Health Equity

Gender inequity in medicine: An expert survey of the landscape


Gender equity gaps in medicine most directly affect women, but the impact can be more widespread.

AMA Moving Medicine Podcast

AMA Moving Medicine highlights innovation and the emerging issues that impact physicians and public health today.

In the first of two “AMA Moving Medicine” podcast episodes about gender bias in medicine, Esther Choo, MD, MPH, explores how gender equity gaps can impact not just women, but an entire health system.

Below is a lightly edited full transcript of the presentation. You can tune in on Apple Podcasts, Google Play or Spotify.

Dr. Choo: The published objectives of this talk are to describe gender equity in the workplace and to discuss practices and processes that eliminate gender bias in hiring, promotion, leadership and inclusivity. …

So, let's just say that we will address gender bias. We'll talk about approaches and frameworks for this problem. I do have a few caveats.

I focus on gender for purposes of efficiency and simplicity. Of course, all the topics I talk about apply to race, ethnicity, sexual orientation, gender identity, disability and many other types of identity. I also do, when I mention gender, simplify to binary, which is again an oversimplification.

And finally, I focus on physician careers because that seemed the best fit for this audience. But recognize that these are issues that span health care, and we should think about our colleagues in other roles in health care when we address these issues.

There are a lot of ways to approach gender bias and a lot of reasons to care. And I will say they're all valid. I think for me, as a health services researcher with an interest in women's health and gender disparities, the issue always comes down to patient care. I think that is a very compelling true north when you think about this topic. For years, I've been aware of some inequities in the provision of health care and its outcomes.

One solution seemed to be diversification of our health care workforce so that we as care providers look a lot more like the population that we serve. And then when I thought, “Why don't we just diversify our health care workforce to match the populations we serve?”

It turns out that our health care workforce isn't a great place for a lot of people. And I want to show you some evidence that this is true.

First … is this really stunning report that came out last year, June of 2018. And actually the entire thing is quite a compelling read. This was put out by the National Academy of Sciences, Engineering and Medicine. And it was a comprehensive review of sexual harassment in the academic scientific fields.

They used this definition going forward: one, gender harassment, which is kind of the whole body of verbal and nonverbal behaviors that convey hostility, objectification, exclusion or second-class status of women. And then the more overt sexual behaviors that we think of: unwanted sexual attention and sexual coercion.

I just want to point out that gender harassment, the most general type, is the most common, and it's just as corrosive to work and well-being as the other types of sexual harassment. So, there's really no reason to exclude it in our consideration of sexual harassment. Using this broad definition, the report found that there's little change over time. This problem is not getting better on its own, as we hoped. It is worst in medicine compared to all the sciences.

Related Coverage

AMA principles will further gender equity among physicians

It is generally overlooked and highly tolerated. It is undermeasured, and when we do measure, we poorly measure it, not using valid data or rigorous instruments to measure the problem.

We are very stalled on litigation. In other words, the objective of most organizations is simply not to get sued, which is a very low bar, and women of color—sexual and gender minority individuals—experience more sexual harassment than others. There is also the least amount of information on these groups.

As far as outcomes, the report finds that sexual harassment undermines women's professional and education attainment. It has measurable negative effects on mental and physical health. It leads to attrition from leadership roles from institutions and even from the field of medicine entirely. And it has a stronger relationship with women's well-being than any other job-related stressor.

We spend a lot of time these days talking about physician wellness, and we talk about EMR and patient volume and regulatory requirements and a whole host of things. Part of that conversation should be the impact of sexual harassment on women because of this profound impact on them.

I want to be clear, too, that this is not just a problem for women, because harassment affects everybody in an organization. It spreads. The negative impacts of sexual harassment spread like a toxin to witnesses of the harassment, their entire working group and, actually, the entire organization. So, I think we trip up sometimes and think that this is a problem for the benefit of women, and I want to reframe that.

This is a problem for everybody in health care, and because of that, it's a problem for our patients as well.

This report actually does an amazing job of looking at the organizational incidents of harassment. Harassment occurs. It is rife in health care. So, what is making it happen? Because I do think that most of us are shocked by this data and do not feel that this is something that we align with or that we wish to be present in our health care workforce. They basically identify three main organizational antecedents to the occurrence of harassment.

One is settings that are male-dominated, male-led, are also climates that tolerate sexual harassment. And I want to be very clear that what we're talking about when we say the climate tolerates sexual harassment is that the climate that tolerates it is one of inequity. And let's talk about some of those inequities.

Let's start with salary, which is kind of the easiest to quantify.

There have been numerous studies over the past decade that demonstrate that there are consistent and meaningful differences in the salary of male and female physicians. This is one study with a large population that was fairly well controlled because of the amount of access to direct data they had. This took advantage of the fact that public medical schools have to disclose their salary.

And the first thing you want to see when you see any study about salary equity is, are the obvious confounders accounted for? And I thought this study did a really lovely job of accounting for the things that you would think might explain a difference in salary between men and women that we would consider fair or at least understandable.

They included things like faculty rank and choice of specialty, the amount of NIH funding you had, participation in clinical trials, your publication count as first or last author, your kind of academic pedigree, a proxy for clinical productivity and some med-school-level fixed effects.

After adjusting for all these things, this is what they found: In the adjusted analysis, they found an unexplained, around $20,000 difference in salary. People will ask me, "Well, that's academia. Surely it's better in private practice where it's more RVU based.” And actually, from available data, it seems like the problem is worse.

This is the third year of the Doximity physician compensation report. They only included physicians who worked at least 40 hours a week, which they called full time. And then on top of that, adjusted for hours worked, choice of specialty and also where in the country you worked, and they found that female physicians earned about $90,000 less on average than male physicians, and, overall, female physicians earned $1 for every $1.25 male physicians earned.

The other thing is, we'll often hear that all we need to do to fix the gender equity problem and salary and advancement and things like that is just bring in more women, right? I heard that when I was in medical school 25 years ago. They said, "Well, we're just about equal in medical school. As those women filter up, all these problems will go away." And it's pretty abundantly clear that's not going to happen by just head count. Because even in specialties dominated by women, like ob-gyn, those salary inconsistencies favoring men exist.

And as of 2018, there was no single specialty in which women earned more than men. And if you really think that the head count will make a difference, just consider nursing, because nursing has been dominated by women for as long as we can remember, and there is a salary inequity there that favors men.

What about promotion?

The same group that actually did the academic physician salary study also looked at differences in academic rank at U.S. medical schools, and they found that, really, this is kind of the curve that represents advancement of women compared to advancement of men. …

Whether you're talking about salary or promotion or leadership roles, we start out kind of about the same but with men slightly ahead. Then, over time, those differences tend to expand, and I consider this kind of the crisis of the mid-career women, which is, as you go up, the air becomes thinner. There are few of you and you feel the opportunity drop away as opportunities become rarer.

When we get to the top leadership, of course, women fall away almost entirely. My friend led this team, and they were initially going to look at the number of chairs who were women, and they thought, "Well, it's patently obvious that there are fewer female chairs than male chairs."

Related Coverage

Grants to fund research on women’s advancement in medicine

So, they were like, "What if we just looked at the chairs with mustaches?" So rather than all men, let's quantify the facial hair to men, and they were very scientific about it. So, you had to match one of these types of facial hair. And they found that women were 13% of over 1000 department to leaders in the top 50 NIH funded U.S. medical schools. Just the mustache leaders: 19%.

And there were only six out of 20 specialties that had more women than mustaches. They created this lovely mustache index, saying that maybe we can't achieve 50-50 equity in this lifetime for men and women in these major leadership positions. But can we at least have a mustache index of greater than one, where at least the women can outnumber the mustaches? I think that's a reasonable goal. Can we go for a mustache index greater than one?  

As I travel around the country and talk about gender inequity, and I talk with a lot of women across fields in medicine, many women will say to me, "I kind of care about the salary thing. I care about the promotion thing. But on a day to day basis, what really demoralizes me and really impacts me every single day I go to work is what we call these microcosms."

These are kind of humorously named, things like “man-terrupting” and appropriation, all the little interpersonal insults that kind of go back to that broad definition of sexual harassment I talked about. These little signals that you do not belong here. You don't have value or worth. Your ideas are not going to be credited. Your voice is not heard. And I hear time and again from women that that is just as profound an impact as any of these other inequities.

This is data from the AAMC [Association of American Medical Colleges] that shows kind of the leaky pipeline of women as you move up the ladder in academia. I've looked at this for a long time, and people told me in the early part of my career that the leaky pipeline was because of women's choices.—that we made choices to step out, to not achieve as much, to not spend as much time or be as engaged, and that's why women didn't move forward.

But looking across this data, I think to myself, "Well, there's a safety gap here, and there's a pay gap. And there's an opportunity gap, and there's a respect gap."

And I'm not totally clear what the true choice is when we have all these gaps. So, let's address these little gaps, these inequities, and then we can see what the true choices of women are. Because in the current setting, you cannot make the same choices as men can.

I just ask you, as an exercise, just take a moment and think about what it would look like in health care if there was no harassment, if pay advancement and opportunity were perfectly equitable, and if all health care workers felt valued and respected. Can you picture that just in your immediate work environment? Does that feel good? So, let's get there.

You can find more episodes of Moving Medicine and other AMA podcasts on Apple Podcasts, Google Play or Spotify.