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Date: December 13th, 2021

Reference: Lee et al. Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine. AEM December 2021

Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called First10EM.com

Case: At the completion of her 1-month elective in your rural emergency department (ED), you are discussing career plans with a medical student. She says that she is very interested in emergency medicine, but she isn’t sure if it is the right choice for her. She has worked in five EDs so far, and a man has filled almost every leadership position. She also just got back from an emergency medicine conference, and more than 90% of the speakers were white males. She loves the clinical work in emergency medicine, but she is worried that these apparent gender inequities will limit her career opportunities.

Background: Gender equity is something we have spoken about often on the SGEM. Some listeners are happy we cover this topic while others have expressed concern. We recognize this can be an emotional issue. Our position is gender inequity exists in the house of medicine and it should be an issue everyone is interested in addressing. Here are some of the previous SGEM episodes that discussed gender equity:

  • SGEM Xtra: From EBM to FBM – Gender Equity in the House of Medicine
  • SGEM Xtra: Unbreak My Heart – Women and Cardiovascular Disease
  • SGEM#248: She Works Hard for the Money – Time’s Up in Healthcare
  • SGEM Xtra: Money, Money, Money It’s A Rich Man’s World – In the House of Medicine
  • SGEM Xtra: I’m in a FIX State of Mind

It is hard to believe some people deny the significant gender inequities that currently exist in medicine. Women are under-represented in leadership positions [1-3]. Women are less likely to be given senior academic promotions [4]. There are fewer women in editor positions in our academic journals [5]. Women receive less grant funding [6-7]. Women are paid less than men, even after accounting for potential confounders [2, 8-10].

Yet a recent twitter poll had more than 1/3 of respondents saying they did not think a physician gender pay gap existed in their emergency department. It is hard to move forward and address a problem when a significant portion of physicians do not even recognize that there is a problem.

The literature describes many factors that contribute to gender inequity. Institutional policies related to promotion or advancement may inherently disadvantage women and are likely exacerbated by implicit bias and stereotyping.

There are an insufficient number of women in current leadership positions, resulting in fewer mentors and role models for women earlier in their career. Policies around parental leave, emergency child-care, and breast-feeding support affect women disproportionately.

Unfortunately, sexual harassment is also still widely documented in emergency medicine and has a major impact on career advancement and attrition [11-13].

The reasons for the gender gap are complex, and likely not completely understood. Existing gender balance within specialties, among other aspects of the “hidden curriculum”, likely influence career decisions, with women trainees more likely to enter lower paying specialties. Current leadership positions are dominated by males, who may consciously or not be more supportive of other males for future promotions. Furthermore, there are numerous gender differences, both internal and external, that influence salary expectations and negotiations [14].

Female physicians are more likely to have female patients, and medical pay structures are often inherently biased. For example, in Ontario, where we both work, a biopsy of the penis pays almost 50% more than a biopsy of the vulva. Similarly, incision and drainage of a scrotal abscess pays twice as much as incision and drainage of a vulvar abscess [14].

There is data that suggests that practice patterns vary between women and men. Women in primary care are more likely to address multiple issues during a single appointment. They are more likely to provide emotional support and address psychosocial issues, and less likely to perform procedures. Although these are features most of us would want in a physician, unfortunately they result in lower remuneration in more medical payment models [14].

And of course, all of this occurs in the larger societal context in which women perform far more unpaid labour outside of medicine, resulting in much larger overall workloads, most of which is often overlooked. For a wonderful book on the topic, considering reading Invisible Women by Caroline Criado Perez.

Too often, women are blamed for the gender pay gap. It is true that women, on average, work fewer hours, and are more likely to work part time. However, this difference in work is not enough alone to explain the pay gap. For example, one study found that women earned 36% less than their male colleagues, despite only working three hours less per week [14].

It is also not true that women earn less because they are less efficient. Data from Ontario revealed that female surgeons earn 24% less per hour spent operating, despite completing procedures in the same amount of time as men. The difference seems to derive from women performing less lucrative procedures [15].

We clearly have a problem in medicine. There is no denying the current state of gender inequity. Solutions, while in some cases glaringly obvious, are probably rather complex. Solutions are unlikely to be “one size fits all”. The needs and desires of individual women will obviously be far more varied and far more complex than the “average woman”, and we should always be wary of unintended consequences when implementing social policy. However, those are not excuses. The data speaks for itself. More action is needed, and it is needed now.

The first step is to acknowledge the current problem widely and openly. This would be aided with transparent reporting on physicians’ payment, stratified by gender. It is worth noting that gender is not the only source of inequality in medicine, and this same data should be used to examine other factors such as race or disability.

We need better training about bias in medicine, especially for those in leadership positions. We need to consider more egalitarian interview processes, where leadership are blinded to characteristics like gender or race. We need to consider the impacts of systemic discrimination and recognize that simply being fair in a single hiring decision is unlikely to be good enough, as it doesn’t account for the incredibly different paths that candidates took to reach the same point.

We need to fix the biased billing codes and referral patterns. We need better parental benefits, and systems to ensure career advancement can continue even when one is taking time to raise children.

So clearly there is a lot that needs to be done on this topic. But neither of us are experts on the topic, so I think we had better get into the meat of the episode and start talking to our guest who is an expert.

Clinical Question: What can be done about gender inequity in emergency medicine?

Reference: Lee et al. Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine. AEM December 2021

There is no real PICO statement for this publication. We also normally do a quality check list to probe the publication for its validity. No such check list exists for this type of study seems to exist. it is still worth thinking critically about their methodology to consider the intrinsic and extrinsic validity of their discussion. When considering whether to develop a similar program, there are three major questions to consider:

  1. Does this program accomplish its intended goals?
  2. Will the results here extrapolate to other settings?
  3. What are the costs and alternative options?

Methods: This article describes the creation of a multi-institutional consortium of women faculty in emergency medicine to promote career advancement and address issues of gender inequity. The consortium brought together female faculty from four hospitals associated with Harvard Medical School.

Dr. Lois Lee

This is an SGEMHOP episode which means we have the lead author on the show, and we can hear about this program directly from the author. Dr. Lois Lee is a pediatric emergency medicine physician at Boston Children’s Hospital and an Associate Professor of Pediatrics and Emergency Medicine at Harvard Medical School.

Neither Ken nor I have experienced these issues firsthand. Is there anything else you think is important to add to the background material we provided?

  • Thank you for continuing to highlight gender inequities in medicine and also for working to figure out some solutions to this complex problem. Although there are some things as an individual that can be done, many—if not most—of the solutions really need to be at the departmental leadership, institutional, and systemic level.

What is the history behind this project and why did you think there was a need for this program?

  • Under our medical school there are five different institutions with separate emergency departments—four adult or general EDs and one pediatric specific. And it turns out over the last 5-10 years four of them had either formally or informally developed women faculty groups for career support. Then in 2018 several women from the different institutions came together and they formed the Harvard Medical School Women in EM Consortium.  Although we all have academic affiliations under the same medical school, we otherwise had no formal connections through our EDs.

Can you briefly describe the consortium and curriculum you developed?

  • Site champions—at least two from each site
  • Developed events based on informal needs assessment and literature reviews
  • Developed systems for information sharing for important policy information among the hospitals
  • Goals and priorities were developed using an interactive cycle: identify, learn, develop, and assess. This informed the activities we planned for the Consortium.

What was the conclusion from your paper?

Authors’ Conclusions: “This consortium-building model could be used to enhance existing institutional career development structures for women and other physician communities in academic medicine with unique career advancement challenges.”

Results: In the 2020 academic year, you had a total of 80 female faculty (representing 37% of the total EM faculty) involved in this consortium. You ran multiple local career development events and organized a larger conference. Unfortunately, the COVID pandemic derailed in person events, but you managed to continue to host quarterly virtual events.

Can you tell us a little bit more about the challenges you faced during this process?

Challenges:

  • Difficult to meet the individual needs of all participants across all career stages.
  • Scheduling is difficult in emergency medicine, with clinical responsibilities continuing 24 hours a day
  • Operating without a formal budget makes sustainability challenging.

Are there any key lessons you would pass along to other trying to replicate your success?

Advice:

  • For key domains: leadership, finances, communications, and curriculum development.
  • Formal leadership structure will improve sustainability and accountability.
  • A formal budget with ongoing funding is important for group sustainability.
  • Although smartphone texting groups allow for very easy group communication, suggest designating a specific communications director.
  • Adopting a formal process for curriculum development based on a formal needs assessment of the faculty members, combined with the published literature, and setting a calendar of events to enhance attendance and relevance for group members.

 Part of the SGEMHOP critical appraisal process is to have at least five nerdy questions for the lead author. This helps us to better understand the publication.

1. Representativeness: We know that women are significantly under-represented in academic emergency medicine. This consortium brought together a group of women who hold academic positions at one of the most prestigious medical schools in the world. They are, by definition, outstanding. How well should we expect their experiences and solutions to extrapolate to women working in other settings?

  • Although we are very fortunate to be working where we are, at the end of the day, working women have many—if not all—of the same challenges. How do you provide excellent clinical care, maintain or increase your academic productivity while caring for your family and loved ones—and yourself.  From talking to women in academic medicine around the country, I think all of us have the same experiences. We all need support in academic productivity, networking and leadership skills as well as work-life integration. So I really do feel our solutions can be extrapolated to not only women in other settings—but other groups who may feel less empowered, including those who are Under-Represented in Medicine (UriM).

2. Trainees: This group chose to focus exclusively on faculty, rather than including trainees, for a variety of good reasons explained in the paper. I wonder how these lessons might translate to trainees, and perhaps more importantly, ways in which you think the needs to trainees might be different.

  • Trainees have fewer academic demands and don’t have the considerations for promotion and leadership, like faculty do. However, they also have much heavier clinical demands, which makes work life integration—already a challenge in EM—even greater.  But they have different needs, including learning from role models, social supports, as well as learning career development and professionalism skills.

3. Differences Between Individual and Group Needs: In the paper, you mention that one challenge was meeting the professional and personal needs of all participating individuals. Even when groups have a very strong shared identify, that shared identity is likely always somewhat overwhelmed by the diversity of individuals who make up the group. I wonder if you can comment on the tension that might exist between a shared group identity and individual identities when approaching career advancement in medicine?

  • Although our Consortium members are all in academic EM, each individual has their own career and goals. Some are much more clinically and less academically focused. Others are the opposite. So when the shared group identity is focused on career advancement, there may be some tension with those in primarily clinical careers. But we do our best to embrace the diversity of careers in the group the best way we can.

4. Best Future Approaches: You make it clear in the article that solutions to gender inequity need to come both from current leadership and from the women seeking academic promotion. I think we need to be pursuing every option to close this gender gap in emergency medicine, I wonder if you have insight into what approaches might offer the biggest return on investment for institutions just starting on this journey?

  • First, there must be intentionality. I think Academic Emergency Medicine has been successful in being intentional in increasing awareness about gender inequities in EM. Similarly, institutions must be intentional in their interviewing practices for trainees and faculty to increase diversity, in building pipeline programs to increase diversity in medicine in general, and in achieving transparency around salaries, promotion, and leadership development.  If you don’t even know there are inequities in your department, then you can’t even begin to work on them.
  • For example for academic promotions, departments should critically examine how they are doing with academic rank in their faculty based on career track and years as faculty. Then they should be intentional in working with the individual faculty to improve equity in academic ranking, including with mentorship and sponsorship and career development coaching.

5. Translation Into Long Term Goals: This program appeared to be quite successful in the short term in generating engagement and developing career skills for female faculty. How successful do you think these early successes will be in generating the desired gender equity in emergency medicine in the long run?

  • We are asking ourselves the exact same question. So our leadership group is developing metrics for the Consortium so we can hopefully measure our successes in gender equity over time—although it may take a long time. But ultimately I think we will be successful. At the individual level we will providing useful skills and actionable changes. And as a Consortium we will work with our department leaders to continue to intentionally work on gender inequity issues related to salary, academic rank, and leadership. Then hopefully this will also contribute to other important issues like faculty retention and physician well being.
  • But ultimately the goal is not about promotion—but about providing optimal care for our patients. And working towards diversity in medicine—not just around gender—is essential for us to achieve that goal.

Those were the five nerdy questions. Is there anything else you think the SGEM audience should know about your study and its limitations?

  • I do want to acknowledge the formation of our Consortium was an important first step. But one of major limitations was we didn’t have a true formal governance structure at the beginning. Just a leadership group comprised of the site champions. So one of the important lessons learned is to develop a formal governance structure from the beginning. But we are changing that now—which will improve the ultimate sustainability and success of the group.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

SGEM Bottom Line: We acknowledge the significant gender inequities that currently exist in emergency medicine, applaud the authors for the tremendous work, and hope that these efforts will eliminate gender inequities for the next generation of doctors.

Dr. Justin Morgenstern

Case Resolution: You discuss the data on gender inequity across medicine with the medical student and turn the discussion to possible solutions. You encourage the student to reach out to the female faculty at Harvard who created an excellent consortium to address issues of gender inequity and offer to support her in her effort to change the culture of emergency medicine from within.

Clinical Application: This is an interesting publication to review and then consider if you could apply some of the ideas to your own workplace.

Dr. Lois Lee

How do you think the SGEM listeners should apply this publication into their department/institution?

  • Form a group! We literally give you a playbook on Table 4 on how to establish a career advancement consortium. And although we use women faculty as an example, this guideline can be used for any group with a shared background who is interested in career support and advancement. Or you can just start with data on faculty academic ranking and salaries to see where the inequities are. And then develop a plan to start addressing them.

What Do I Tell the Medical Student? Gender inequity exists in the house of medicine. There are many people trying to address this serious issue and implement solutions. While change is not happening quickly enough you should select the area of medicine that interests you the most.

What would you tell the medical student?

  • Change will come slowly—but I feel it is coming. As the three of us know, emergency medicine is one of the most gratifying and also one of the most challenging jobs a person could have. So if that is where her passion lies, I wouldn’t let gender inequity prevent her from pursuing it. Instead, I would challenge her to be a part of the solution.  Only by increasing diversity in EM—including in the numbers of women—can we work towards gender equity and improved care of our patients.

Keener Kontest: Last weeks’ winner was John Carter an EM consultant from Scotland. He knew Delirium Prevention, Detection, and Treatment in Emergency Medicine Settings was the other scoping review published by the Geriatric Emergency Care Applied Research (GEAR) Network

Listen to the SGEM podcast for this weeks’ question. If you know, then send an email to thesgem@gmail.com with keener in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on gender equity? Tweet your comments using #SGEMHOP.  What questions do you have for [name] and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

 References:

  1. Gold JA, Roubinov D, Jia LS, et al. Gender Differences in Endowed Chairs in Medicine at Top Schools. JAMA Intern Med 2020;180(10):1391–4.
  2. Madsen TE, Linden JA, Rounds K, et al. Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians. Acad Emerg Med 2017;24(10):1182–92.
  3. Cheng D, Promes S, Clem K, Shah A, Pietrobon R. Chairperson and faculty gender in academic emergency medicine departments. Acad Emerg Med 2006;13(8):904–6.
  4. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex Differences in Academic Rank in US Medical Schools in 2014. JAMA 2015;314(11):1149–58.
  5. Ravioli S, Rupp A, Exadaktylos AK, Lindner G. Gender distribution in emergency medicine journals: editorial board memberships in top-ranked academic journals. Eur J Emerg Med 2021;28(5):380–5.
  6. Sege R, Nykiel-Bub L, Selk S. Sex Differences in Institutional Support for Junior Biomedical Researchers. JAMA 2015;314(11):1175–7.
  7. Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Stroke 2016;47(3):750–5.
  8. Wiler JL, Rounds K, McGowan B, Baird J. Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians. Acad Emerg Med 2019;26(3):286–92.
  9. Read S, Butkus R, Weissman A, Moyer DV. Compensation Disparities by Gender in Internal Medicine. Ann Intern Med 2018;169(9):658.
  10. Frintner MP, Sisk B, Byrne BJ, Freed GL, Starmer AJ, Olson LM. Gender Differences in Earnings of Early- and Midcareer Pediatricians. Pediatrics 2019;144(4):e20183955.
  11. Lu DW, Dresden S, McCloskey C, Branzetti J, Gisondi MA. Impact of Burnout on Self-Reported Patient Care Among Emergency Physicians. West J Emerg Med 2015;16(7):996–1001.
  12. Choo EK, Byington CL, Johnson N-L, Jagsi R. From #MeToo to #TimesUp in health care: can a culture of accountability end inequity and harassment? Lancet 2019;393(10171):499–502.
  13. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med 2014;89(5):817–27.
  14. Cohen M, Kiran T. Closing the gender pay gap in Canadian medicine. CMAJ 2020;192(35):E1011–7.
  15. Dossa F, Simpson AN, Sutradhar R, et al. Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada. JAMA Surg 2019;154(12):1134.