SGEM#352: Amendment – Addressing Gender Inequities in Academic Emergency Medicine

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: Does this program accomplish its intended goals? Will the results here extrapolate to other settings? 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