 10 Moreover, women are underrepresented as authors in the literature. A 2017 review11 of over 1. 5 million medical research articles found that 35% of authors per author group were women. Forty percent of first authors and 27% of last authors were women. Mentors to help women faculty deal with such challenges appear to be in short supply; a 2016 study12 published by our journal found that across 13 medical schools, 34% of female medical school faculty did not currently have a mentor and 13% had never had one at all. It is no wonder that the percentage of women who leave academic medicine has steadily increased each year, to 41% in 2019. 2 The number of women joining academic medicine is not reassuring if the entrance is better characterized as a “revolving door. ” Given the extraordinary intellectual talent and skill and the investment in each individual faculty recruit, loss of women faculty—at all, and especially at this rate—is of immense concern to academic medicine. A major report13 from 2018 indicates that half of women in medical school have experienced sexual harassment, most commonly gender-based harassment, and even more women faculty, cumulatively, have these experiences across the course of their careers in medicine. And while attitudes do seem to be changing, the problem of negative gender-based experiences starts early in medical training. For instance, in the 2019 Medical School Graduation Questionnaire14 with 16, 657 respondents, more than 7% of recent graduates felt that they had received lower evaluations or grades because of gender rather than performance, 6% had been denied opportunities for training or awards based on gender, and nearly 5% had been subjected to unwelcome sexual advances during the course of medical school. Sixteen percent of recent graduates had been subjected to offensive sexual remarks during their undergraduate medical education. And 1 in 5 recent graduates reported that respect for diversity had been demonstrated inconsistently in the conduct of their faculty teachers. The experiences of recognition and respect in the academic workplace also differ by gender. Women in training and women faculty perceive higher performance expectations and “necessary behavior” to receive recognition for their merit and contribution. 15–17 In specialties of medicine where men far outnumbered women, a study18 published last year found that women physicians reported more severe, frequent, and stressful microaggressions; were less likely to recommend their specialties; and were more likely to anticipate leaving medicine or retiring early due to gender bias compared with women physicians in specialties where women outnumbered men. In a recent survey2 of more than 22, 000 faculty respondents, fewer women than men felt respected in the academic workplace. Moreover, in this study, 17% of female faculty, compared with 1% of male faculty, had experienced an incident of overt disrespect in the prior year. A smaller proportion of women than men (65% versus 85%) agreed that their medical school offered equal opportunities irrespective of gender. Researchers in a study published in 201419 found that work demand in an unsupportive culture more greatly undermines women’s academic success and increases work-to-family conflict more than does the same level of work demand in a culture that is seen as supportive. Such data reinforce the important role of a welcoming culture characterized by equity, inclusion, and belonging that is free of oppression, discrimination, microaggressions, and bias. 20 Across society, women are expected to have greater responsibilities than men in their personal and family lives, and the field of medicine is not immune to this phenomenon, which contributes to role strain and stress. In one study21 of married or partnered young, high-achieving physician–researchers, women spent 8. 5 more hours each week on responsibilities at home (“domestic” activities). Female physicians with spouses who worked full-time were more likely than their male partners to take time off upon the disruption of child care resources or services, 21 a trend widely noted in the context of the present-day coronavirus pandemic. 22 Greater expectations in personal and professional roles can lead to greater fatigue. Women physicians report a variety of risk factors for mental and physical illness at higher rates than men do, and often have poorer health outcomes. 23–25 A 2010 meta-analysis25 found that women physicians are more emotionally exhausted than their male colleagues. For instance, a recent study24 of 253 physicians found that the risk of burnout for women was about 2 times greater than for men and that women were disproportionately likely to suffer from psychological distress, a risk factor for mental disorders. An analysis26 published in our journal in 2010 found that women in academic medicine were more likely to report never or rarely getting adequate sleep, never or rarely feeling refreshed when waking, and experiencing excessive sleepiness during waking hours. Very worrisome are the findings of a rigorous meta-analysis of physician suicide published this year that demonstrates a significantly higher suicide risk for female physicians—higher than for other women and higher than for their male physician counterparts of the same age. 27 A 2016 study28 of female physicians found that almost 50% of the women surveyed believed that they had suffered from mental illness yet did not seek treatment for reasons including limited time, fear of reporting to a licensing board, and a belief that a diagnosis would be embarrassing or shameful. My early work29–31 on medical student and resident health care, conducted with trainees from many different medical schools across the nation, showed that women were highly concerned about stigma and negative assessments (by supervisors or the dean’s office) associated with any kind of health concern. Over the years, increased health risks for women have also been observed in studies of medical students: in a systematic review32 published in this journal in 2006, first-year female medical students developed higher anxiety and depression levels than male students did. In an early cohort study33 of medical students, among those who reported excessive drinking, female students were more likely to report meeting or exceeding binge drinking levels. Finally, across all physicians, whether in academia or in practice, tangible indications of gender inequity exist in terms of financial compensation. A recent study34 of physician pay showed a 33% pay gap favoring men in specialty fields (372K versus 280K) and in primary care fields (258K versus 207K). Men in this study had greater overall net worth than women in the same age brackets, and fewer women reported having paid off their education-related debt, even several years after completing their training. The evidence, taken together, demonstrates that inequities for women in academic medicine start early and persist. Women’s experiences in training and in pursuing their careers differ considerably from those of their male counterparts. 35 The stresses that accompany becoming and being a physician as a woman may result in lessened career opportunities, a pattern of departures from academic medicine, more role strain, and sometimes very negative health outcomes. Expertise well beyond my own and well beyond what is referenced in this editorial suggests that our experience in the profession of medicine reflects a larger set of concerns in society; readers are referred to an immense body of literature in gender studies, 36 medical anthropology, 37 and interdisciplinary social sciences38 to gain greater understanding. Intersectionality won’t you celebrate with me what i have shaped into a kind of life? i had no model. born in babylon both nonwhite and woman what did i see to be except myself? i made it up here on this bridge between starshine and clay, my one hand holding tight my other hand; come celebrate with me that everyday something has tried to kill me and has failed. —Lucille Clifton, “won’t you celebrate with me”39 The 19th amendment stipulated that citizens could not be denied the right to vote based on sex, yet many women were still left out. Voting rights for women of color were won piece by piece in communities across the nation, until the Voting Rights Act of 1965 was passed. In academic medicine, progress at the intersection of gender and race/ethnicity has similarly been fragmented, slow, and incremental. Much remains to be done to achieve true equity. White preference, for example, has been shown in the findings of a number of studies40, 41 relevant to medical school admissions and academic hiring. Women and men who identify as underrepresented in medicine (URiM) have reported racial bias in the form of microaggressions, othering, and extra workplace burdens that contribute considerably to workplace stress reported in many studies. 42–44 One study45 of 25 physicians of African descent developed the term “racial fatigue” to characterize “the potential emotional and psychological sequelae of feeling isolated in a work environment in which race regularly influences behavior but is consistently ignored. ” Focusing on the intersection of gender and race/ethnicity, the failure to promote URiM women into leadership roles is of special concern. Recent data6 from the Association of American Medical Colleges (AAMC) document that 66% of clinical departments and 62% of basic science departments are led by White men. As with their male counterparts, most women in leadership roles are White: 73. 9% of female chairs in clinical departments are White and 74. 9% of female chairs in basic science departments are White. 6 Among women who lead basic science departments, only 8% are Hispanic, 7% are Asian, and 4% are Black or African American. 2 Among women who lead clinical departments, 5% are Hispanic, 11% are Asian, and 8% are Black or African American. Just 1. 3% of clinical departments and 0. 75% of basic science departments are led by Black or African American women. Furthermore, few full professors in U. S. medical schools are URiM women. 46 Academic medicine has, as yet, failed to achieve equity for URiM women, especially for leadership roles and senior positions. 2 The U. S. population, based on U. S. Census Bureau estimates in 2018, 47 is 327 million, of which 13% are Black or African American and 18% are Hispanic, Latino, or of Spanish origin. With 7% of 2019–2020 matriculants identifying as Black or African American and 6% of 2019–2020 matriculants identifying as Hispanic, Latino, or of Spanish origin, the body of medical students in the United States does not reflect the U. S. population. 48 The nonrepresentative distribution of women physicians by race/ethnicity within medicine is well characterized in the American Medical Association Physician Masterfile database. 49 It is astonishing to note that there are 60 or fewer Black or African American women physicians who specialize in neurosurgery, orthopedic surgery, pulmonary medicine, or urology in this country of 3. 8 million square miles, and there are 60 or fewer Hispanic women physicians who specialize in neurosurgery, orthopedic surgery, pain management, or pulmonary medicine. In light of the evidence that a more diverse workforce leads to better health care for underserved communities, 50 the underrepresentation of people from different backgrounds in medicine may continue to perpetuate health disparities. Given health disparities for minority populations and heightened mortality among urban Black or African American and Hispanic, Latino, and Spanish-origin communities, the lack of sufficient representation is deeply troubling and should be a call to action. According to a cohort study51 of 27, 504 graduating medical students in 2016 and 2017, women who identified as a sexual minority reported higher rates of mistreatment than did their male and heterosexual colleagues. In this study, female medical students who identified as Asian, as belonging to a URiM group, or as having a multiracial background also reported higher rates of mistreatment than did male and White students. A study published in 200352 found that lesbian physicians were more likely to report histories of depression, sexual abuse, and orientation-related workplace harassment than were heterosexual female physicians. In a 2011 study, 53 physicians who identified as lesbian, gay, bisexual, or transgender (LGBT) reported high rates of social ostracism (22%), derogatory comments at work about individuals identifying as a sexual minority (65%), and discriminatory treatment of sexual minority coworkers (27%). In a 2018 study, 54 18% of respondents reported using negative coping strategies to respond to stress related to their LGBT or other sexual or gender minority (LGBTQIA+) identity. Little is known about the barriers and inequities experienced by transgender women of all races and ethnicities in academic medicine. According to recent data reported by the National Academies of Sciences, Engineering, and Medicine, 55 in the general population, transgender women suffer some of the greatest health disparities. In 2016, over 1. 4 million Americans (0. 6%) identified as being transgender, 56 and, on the 2019 AAMC Medical School Graduation Questionnaire, 14 of the 15, 541 respondents who answered questions about gender identity, 0. 4% identified as having a gender identity different from their sex assigned at birth. Other important and underappreciated issues exist at the intersection of gender and minority identity related to religious beliefs. A 1999 study57 reported that female physicians are more likely to practice religions that are underrepresented in the United States and thus are at risk for compounded discrimination. Women physicians, compared with other Americans, were 6 times as likely to be Jewish, 4 times as likely to be Buddhist, 9 times as likely to be Hindu, and 9 times as likely to be atheist or agnostic. 57 In one study58 of Muslim physicians, 24% of respondents stated that they encountered religious discrimination during their careers and 14% of respondents reported that they currently experienced religious discrimination at work. The risk of discrimination was higher for those who reported that their faith was of deepest importance in their lives. Disability status may further contribute to inequity and distress for female physicians who already experience gender bias. While 12. 6% of the U. S. population reported living with a disability in the U. S. Census’s 2017 American Community Survey, 47 just 2. 3% of 15, 653 medical students reported a disability in the 2019 AAMC Medical School Graduation Questionnaire. 14 Within this small percentage, a significant number of participants reported a mental health issue, a learning disability, or a mobility or sensory impairment. Some respondents reported being denied accommodations associated with their reported disability. Evidence suggests that health professionals perceive disabilities negatively, perhaps even more so than the members of the general population of race and gender it that experiences of discrimination are compounded by The at hand are to and and to and that promote on a a more individual that members of academic communities are from discrimination, offered opportunities, and their professional In of the In this of Academic have a of and on the experiences of women in medicine that to the of gender and by our authors document disparities and challenges for women in academic medicine in with in faculty and and in and ask the field to the negative impact of gender and gender bias in the specialties of medicine and the for research and that disparities not of gender which are and have shown over identified the 4 of increased and to workplace in the experiences of female at different professional reported the rates and of and bias The challenges in the culture of disciplines were also noted in the by and by and by into the experiences of residents related to and these some of the personal and family health issues experienced by women residents and concerns leave and negative and the of physical and psychological stresses encountered in clinical training. and experiences in are very troubling and expectations of women in example, to be married to members of the sex, to have or to be of contribute to the feeling of being of not to promote gender equity is the of the by the status they a rigorous equity that investment of resources and new to and with leadership and for and a of the in Academic and impact over the past 25 years in over women in academic medicine, of identified as members of racial or over several years at the NIH to promote the research and academic success of women across medicine and the Such are to that support women in academic medicine, as demonstrated by who found that from gender support for equal to opportunities, and a or a culture that was to women’s academic Such academic medicine and a to a more just for our discrimination, and an culture in academic despite our and result in distress, and negative professional and personal among underrepresented in medicine, including greater challenges are encountered by women with a or religious identity and by The health status and disability status of women in academic medicine may also be of compounded distress, and negative career Such burdens based on gender or identity are and are to the and social of academic that many women were and on the to in the United The of and among of in our as well as the and of such as White for Black and Black are important both in their and their to a in which the of each of our is be by to discrimination, harassment, and bias and to and the of these The to inequity for women in academic medicine is to support academic and for women and to discrimination, harassment, and bias are not be or also equity for individuals of all underrepresented in a of in academic medicine work to attain social the and of academic medicine.