Since gender-based discrimination in education was prohibited by the passage of Title IX, women have steadily gained parity in the numbers graduating from medical school classes. The illusion of gender equity, however, starts to erode rapidly as women lose ground at each subsequent rung of the professional ladder. Women leaders of hospital medicine and full professors in hospital medicine are a rarity. Gender-based disparities in income among hospitalists also continue to exist, culminating in perverse, pervasive, and persistent disparities for women in medicine.
Multiple factors contribute to the current state, including gender bias and harassment from colleagues, supervisors, and patients, the disproportional burden of household and parental responsibilities placed on women, and the expectations that women should take on more nurturing tasks that are often less highly weighted towards academic promotion (e.g., leading non-academic committees such as wellness or diversity, equity, and inclusion instead of focusing on obtaining grants for research). Additionally, women often receive biased feedback in evaluations which can also impact career trajectories.1-3 While gender bias can be subtle, like assuming a woman colleague will be in charge of taking notes in a meeting instead of a man, some policies explicitly widen the gender divide. Paid parental leave is one example of such a policy.
Institution-level policies emphasizing maternal rather than parental leave perpetuate gender inequity. Restricting family leave to the primary caregiver forces women to assume the brunt of childbearing responsibilities from the outset, propagating the existing gender discrepancy in household duties. Women consequently experience a “motherhood tax” where mothers are perceived as less committed or too busy to take on leadership roles. Compared to men academic hospitalists who take leave, women report far more negative impacts related to financial well-being, work-life integration, and career advancement. Even if a woman is childless, the assumption of future motherhood may lead to discrimination.
The factors that prevent women from climbing the leadership ladder are the same circumstances that often lead women to leave the workforce. Since women account for 50% of employed hospitalists and have been shown to have better clinical outcomes, their retention in the workforce is vital to the future of this field.
Strategies that make a difference
There are organizational strategies that have been shown to mitigate disparities in salary, career advancement during life transitions (e.g., parental leave), speaking opportunities, and micro- or macro-aggressions. Much of the literature suggests there are basic principles organizations can adopt to address these disparities.
Applying Donabedian principles
Hospitalists well-versed in the quality sphere may be familiar with Donabedian principles, which highlight that outcomes are a direct result of intertwining processes and structures. Much of the literature on successful outcomes in eliminating gender disparities in the workplace comes from processes and structures that systematically address the issues that lead to gender disparities in the first place.
One example of a successful process is open calls for speaking roles at national meetings. SHM has implemented an open-call process for workshop and didactic speakers, and more recently plenary speakers. Northcutt, et al.,4 showed that when an open-call system is in place, gender disparities are eliminated without a negative impact on conference ratings (in fact increasing scores were seen).
Regarding minimizing the motherhood tax, offering equal paid parental leave to birthing and non-birthing parents is only a start. Pylkkänan, et al.,5 found equitable leave policies did not necessarily translate to men taking longer leaves, suggesting that specific encouragement of men to take parental leave is also necessary to promote gender equality within the workforce. Moreover, allowing for flexibility in terms of when the leave is taken can help allow for a ramping-up period while returning to work to prevent the perceived negative impacts of taking extended leave.
Promoting transparency
A key component of any organizational initiative to mitigate disparities is increasing transparency around decision-making processes and sharing the policies and procedures for determining salaries, promotions, and job opportunities. Research suggests that one way to mitigate bias in negotiations for women is to ensure there is decreased ambiguity in the economic structure of a negotiation.6 One strategy that helps to level the playing field is posting salary ranges for open positions and requiring that all positions available are publicly posted. In the state of Colorado, the Equal Pay for Equal Work Act requires that employers do not discriminate between employees based on sex by paying an employee of one sex a wage rate less than the rate paid to an employee of a different sex for substantially similar work. A specific requirement of this act is that all job openings and open promotional opportunities are posted with a hiring rate or range.7
Commitment to following outcomes
Once institutions have evaluated practices for inequities within salaries, leadership appointments, workload distributions, and gender-based harassment, to name a few, leaders must stay committed to evaluating whether proposed interventions lead to gender equity in the long term. Furthermore, institutions should be willing to re-evaluate strategies if inequity persists.
Gender gaps persist in medicine; however, processes, policies, organizational culture, and commitment make a difference and should be emphasized as we envision an equitable future.
Dr. Defoe
Dr. Kara
Dr. Burden
Dr. Defoe (@mdefoe3) is a hospitalist at Northwestern Memorial Hospital in Chicago, and an assistant professor of medicine at Northwestern University Feinberg School of Medicine in Chicago, where she is the recruitment director for the division of hospital medicine and as medical director of clinical documentation. Dr. Kara (@areeba_kara) is a hospitalist and associate professor of clinical medicine at the Indiana University School of Medicine in Indianapolis, where she is associate division chief for the division of general internal medicine and geriatrics, director of faculty development programming for the division, and serves on the department’s graduate medical education committee. She is also an assistant editor for the Joint Commission Journal on Quality and Patient Safety. Dr. Burden (@marishaburden) is the division head of hospital medicine and professor of medicine at the University of Colorado School of Medicine in Aurora, Colo. She is the co-lead for the Hospital Medicine ReEngineering Network (HOMERuN) research network workforce planning group, and the executive co-chair and co-founder of SHM’s diversity, equity, and inclusion special interest group. They’re all members of SHM’s diversity, equity, and inclusion committee.
References
- Nittle N. The language of gender bias in performance reviews. Insights by Stanford Business. Stanford Graduate School of Business website. https://www.gsb.stanford.edu/insights/language-gender-bias-performance-reviews. Published April 28, 2021. Accessed November 1, 2023.
- Correll SJ, Weisshaar KR, et al. Inside the black box of organizational life: The gendered language of performance assessment. Am Sociol Rev. 2020;85(6):1022–50.
- Northcutt N, Papp S, et al. SPEAKers at the National Society of Hospital Medicine Meeting: A follow-up study of gender equity for conference speakers from 2015 to 2019. The SPEAK UP study. J Hosp Med. 2020;15(4):228-231.
- Doldor E, Wyatt M, et al. Research: Men get more actionable feedback than women. Harvard Business Review website. https://hbr.org/2021/02/research-men-get-more-actionable-feedback-than-women. Published February 10, 2021. Accessed November 1, 2023.
- Pylkkänen E, Smith N. Career interruptions due to parental leave: a comparative study of Denmark and Sweden. Organisation for Economic Co-operation and Development website. https://www.oecd.org/denmark/2502336.pdf. Published March 13, 2003. Accessed November 1, 2023.
- Bowles HR, Babcock L, et al. Constraints and triggers: situational mechanics of gender in negotiation. J Pers Soc Psychol. 2005;89(6):951-65.
- SB19-085: Equal pay for equal work act. Colorado General Assembly website. https://leg.colorado.gov/bills/sb19-085. Final Publication May 19, 2019. Accessed November 1, 2023.
1. It seems that the article targets a distribution of men/women in positions of leadership in medicine at 50/50. Why is that equal ratio the “ideal?” If the ratio was 70/30 in favor of women, would the authors be advocating for more men to be advanced ‘up the ladder?’
2. The article mentions “…harassment from colleagues, supervisors, and patients.” This was surprising to read, since having been a hospitalist for 25 years, working in many different hospital in many different environments, I have never witnessed, nor heard of any type of harassment of a woman physician based on gender. I have however, witnessed discrimination against male physicians, albeit rare.
3. I agree with the authors that institution-level policies that emphasize maternal rather than paternal leave perpetuate gender inequality, but disagree with the reference to household and parental responsibilities being referred to as “burdens.” Rather, the acts involved in parenting and structuring/maintaining a household are a privilege and gift that men have been discriminated against from being able to experience to the same extent as women. This is due to the long-held assumption that men will continue to bear the burden of leaving the home to go to work to earn the needed money to support the household, and necessarily suffer the consequences of having to be away from the family. I would call this a “fatherhood tax.” It seems to me that this perspective is not considered here. The authors paint a picture that achieving a position of leadership in medicine is of greater value than motherhood. Considering the fact that motherhood is a choice, if a woman views the value of the roles of mother versus the role of leader as these authors seem to do, it is certainly reasonable, if not admirable, to conclude that these two roles in life may oppose each other, with the more committed a person is to one role, their performance in the other role will necessarily suffer. We are human, after all.