How inequities such as salary gaps and more subtle professional slights lead to the “invisibility” of mid-career women in academic medicine.
Outside, dark grey clouds ominously brew a blustery storm. Dr. Resa E. Lewiss has just managed to escape it. She shakes away the rain drops that still cling to her coat, with a bright smile. When asked about gender equity in medicine, her smile turns into a thoughtful expression. She wants to focus on positive action and solutions.
A 2018 report from the National Academies of Science Engineering and Medicine (NASEM) showed that 58% of women faculty and staff in academia across science, engineering and medicine experienced sexual harassment and gender bias. Surprisingly, the field with the most harassment and inequities was not engineering – a field still largely dominated by men – but academic medicine.
As one of the founding members of Time’s Up Healthcare, Dr. Lewiss, a professor of Emergency Medicine and the director of Point-of-Care Ultrasound at Thomas Jefferson University, is writing, speaking and educating others on the unique environment of medicine and why it breeds inequities. As first author on a recent publication in the Journal of Women’s Health, she delineates larger scale, or “macro” inequities like the salary gap, and the more subtle, “micro” ones like the omission of professional titles or credentials. Together these inequities lead to a pattern of “invisibility” among mid-career women physicians.
We sat with Dr. Lewiss to discuss the inequities in academic medicine, the words and behaviors that contribute to them, and how to dismantle them.
Which aspects of medicine make gender inequities and harassment such significant problems?
Medicine is exquisitely hierarchical. You learn your role as a medical student, which is different than your role as a trainee. And a first year intern is very different than the chief resident, whose status is different to that of the attending in charge. This hierarchy sets up power differentials, and makes medicine a breeding ground for status anxiety, which is a fear or concern for one’s standing or position in the work environment. Unsurprisingly, when people feel their power or their position is being threatened, they may react aggressively in subtle and not so subtle ways. These aggressive behaviors and bullying, such as verbal outbursts, especially by men, have been historically allowed or excused. When women are the objects of these aggressive behaviors, they are often lower in the hierarchy, have less power and are afraid of retaliation. They often will not speak up.
Academic medicine does not reward women equally to men, financially or in terms of leadership positions. Term limits, which are standard in many organizations, do not apply to academic medicine, so there are fewer leadership opportunities for women in medicine.
What does the lack of gender equity look like in academic medicine?
Women do not make the same amount of money as men for doing the same job. There are innumerable reports documenting this. The disparity persists in virtually every specialty and at every level of promotion. It worsens over time because women are promoted at slower rates. So a woman who starts at a lower salary and is promoted after five years from assistant to associate professor will always be playing catch up to a man who is promoted at the three-year mark who started at a higher salary and whose salary increases at a faster rate.
Women are less likely to hold leadership positions. So even though women comprise greater than 50% of the healthcare workforce, only 22% of full professors are women, 18% of department chairs are women and 17% of medical school deans are women.
And perhaps more damaging and certainly more subtle are micro-inequities. These are harder to measure and to illustrate. Nonetheless, they are cumulatively problematic. One example is the language, adjectives, and descriptions used in letters of recommendation. Women may be described as “lovely” or “she always has a smile on her face” whereas men may be praised for academic accomplishments and described as “well prepared” and “handles cases well.” There can be a seemingly benign omission of a professional title that is inconsistent with the rest of a working group. For example, I was once leading a project with an all-male team comprised of medical colleagues. The project manager always called me by my first name but referred to my male colleagues as “Dr.” so and so. Studies show that this experience is very common for women.
How do these inequities impact a woman mid-career? What leads to invisibility?
This is not simple-to-explain nor easily-understood. It is multifactorial. There is a build-up of these inequities and unconscious biases over time. They begin as early as high school and college, when people are more vulnerable to certain kinds of messaging. These macro and micro inequities accumulate through medical school, residency training and then the early career phase. Mid-career is when we see these inequities take a toll. Women leave by choice or the system, which is not designed to treat them fairly or respectfully, makes them leave. Women become “invisible.”
It is often convenient, but reductionist, and inaccurate when women leaving is explained away by family responsibilities. Related to the challenge is that pregnancy is characterized as a disability. In fact, women must often utilize their disability insurance when they take maternity leave. There are countless examples of women colleagues in medicine who have been intentionally left off of communications or had decisions made on their behalf, when they are pregnant or out on family leave. Moreover, women report that resentful colleagues equate family leave with taking a vacation. Women lose ground during this early and mid-career time period; they miss out on job opportunities and promotions. There’s sometimes even subtle resentment from a woman’s colleagues or leadership because they’ve had to account for cases and patient care while she was on leave. Finally, there is an element of women having to work extra hard before they leave or once they return to prove themselves. Neither men nor women should be punished for wanting a full life outside of the workplace. This culture has to change.
Mid-career is also a time when there is a shift in mentoring and sponsorship by men in leadership positions. Earlier in their careers, women have many more opportunities to take part in mentoring programs and men higher up the hierarchy are more intentional about supporting them. However, as women gain more status and experience, and are eligible for more opportunities for promotion, they become more of a threat. Women are now competition and it is not uncommon that women are bullied, verbally threatened or approached with aggressive body language and behaviors. As support from male mentors and colleagues wanes, these verbal outbursts are explained away and allowed. These same men are often promoted.
How can healthcare institutions and organizations prevent invisibility from happening?
At the end of the day, hospitals and healthcare systems are businesses and the leaders prioritize their return on investment. They want the best clinicians and the best researchers. There’s so much evidence for the statement: diverse teams are better teams. Diverse means many things and for the sake of describing the invisibility phenomenon, it means having more women on the team. Better means more productive, better morale, better patient care, better outcomes, more innovation and more return on investment. If organizations work on the premise that women are as able, competent, and intelligent as men, then they should create an environment where women feel welcomed and want to stay. If you have a system that is not safe, equitable and dignified, then women will leave and the systems will lose talent and high performers.
Institutions and organizations can be more intentional about whom they are training for leadership positions and about whom they are naming to these positions. They can work to recognize when a pool of candidates lacks diversity. One positive and intentional example I have seen in my specialty is through the Academy of Academic Chairs of Emergency Medicine. This is a chairperson development program that looked at itself and realized that most of their participants were white men. So they have been very intentional about encouraging and accepting of women, women of color and underrepresented minority applicants to become leaders in Emergency Medicine.
If organizations work on the premise that women are as able, competent, and intelligent as men, then they should create an environment where women feel welcomed and want to stay.
Institutions can also be more supportive of women and men who return to work after family leave. They should be kept on the radar for promotions and leadership positions. Some healthcare systems have created re-entry fellowships, such as financial grants for women with childcare responsibilities.
How can men and women physicians in leadership roles position themselves as better allies and educate themselves on gender equity?
The change that we seek cannot happen without men at the table and as allies. Men are in leadership roles with power to help change, endorse and approve policy. I think there’s an opportunity for men to reflect on who they’ve sponsored and mentored and to whom they’ve given opportunities. Because the macro and micro inequities start well before mid-career, we all must model appropriate behavior, constructive comments and respectful ways of referring to each other.
Generally speaking, people want to help and do the right thing, but they don’t always know what to do. Increasingly, we are seeing training in med school on unconscious and implicit bias and also on messaging and language. Similar faculty training has been rolled out.
We all have responsibilities as individuals to educate ourselves, both men and women. We all have access to journals and articles and social media posts; we can all take part in the conversation. We can also all make a commitment to publishing or supporting research on these topics, or having speakers and lectures on these topics. Peer reviewers and editors can demonstrate intentionality in whose work they are promoting. If you have been chosen to be on a panel of experts, you can advocate for inclusion. For example, recently the NIH director Francis Collins recently declared that he would no longer participate in all male speaking panels — aka manels.
Have there been changes that you are optimistic about?
The creation of Times Up Healthcare has been very impactful. We have over 70 signatory institutions; these are schools of medicine, schools of nursing and hospitals and hospital systems that have signed on to support the core statements of the organization.
The fact that our publication and others on equity and harassment are published in visible and high impact journals such as the Lancet and the New England Journal of Medicine, underscore the credibility of the issue. Everyone is realizing that it’s very real and has to be taken seriously.
The mid-career invisibility paper has resonated with a lot of people. Women in their mid and late careers identify with what we describe, and this acknowledgement alone can lead to shared understanding and goals. A critical piece of the response is that male colleagues who have learned of this work want to be a part of the solution. As discussed earlier, increased diversity leads to better outcomes. The goal of all of this is to create a path to a better environment for everyone. Because this leads to better patient care. People wish to be the best clinicians; they cannot achieve that if they don’t feel safe, respected and fairly treated in their workplace.