Identifying as a woman in medicine can present numerous challenges, as we know. As we work toward equal representation for women in medicine, it is imperative to consider the inequalities which exist in leadership roles within medicine as well. Drs. Chary and Thomas visit the blog today to talk about the important topic that is needing more women in leadership.
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Authors’ Note: In this article, we use the word “female” as an adjective and “women” as a noun by convention, but recognize this language does not accurately reflect distinctions between gender and sex. An inherent limitation of writing about “women in medicine” is that the terms we use and the studies we cite may not accurately depict how individuals identify their gender.
Despite women comprising more than half of medical students in the United States, leadership in medicine is largely male and White. Gender gaps in leadership widen as one ascends institutional hierarchies: while a recent national survey in our specialty, emergency medicine, demonstrates equal proportions of female and male chief residents, in medicine in general, less than 10% of department chairs, division chiefs, chief medical officers, and healthcare CEOs are women.
Both of us identify as women in medicine. We served as chief residents for our Emergency Medicine (EM) training programs, and Dr. Thomas subsequently completed an Administrative Fellowship focused on Sex and Gender Equity. For context, our field is numerically male-dominated: women represent about one-third of academic emergency physicians, about one-third of resident physicians, and a little over a quarter of emergency physicians in general. Our experiences reinforced a lesson that women, and particularly women of color, need a seat at the leadership table. As women in medicine, we face too many issues in the workplace that will not be improved for future generations if we do not have a platform. We would like to offer some examples of how we, as women, tried to effect change in our institutions, in some cases regarding issues that were not on the radar of male colleagues in leadership, and in many cases regarding issues that benefited from the involvement and support of male allies and leaders in medicine. We also reflect on some crucial lessons and limitations from our experiences.
Being a sounding board for navigating difficult workplace experiences
For many women, the early years of hospital life are characterized by hazing and exclusion by colleagues and the constant experience of patients mistaking us for nurses or other non-physician roles. The cumulative daily experiences of being addressed as ‘Miss’ or ‘Honey’ in the hospital and patients’ frequent requests for blankets, food, or water—directed to us but not our male colleagues—can be incredibly tiresome. It is imperative for interns and junior residents to have seniors with whom they can debrief such experiences. As an intern, I went to my residency’s female chief, who helped me through these experiences. Going to male seniors and faculty members—who were far more numerous—felt less natural, and when I did, many of them were at a loss on how to advise me. As a senior resident, I was able to draw from my own experiences to teach juniors about strategies to establish authority, respectfully reinforce their roles as physicians, and develop positive (or at least neutral) interprofessional relationships. Part of my formal work in this area involved developing trainings in responding to microaggressions for my residency, hospital system, and within my specialty at the national level. Notably, the vast majority of my colleagues in this work have been women.
Creating policies that support pregnant and breastfeeding women
For many women in medicine, our reproductive lives coincide with our early and mid-careers. However, medical training and workplace environments are rarely designed to take into account women’s reproductive health needs. As one example, consider that at some hospitals, initial COVID-19 vaccination policies did not include information for pregnant and breastfeeding healthcare workers. Pregnant women were not included in initial COVID vaccination trials, which likely shaped the lack of institutional guidance offered, but failure to mention these populations in initial recommendations was a large oversight.
Female leaders in medicine can play important roles in recognizing and addressing such institutional omissions. For instance, women may be scheduled to avoid working night shifts during their first and third trimesters of pregnancy to reduce complication risks. Similarly, a lactation support policy could be implemented to provide protected time for mothers to pump, as well as the creation of a dedicated pumping room within the ED, equipped with a chair, desk, sink, fridge, computer and phone. As chief resident, I wrote our department’s lactation support policy and secured a hospital grade breast pump, which empowered our breastfeeding women to be excellent clinicians, without sacrificing their personal commitments.
We offer the important acknowledgment that not every woman in medicine pursues a family life. Furthermore, the pursuit of family life is not straightforward for everyone in medicine, as many struggle with infertility. Our advocacy for female physicians’ reproductive needs is in no way intended to diminish these experiences.
Rethinking honors, recognitions, and amplification
Over my years of residency, I noticed that male physicians tended to win annual departmental awards. Women seemed less likely to promote themselves or be recognized at the departmental level as leaders, champions, and mentors. In the last two years, I critically discussed these observations with the resident and faculty leaders of our Women’s Initiative. We created new award categories to recognize female physicians for academic excellence, leadership, and outstanding mentoring in diversity and inclusion. At the same time, through discussions with our program leadership, we made efforts to diversify speaker series and guest lectures, which historically predominantly featured male physicians and occasionally White female physicians.
At the national level, I serve as the Co-Chair for the Awards Committee of the Academy for Women in Academic Emergency Medicine (AWAEM), and we have the honor of recognizing dozens of incredible women in our field. One lesson that I have learned is that women are more critical of their accomplishments than my male colleagues. There are many qualified women for the awards who discount their incredible achievements when asked if they would apply. I have also noticed that, as women, we are more likely to believe that we need additional experience or education before we consider an opportunity. We need women in leadership to not only amplify these women and their accomplishments, but to remind them that they are qualified. As Co-Chair, I have focused on reaching out to female colleagues individually to discuss the awards and reasons they are well-suited candidates. My observation is that sometimes a simple word of encouragement can have a significant impact.
Creating evidence, using evidence
A common experience within a minority group can be questioned or dismissed as anecdotal by a majority group, particularly in within medicine, which favors evidence from randomized controlled trials. Sometimes, female leaders have to collect data—whether through research or quality improvement initiatives—to create evidence that others will accept as such to start conversations about sex and gender equity.
As one example, women in my residency had a common experience of feeling like we had to fight for opportunities to do procedures. We noticed that male senior residents in the critical care area would pull male interns from the minor care area to perform intubations on overnight shifts, but did not seem to pull us when we worked overnights in the minor care area. We felt like our male colleagues who wanted to place central lines enjoyed support from floor supervisors and nurses, whereas we encountered resistance and friction and were told lines could be placed in the intensive care units. When we brought up our experiences as junior female residents, the reactions of male senior residents attendings ranged widely from shock and support to invalidation and dismissal of our concerns. When I became a senior resident, I turned to a co-resident with expertise in data science who helped pull all residents’ procedure notes from the electronic medical record over a yearlong period. His analysis showed that there was a relatively equal distribution of procedures for male and female residents. I worked with my program’s leadership to have the data presented at our didactic conference, which led to a residency-wide conversation about the gap between the numerical findings and female residents’ experiences. Ultimately, this led to broader awareness in our departments about advocating for female residents’ procedural experiences.
Being in a leadership position as a woman is a privilege and a valuable opportunity to shift the culture of medicine. However, we want to offer caveats about the ways it can feel burdensome.
The time commitment associated with mentoring juniors and advocating for change should not be underestimated, even in early career stages. Female junior colleagues seek out female senior colleagues in leadership roles, and because there are fewer female leaders in medicine, women in leadership roles tend to end up with a disproportionate load of mentees when compared to male colleagues. While this problem is well-recognized at the faculty level, the same happens to female senior residents. A mentorship burden exists not only in developing relationships at one’s own institution, but can also be an all-too-common feature of employee recruitment. Consider this example: Say that, in the spirit of exposing female residency applicants to female mentors, a residency program in a predominantly male specialty strives to have every female candidate (about half of the applicant pool) be interviewed by a female faculty member and a female resident (about one quarter to one third of the department). At the same time, female residents are disproportionately contacted by female applicants hoping to get a feel for the program. This mentoring and networking work usually does not result in a reduced clinical burden for female physicians. These situations reflect a ‘minority tax,’ in which those in a less-represented group are assigned greater workloads in the name of diversity on the basis of their social identity. Regardless of how rewarding it can be, mentoring junior colleagues takes time and often feels underrecognized and undervalued by administrators.
Being recognized as a point person for gender equity issues entails being asked to tackle projects that do not contribute to one’s professional aspirations or promotion. As one example, women, and particularly women of color, are often asked to serve on not just one, but multiple diversity committees—at the departmental and hospital level, and sometimes across multiple institutions. We have said yes to these asks because it felt like the right thing to do. Even when we felt we did not have the time or expertise, it was hard to turn down requests to take on gender equity initiatives, because a lot was at stake in saying no: would we be disappointing our leadership? Would we diminish our status as ‘team players’ or ‘good citizens’ of our departments? Would the issues stagnate or remain unresolved if we did not take them on? As women, we felt like we had disproportionately more of these service commitments, which are not as highly valued for academic career advancement as publishing papers or obtaining grants.
Advocating for sex and gender equity in medicine can be isolating and lead to worry about one’s professional reputation. Becoming respectfully vocal about the numerous ways that sex and gender affect our training and work experiences can be isolating. Our supervisors may be unaware of the extent of the issues at hand, and speaking up can be perceived as hypercritical or perseverative. We appreciate that this problem is amplified for women from racial and ethnic minority backgrounds—i.e. Black and Latinx women—who face greater stereotypes about being angry or impassioned. As such, we need to work towards consensus building by continuing to share and amplify our stories.
Ultimately, despite these challenges, we have felt privileged to play any role, however small, in ushering in improvements for future generations of women in medicine. We hope that we see within our careers a time in which female leadership in medicine is not the exception, but a norm.