Women Physicians and the Suffrage Movement

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Indexed in MEDLINE, PubMed, and PubMed Central National Library of Medicine S P E C I A L I S S U E

September 2020

A peer-reviewed journal of medical science, social science in medicine, and medical humanities

Women in Medicine

Commentary Original Research Articles 1 Celebrating Women in Medicine 32 Assessment of Burnout: A Pilot Study of International 3 They Were There: American Women Physicians Women Physicians and the First World War 37 Let’s Get Personal: Academic Office Displays 7 Women Physicians and the Suffrage Movement and Gender 11 Inequity and Women Physicians: Time to Change Special Report Millennia of Societal Beliefs 43 Proceedings from the American Medical Women’s 17 Discovering and Reflecting on Bias: A Discussion about Association Graduate Medical Education Symposia: Challenges and Benefits of Culturally Centered Patient The First Three Years, 2018-2020 Care with Women Physicians of the East Bay Narrative Medicine 22 Women in Podcasting: We Should Tune In 58 Collaborations, Connections, and Conversations: 25 Preinvisible: An Early-Career Perspective on a A Journey to Meaning in Medicine Midcareer Phenomenon 29 Been There, Tried That, Learned This: Two Physicians’ Life-Care List for Colleagues TABLE OF CONTENTS

COMMENTARY Williams, MS; Anisa Haffizulla; Patrick 49 Stress, Burnout, and Depression in 1 Celebrating Women in Medicine. H Nicole Hardigan, PhD; Kim Templeton, MD, FAAOS, Graduate Medical Education. Carol A Tran, MD, PhD; Eliza Lo Chin, MD, MPH FAOA, FAMWA Bernstein, MD ’ fi 3 They Were There: American Women 37 Let s Get Personal: Academic Of ce Medical Humanities Physicians and the First World War. Displays and Gender. Katelyn Moretti, MD, 50 Using Story to Change Medical Culture. Mollie C Marr, BFA; Iris Dupanovic, MS; MS; Andrew Musits, MD, MS; Alyson Jessica Nutik Zitter, MD, MPH Victoria Z Sefcsik, MS; Nitisha Mehta; McGregor, MD, MA; Adam Aluisio, MD, MSc Eliza Lo Chin, MD, MPH 51 Art and Critique in Medicine. Somalee Banerjee, MD, MPH; Yoko Kiyoi, MA 7 Women Physicians and the Suffrage SPECIAL REPORT Movement. Eliza Lo Chin, MD, MPH; 43 Proceedings from the American Preparing Trainees for Practice Morgan S Levy, BS; Alyssa D Brown, BS; Medical Women’s Association 52 Developing a Fellows’ Academy to Mollie C Marr, BFA; Prachi M Keni, BS; Graduate Medical Education Symposia: Prepare Senior Trainees for Independent Naveena Daram, BS; Courtney A Chau; The First Three Years, 2018-2020. Practice. Rini Banerjee Ratan, MD Naseem Rangwala, BA; Katarina Watson Women in Graduate Medical Education 52 Physician Reentry to Practice: The Role of 11 Inequity and Women Physicians: Time to 43 Establishing a Graduate Medical Graduate Medical Education. Kimberly Change Millennia of Societal Beliefs. Education Task Force for the American Templeton, MD, FAMWA Connie Newman, MD; Kim Templeton, MD; Medical Women’s Association. Eliza Lo Chin, MD, MPH Joan C Lo, MD, MS, FACP Expanding Graduate Medical Education 53 So You Think You Want to Start a Family 17 Discovering and Reflecting on Bias: A 44 Leveling the Playing Field for Women Medicine Residency. Deborah Edberg, MD; Discussion about Challenges and Benefits in Medicine and Training. Theresa Lauren Anderson, MEd of Culturally Centered Patient Care with Rohr-Kirchgraber, MD, FACP, FAMWA Women Physicians of the East Bay. 54 Graduate Medical Education Expansion Chelsea Gong, MD; Carroll-Anne Heins, DO Institution and Environment to Rural Community Hospitals: 45 Women in Medicine: Creating a JEDI Residency Training Beyond the 22 Women in Podcasting: We Should Tune Health Care Environment. Darilyn V Moyer, Academic Health Center. Stephen John In. Jessie L Werner, MD; Resa E Lewiss, MD; MD, FACP, FRCP, FIDSA Cico, MD, MEd Gita Pensa, MD; Alyson J McGregor, MD, MA 46 Ensuring Safe and Equitable Faculty Development and Advancement 25 Preinvisible: An Early-Career Perspective Environments for Women Training to 55 Training Future Faculty with the on a Midcareer Phenomenon. Chen He, Become Physicians. Samyukta Mullangi, Clinician-Educator Training Pathway. MD; Alyson J McGregor, MD, MA; Resa E MD, MBA; Reshma Jagsi, MD, DPhil Christen K Dilly, MD, MEHP Lewiss, MD Trainee Support and Mentorship 56 Advancing an Academic Career in the 29 Been There, Tried That, Learned This: — Graduate Medical Education ’ 46 Nurturing Residents A Rewarding Two Physicians Life-Care List for Career. Marshall A Wolf, MD, MACP Environment. Anne Walling, MB, ChB Colleagues. Linda Hawes Clever, MD, MACP; Sharon Krejci Mowat, MD, FAAP 47 Women’s Leadership and Gender Bias Curriculum for Internal Medicine NARRATIVE MEDICINE Residents. Maria A Yialamas, MD 58 Collaborations, Connections, and ORIGINAL RESEARCH ARTICLES Conversations: A Journey to Meaning 32 Assessment of Burnout: A Pilot Study Resiliency and Wellness in Medicine. Lisa Sanders, MD; of International Women Physicians. 48 Promoting Wellness during Residency Belen Gallarza-Wilson, MD Farzanna S Haffizulla, MD, FACP, FAMWA; Training: Examples from the Field. Connie Newman, MD, FACP, FAHA, Joan Younger Meek, MD, MS, FAAP, FABM FAMWA; Shivani Kaushal, BS; Caitlin A

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ON THE COVER Artwork for Women in Medicine Special Issue: Mighty Women Mighty Women, oil on canvas. Kathryn Ko, MD, MFA. This painting was created in 2016 for the American Medical Women’s Association Artist in Residence program 2015-2016. The painting was inspired by the Statue of Liberty and the poem inscribed on her pedestal, “The New Colossus,” by Emma Lazarus. Women physicians are the new colossus in medicine and will fundamentally change the practice.

The Permanente Journal·Sept 2020·SPECIAL ISSUE PermanenteThe Journal

EDITOR-IN-CHIEF: Stephen L. Tarnoff, MD ISSUE EDITOR: Nicole Tran, MD

SENIOR EDITORS James J. Annesi, PhD, FAAHB, FTOS, FAPA Gus M. Garmel, MD, FACEP, FAAEM Professor, School of Health Professions Clinical Professor of EM (Afﬁliate) University of Alabama at Birmingham Stanford University Senior Emergency Physician Philip I. Haigh, MD, MSc, FRCSC, FACS Kaiser Permanente Santa Clara Medical Center Assistant Chief, Department of Surgery Santa Clara, CA Kaiser Permanente Los Angeles Medical Center Los Angeles, CA Eric Macy, MD, MS, FAAAAI Department of Allergy David Riley, MD Kaiser Permanente San Diego Medical Center Founder, Scientiﬁc Writing in Health and Medicine Southern California Permanente Medical Group Adjunct Instructor San Diego, CA National University of Natural Medicine Portland, OR H. Nicole Tran, MD, PhD Internal Medicine Physician, Department of Adult and Family Medicine Director for Quality Improvement and Patient Safety, Internal Medicine Residency Kaiser Permanente Oakland Medical Center Oakland, CA

ASSOCIATE EDITORS Gary W. Chien, MD Wynnyee Tom, MD Urology Residency Program Director Department of Pediatrics Kaiser Permanente Los Angles Medical Center San Jose Medical Center Los Angeles, CA San Jose, CA

Carrie Davino-Ramaya, MD Calvin Weisberger, MD, FACC, FACP Practice Leader and Methodologist of Guidelines Cardiologist and Evidence-Based Medicine Partner Emeritus Department of Quality Management and Systems Southern California Permanente Medical Group Northwest Permanente, P.C. Pasadena, CA Portland, OR Chairman, Southern California Regional Product Council Los Angeles, CA Lisa J. Herrinton, PhD Research Scientist, Division of Research Scott S. Young, MD Kaiser Permanente Northern California Associate Executive Director, Clinical Care and Innovation Oakland, CA Senior Quality Director The Permanente Federation Tom M. Judd, MS, CPHIMS, CPHQ, CCE, FACCE, FHIMSS, FAIMBE Oakland, CA Information Technology and Quality Senior Medical Director and Executive Director, Care Management Institute Former National Project Director Oakland, CA Kaiser Permanente Clinical Technology Marietta, GA Pat Zrelak, RN, PhD, FAHA, NEA-bc, CNRN, SCRN Health Technology Advisor Clinical Practice Consultant World Health Organization Clinical Education, Practice, & Informatics Washington, DC Kaiser Permanente Board Chair, Global Clinical Engineering Federation Sacramento, CA

Ashok Krishnaswami, MD, MAS Cardiologist Kaiser Permanente San Jose Medical Center San Jose, CA

EDITORIAL & PUBLISHING OFFICE The Permanente Press Monica Leigh: Managing Editor The Permanente Journal is published Sheridan Composition services by The Permanente Press Patrick Versteeg: Web Developer

The Permanente Journal·Sept 2020·SPECIAL ISSUE 3 n COMMENTARY Celebrating Women in Medicine

H Nicole Tran, MD, PhD1; Eliza Lo Chin, MD, MPH2 Perm J 2020;24:20.069 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.069

ABSTRACT Dr Van Hoosen2 wrote, “When I was born, the door that In collaboration with the American Medical Women’s Associ- separates the sexes had opened scarcely more than a crack. And it ation, The Permanente Journal is pleased to present this special has been my privilege, my pain, and my pleasure to pound on issue in celebration of Women in Medicine Month in September that door, strain at its hinges, and finally to see it, although 2020. This designation was created by the American Medical not wide open, stand ajar.” During World War II, AMWA Association to recognize the growing number of women in the President Dr Emily Dunning Barringer helped women phy- profession. We aim to introduce the history, education, leader- sicians achieve commissioned status, and during the 1980s, ship, society beliefs and inequities faced, reflections on bias, and AMWA played a key role in advancing women’s health.1 perspectives on work-life-balance. We hope you will allow the   personal stories, commentaries, and research reports to inspire e history of e Permanente Medical Group (TPMG) you to create workplaces and life moments with a view toward dates to 1944, when Dr Beatrice Lei was recruited as 1 of equity and inclusion. 16 young physicians to work for Sidney Garfield, MD, at the Kaiser Richmond shipyards in Richmond, California.3 She became the first woman and first Asian physician to In collaboration with the American Medical Women’s be accepted as a partner in TPMG in 1948. Since those Association (AMWA), e Permanente Journal is pleased to early years, an increasing number of women physicians have present this supplemental issue in celebration of Women joined Permanente Medical Groups (Permanente Medi- in Medicine Month designated by the American Medical cine) across our 8 Regions. In 1991, Sharon Levine, MD, Association this September 2020. In this issue, we intro- was the first woman physician to be appointed the Associate duce themes relevant to women in medicine, from a his- Executive Director of TPMG, and in 1992 she organized torical context as well as current perspectives on education, the first TPMG Women Physician Symposium, on “Bal- leadership, gender equity, and work-life balance. Although ance, Leadership, Empowerment.” most of the articles in this issue reflect on physician expe- A review of Association of American Medical Colleges riences, we wish to recognize important contributions from data shows that the percentages of women entering medical other female health care providers. is includes nurses, school have steadily increased over the years to surpass 50% medical assistants, therapists, and many others, who have in 2017.4 Yet those same reports underscore a substantial shaped health care. We hope you will allow the personal gender gap in leadership. Women make up only 16% of stories, commentaries, and research reports in this issue to deans, 17% of department chairs, and 24% of full professors, inspire you to create workplaces and life moments with a although they make up the majority (58%) of faculty at the view toward equity and inclusion. instructor level.5 National reports also indicate that certain In the early years of my career as a woman in medicine, I medical specialties are now predominantly female, whereas (HNT) have gained much from the courage, perseverance, many procedural and surgical specialties remain tradition- and leadership from the women before me, who paved the ally male-dominated professions. is trend is reflected in path for me to pursue my dream of studying medicine; to the specialty choice data reported by the American Medical develop a career as a physician, researcher, and educator; and Association: Women make up most residents in obstetrics to find fulfillment in becoming a mother. and gynecology (83.4%), allergy and immunology (73.5%), In 1915, when most women physicians had no voice to pediatrics (72.1%), medical genetics and genomic medicine vote and faced marginalization in their own profession, (66.7%), hospice and palliative medicine (66.3%), and der- pioneer surgeon Dr Bertha Van Hoosen founded AMWA.1 matology (60.8%). ey comprise 38% of trainees in general Over the next century, the organization would become a surgery, yet only 15% in orthopedic surgery.6 Contributing leading proponent for advancing women in medicine, ad- factors for these disparities may be multifactorial. vocating for equity, and improving health care. Years later, Author Affiliations 1 Department of Internal Medicine and Graduate Medical Education, Kaiser Permanente Oakland Medical ’ Editor s note: This issue went to press at the height of the coronavirus disease Center, Oakland, CA 2019 (COVID-19) pandemic. All aspects of societal behavior are in upheaval, with 2 American Women’s Association, Schaumburg, IL, and University of California, San Francisco, San Francisco, CA epidemiology and medical practice at the center of the storm. Everyone and everywhere in all medical fields are profoundly affected both at work and at home. Corresponding Author Never before has the balance of providing healthcare and family life been so arduous. H Nicole Tran, MD, PhD ([email protected]) One gratifying aspect is the widespread recognition of the risks taken by many, especially in the hands-on health care fields. Keywords: academic medicine, equity, inclusion, women The Permanente Journal·https://doi.org/10.7812/TPP/20.069 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 1 COMMENTARY Celebrating Women in Medicine

A growing body of literature has focused on the expe- go to work, and my son said, “But he’s a man, and men don’t rience of women physicians. Compared with men, women work; only women work.” at made me smile. We’ve really physicians are more likely to report satisfaction with their come a long way.” specialty, patients, and colleagues but are also at increased We have really come a long way. May we take inspiration odds of reporting burnout as they attempt to meet gendered from the past, live in the present, and strive to create a world expectations7 of empathetic listening and longer visits, es- of equity and inclusion for the future. v pecially in the outpatient setting. Unfortunately, the gender pay gap still exists,8 and workplace issues such as sexual ha- Disclosure Statement rassment and gender discrimination have become growing The author(s) have no conflicts of interest to disclose. areas of concern. Motherhood and reentry to the work force are further Acknowledgments The authors would like to thank Tom Janisse, MD, MBA; Max McMillen, ELS; challenges many women physicians face. Social media groups Joan Lo, MD; Gus Garmel, MD; and Arthur Klatsky, MD, for their assistance in the have arisen to meet a need for networking among physician conception and creation of this special issue. mothers. Camaraderie, family support, wellness, career Kathleen Louden, ELS, of Louden Health Communications performed a primary satisfaction, and fulfillment are vital to women leaders to copyedit. succeed and take charge. Some physician leaders at Kaiser fl Authors’ Contributions Permanente (KP) East Bay re ected on their journeys in H Nicole Tran, MD, PhD, and Eliza Lo Chin, MD, MPH, participated in the medicine and their passions and shared them with us. design, literature review, and preparation of the manuscript. Both authors have Lindsay Mazotti, MD, Assistant Physician in Chief of given final approval to the manuscript. Education at KP East Bay, identified themes in her development: “My personal journey as a physician is how much How to Cite this Article Tran HN, Chin EL. Celebrating women in medicine. Perm J 2020;24:20.069. DOI: being a mother has helped me in every aspect of my clinical care https://doi.org/10.7812/TPP/20.069 and leadership. I’ve learned, in the last 11½ years, to not take myself so seriously, to prioritize my family and my time better, and to be a more compassionate human and citizen. I am References 1. American Medical Women’s Association. About AMWA: AMWA’s history of success thankful every day for the privilege of raising 2 girls, trying to [Internet]. Schaumburg, IL: American Medical Women’s Association [cited 2020 Mar 18]. be a good role model, and instilling in them a sense of pride in Available from: www.amwa-doc.org/about-amwa/history/ ” 2. Van Hoosen B. Petticoat surgeon. New York, NY: Pellegrini & Cudahy; 1947. working in service to others. While on maternity leave with 3. Cushing L, contributor. Beatrice Lei, MD: From Shantou, China, to Richmond, her daughter, Ashley McClure, MD, Green Team leader at California [Internet]. Kaiser Permanente. 2017 Mar 7 [cited 2020 Mar 18]. Available from: https://about.kaiserpermanente.org/our-story/our-history/beatrice-lei-md-from-shantou- KP Oakland Medical Center, felt the urge to promote china-to-richmond-california advocating for climate solutions: “Strong physician leadership 4. More women than men enrolled in U.S. medical schools in 2017 [Internet press release]. Association of American Medical Colleges; 2017 Dec 17 [cited 2020 Mar 18]. Available [is needed] for urgent climate solutions, as public health pro- from: www.aamc.org/news-insights/press-releases/more-women-men-enrolled-us- tection is the invaluable legacy of safety and health we can leave medical-schools-2017 for our children.” Lindsay Pierce, MD, Assistant Chief of 5. Table 15: U.S. medical school faculty by sex, race/ethnicity, rank, and tenure status, 2017 [Internet]. Association of American Medical Colleges [cited 2020 Mar 18]. Available from: Family Medicine at KP Oakland Medical Center, reflects: www.aamc.org/system/files/2020-01/2017Table15.pdf I know the glass ceiling is still really in many jobs, but “I never 6. Murphy B. These medical specialties have the biggest gender imbalances [Internet]. Chicago, IL: American Medical Association; 2019 Oct 1 [cited 2020 Mar 18]. Available from: felt it being a woman in medicine and even as a leader in my www.ama-assn.org/residents-students/specialty-profiles/these-medical-specialties-have- department. I feel honored I get to work along so many strong biggest-gender-imbalances 7. Linzer M, Harwood E. Gendered expectations: Do they contribute to high burnout among women, and I feel I am being a role model to my kids. My female physicians? J Gen Intern Med 2018 Jun;33(6):963-5. DOI: https://doi.org/10.1007/ husband took off work for 7 years to stay home and take care s11606-018-4330-0 8. Read S, Butkus R, Weissman A, Moyer DV. Compensation disparities by gender in of our kids. In addition, his doctor and his dentist were both internal medicine. Ann Intern Med 2018 Aug;169(9):658-61. DOI: https://doi.org/10.7326/ women. One day we were talking about my brother needing to M18-0693

2 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.069 n COMMENTARY They Were There: American Women Physicians and the First World War

Mollie C Marr, BFA1; Iris Dupanovic, MS2; Victoria Z Sefcsik, MS3; Nitisha Mehta4; Eliza Lo Chin, MD, MPH5 Perm J 2020;24:20.032 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.032

INTRODUCTION Women’s Oversea Hospitals, and the American Fund for is past decade marked the centenary of World War I French Wounded. In fact, registrations conducted by the (WWI). For the first time in American history, women AWH showed that “almost one-third … of the medical women participated on a large scale in war efforts through the in the country…, active and retired, signified their willingness to military and other government agencies. Although much is provide medical service as part of the war effort … and compared known about the importance of medicine during WWI, favorably to the service rates of male colleagues.”4 most of the focus has been on male physicians who served In this article, we shed light on the underrecognized abroad. Tens of thousands of women went abroad as nurses, women leaders of WWI. rough their stories, we explore ambulance drivers, and relief workers, but the contributions the barriers they faced and the opportunities they created. of women physicians in the war are less well known. When the US entered the First World War in 1917, WOMEN PHYSICIANS’ CONTRIBUTIONS DURING THE WAR women physicians represented less than 5% of the physician President Woodrow Wilson appointed Dr Anna Howard workforce.1 Anticipating a surge in the demand for medi- Shaw, physician and former president of the National cal services, the Army Surgeon General sent Army Medical American Woman Suffrage Association, to chair the Reserve Corps registration forms to all physicians. ese Woman’s Committee of the Council of National Defense.9 forms did not request physician sex because the respon- In June 1917, this committee convened the leaders of 50 dents were assumed to be male.2 Many women physicians various national women’s organizations—including social, completed the forms, volunteering to serve in the Army community, religious, and professional groups—to contrib- Medical Reserve Corps. eir applications, however, were ute to the war effort.10 As an immigrant from East England, rejected on the belief that women could not handle the Dr Shaw felt that it was important for women of all demands of the battlefield and were not qualified to com- backgrounds to have a part in the war, stating, “[N]ow that mand men.3,4 Women physicians were also told they could war has come I shall … begin at once to organize the women not serve because “it hadn’t been done” before, despite of the country for war service.… [I]t is time for us … to act women serving in military nursing corps since 1901.5 Finally, definitely.”10 Another accomplished physician, Dr Rosalie they were told that because they could not vote, the use Slaughter Morton, was appointed to represent the nation’s of the word “citizen” in the legislation that expanded the women physicians on the Council of National Defense.11 Army Medical Reserve Corps did not apply to them.6 In During the war, she was also appointed Special Commis- 1917, the Medical Women’s National Association (later sioner by the Red Cross, a role through which she helped renamed the American Medical Women’s Association) transport supplies from Paris to the war front.12 lobbied the US government to include women in the Army In 1917, the Medical Women’s National Association Medical Reserve Corps, asking that “opportunities for med- founded the American Women’s Hospitals (AMH). Led ical service be given to medical women equal to the opportuni- by Dr Morton and later Dr Lovejoy, AWH was the largest ties given to medical men … and that the women so serving all-women’s medical group and would eventually become a be given the same rank, title and pay given to men holding clearinghouse for registering women interested in overseas equivalent positions.”7 Ultimately, all petitions and appeals war work.13 During its first year, the AWH registered more for inclusion in the Army Medical Reserve Corps were denied.3,4 Author Affiliations Exclusion from the Army Medical Reserve Corps did not 1 ff Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR stop women physicians from contributing to the war e ort. 2 Biomedical Sciences Department, Tufts University, Boston, MA Dr Esther Pohl Lovejoy8 wrote, “e women of the medical 3 Pacific Northwest University of Health Sciences, College of Osteopathic Medicine, Yakima, WA profession were not called to the colors, but they decided to go 4 Morsani College of Medicine at the University of South Florida, Tampa, FL ” 5 American Medical Women’s Association, Schaumburg, IL, and University of California, San Francisco, San anyway. Women physicians held government and civilian Francisco, CA leadership roles, created and ran their own hospital units, served in the US and French army as civil contract sur- Corresponding Author geons and volunteered in various organizations such as the Mollie C Marr ([email protected]) ’ American Red Cross, American Women s Hospitals (AWH), Keywords: activism, American Medical Women’s Association, American Women’s Hospitals, Medical Women’s National Association, women physicians, Women’s Oversea Hospitals, World War I The Permanente Journal·https://doi.org/10.7812/TPP/20.032 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 3 COMMENTARY They Were There: American Women Physicians and the First World War

than 1000 women physicians.14 Dr Barbara Hunt oversaw as a contract surgeon in the US Army so that she could the opening of their first hospital, AWH No. 1, in France in remain with the unit.14 1918. Located in the war zone, the hospital was mandated Dr Elizabeth Hocker also served as a contract surgeon to treat both civilian and military cases.14 Physicians treated during WWI. Like Dr Tjomsland, she served as an anes- bullet and shrapnel wounds, infections, and broken bones thetist and was assigned to base hospitals stationed overseas. from the conflict and struggled to manage epidemics affect- Dr Hocker’s impact extended beyond the immediate care of ing both military and civilian populations such as dysentery, the soldiers she treated. She often sent a sprig of flowers typhoid, and influenza. As the battlefields shifted, teams of from the grave of those killed with a letter to each of the nurses and physicians from the hospital were sent to areas of families.17 Drs Tjomsland and Hocker were 2 of only 11 greater conflict to treat wounded French soldiers closer to women contract surgeons to be deployed overseas. Most the front line. AWH No. 1 moved locations during the war women contract surgeons served on the home front.3 to meet the medical needs of the district. As one of only a Dr Dolores Pinero was the first Puerto Rican woman to few places to receive medical care in the area, its ambulances serve as an Army contract physician. Like many other were frequently stopped by officials from other districts women physicians, Dr Pinero’s application to the US Army seeking help.13 was denied. However, after appealing to the US Surgeon Another all-women’s group to go abroad was the Women’s General and highlighting her expertise in anesthesia, Oversea Hospitals Unit. Supported by the National Amer- Dr Pinero was accepted as an Army contract surgeon in ican Woman Suffrage Association, this unit provided aid to October 1918.3 She was assigned to the San Juan, Puerto multiple hospital units in France. Dr Anna Von Sholly Rico, base hospital where she served as an anesthesiologist, wrote about her experience as a suffragist in France, pro- laboratory physician, and nursing director.3 A few weeks viding medical assistance to their military units, as part of after beginning her assignment, Dr Pinero and 4 male the Women’s Oversea Hospitals Unit. She was among physicians were ordered to establish a 400-bed hospital to those women physicians who served with the French Army treat influenza patients.3 Once the influenza epidemic sub- in the Chateau Ognon at Senlis near Paris, where the sided, Dr Pinero completed her service at San Juan base hospital was under fire every night. She wrote, “Some of the hospital and received an honorable discharge in 1919.3 sights are pitiful beyond words.… [Mangled men] have waited Other women physicians, such as Dr Caroline Purnell, days with no attention.”15 In 1918, Dr Von Sholly received turned down an offer to become a contract surgeon. Dr the Croix de Guerre award by the French government for her Caroline Purnell stated that it “would mean our ability to commitment to the war effort.15 Dr Mabel Seagrave also be under the cook, the head nurse, or others, and be ordered served as a volunteer in the Women’s Oversea Hospitals, around.”4 Instead, the prominent Philadelphia surgeon leaving her practice in Seattle to treat battle wounds in served as Special Commissioner of the American Women’s France. She stated that “[war surgery] will give the surgeon a Hospitals in France, helping to secure medical supplies, chance to demonstrate things which have heretofore been more or food and clothing, and established a network of locations less experimental.… Military surgery in France today is … an for soldiers and civilians to gain access to needed supplies. opportunity all surgeons must covet.”1 Dr Purnell stated, “[W]e started out about nine o’clock to make e desperate need for anesthetists led the Army to the dispensary rounds with the doctors.… We visited three dis- allow women to enlist as contract surgeons beginning in pensaries… covering over fifty miles and seeing about fifty-four March 1918.6 Contract surgeons were considered civil- people.”18 rough her role with the American Women’s ians and were denied military commissions, benefits, and Hospitals, she became a powerful liaison with the Red command authority.6 ey had no official rank, were Cross, the American Committee for Devastated France, paid a salary equivalent to a first lieutenant, and did not and the Serbian Legation in Paris. receive disability coverage.6,14 Dr Anne Tjomsland, an e American Red Cross gave women physicians the experienced anesthetist, was one of the firstcontractsur- opportunity to serve overseas during the war. Because the geons to go overseas, serving in Vichy, France. She was Red Cross’ primary focus was philanthropic, most women part of the team at Bellevue Hospital in New York that physicians serving with the American Red Cross treated wouldgoontoformBaseHospitalNo.1.Anticipating civilian women and children.13 A minority of American America’s entry into the war, Base Hospital No. 1 began Red Cross physician volunteers were stationed in French training in 1916.16 When the unit was mobilized in military hospitals, where they treated wounded soldiers. November 1917, the army initially barred Dr Tjomsland Despite her family’s disapproval and leaving her husband from joining the unit as a physician because she was a and son behind, Dr Jessie Fisher left to volunteer for the woman.3 e Base Unit commander considered her ir- American Red Cross hospital in Beauvais, France, at age 45 replaceable and successfully fought for her to be appointed in April 1918. She describes being woken by the sound of

4 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.032 COMMENTARY They Were There: American Women Physicians and the First World War

gunfire and “shrapnel [falling] around us like hail” during an women physicians today. Women faced unequal pay and air raid. Dr Fisher also recounted the demands of service lack of recognition for their work. ey frequently vol- stating that “in 48 hrs they admitted 185 and did 115 major unteered their labor and worked without commission while operations no account was taken of minor ones.” Her diaries their male counterparts were paid and promoted.6,24 ey described the unpredictable and long days: “I began giving were expected to balance work and family, leaving behind ether at 2 a.m. quit at 4:30 a.m. went to bed got up at 7:30 had children and ailing parents to serve, and were met with breakfast and went to work again helping with minor dressings criticism when they prioritized war service.19 ey faced and sorting out the wounded.… We had two operating tables sexism, nativism, and racism, fighting for the rights and going for 24 hours.”19 privileges freely granted to their male colleagues.20,21 In fact, Unlike Dr Fisher, Dr Harriet Alleyne Rice was denied the pervasiveness of racism at the time limited the partic- work through the American Red Cross because she was ipation of Black, Latina, and Native American women African-American. She next contacted the French gov- physicians in the war effort. e stories of European and ernment and ultimately served as an interne at a French European-American women physicians are the focus of military hospital, overcoming both sexism and racism. Her most of the extant historical texts, and photographs from service was recognized with the Médaille de la Reconnaissance the time speak to the homogeneity of women’s organiza- française (Medal of French Gratitude). Overseas war work tions and groups. Black, Latina, Native American, and brought her a level of respect that she had never experienced immigrant women physicians faced additional bias and in her home country.20 discrimination compared with their white counterparts Dr Olga Stastny—an accomplished physician and advo- because of the intersection of their different identities, a cate, Czech-American, and widowed mother of 2 children— barrier that remains true today.25 unsuccessfully attempted to volunteer with the American Despite these challenges, women physicians answered Red Cross twice. She stated, “I want to get to France, even if the call to serve by creating opportunities for themselves and I have to scrub floors.”21 Dr Stastny did not give up on her others, founding hospitals, running ambulance services, goal of war service, and finally in January 1919, she ar- and organizing volunteers to provide services at home and rived in France to work as an anesthesiologist through the abroad. Like today, women supported each other and American Women’s Hospitals.21 Despite her service, she underserved individuals, advocating for national changes felt that she missed out by not being able to go earlier, to military policy and continued medical services for ci- stating, “I feel that my part in it [the AWH in France] was vilians affected by the war. e impact of their work dur- earned, to a great extent, by those who preceded me, as I was one ing the war and their inspiration to future generations of of the late comers and the greatest war work was done by the first women physicians to advocate for themselves cannot be members to go.”21 underestimated. Dr Alice Barlow Brown,26 who served with is desire to serve was shared by many women physi- the American Fund for French Wounded, wrote in a letter, cians. Some who went overseas did not even practice as “e faces of these poor people have changed in expression since physicians. Dr Marguerite Cockett was an early YMCA our visits. ey say not only has America come to their aid in canteen volunteer and later established the first US unit of the war, but she has sent her women to help the civilian volunteer women ambulance drivers.22 Others went with population.” civilian relief groups such as the Smith College Relief Unit By the time of WWII, women were joined by male or found opportunities through the Rockefeller Foundation allies who urged the military to recognize the contri- or the Commission for the Prevention of Tuberculosis in butions of women physicians.27 AMWA President Dr France.11 Emily Dunning Barringer and other advocates success- Women physicians were not immune to the effects of the fully lobbied for the passage of the Sparkman-Johnson war. Dr Purnell contracted influenza and endured psy- Bill, which allowed women physicians to become com- chological effects of her service during the war. In fact, her missioned officers of the military. anks to these efforts, 1923 obituary states that her death at 61 was caused by an womenphysiciansnowserveinallbranchesofthemil- illness related to overwork during the war.23 Like all the itary, and many have assumed leadership roles. As we women physicians who had to find their own way to serve, celebrate these gains, let us remember the efforts of the she was ineligible for government disability or healthcare WWI pioneers, who through their courage and dedica- benefits related to her war service. tion helped create opportunities for women physicians of today. v CHALLENGES AND ADVANCES Some of the challenges women physicians faced during Disclosure Statement WWI were specific to the war, but most will resonate with The author(s) have no conflicts of interest to disclose.

The Permanente Journal·https://doi.org/10.7812/TPP/20.032 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 5 COMMENTARY They Were There: American Women Physicians and the First World War

12. Changing the face of medicine: Dr. Rosalie Slaughter Morton [Internet]. US National Acknowledgments Library of Medicine, National Institutes of Health; 2004 Oct 14. Updated 2015 Jun 3 We would like to thank Kimberly Jensen, PhD, for review of the manuscript. [cited 2020 Feb 4]. Available from: https://cfmedicine.nlm.nih.gov/physicians/ Source material for this article was taken from materials gathered for the American biography_231.html Medical Women’s Association online exhibition, “American Women Physicians in 13. More E. “A certain restless ambition”: Women physicians and World War I. Am Q 1989 World War I” (www.amwa-doc.org/wwi-exhibition). Dec;41(4):636-60. DOI: https://doi.org/10.2307/2713096 Kathleen Louden, ELS, of Louden Health Communications performed a primary 14. Gavin L. American women in World War I: They also served. Boulder, CO: University Press of Colorado; 2006. copy edit. 15. Lemay KC, ed. Votes for women: A portrait of persistence. Princeton, NJ: Princeton University Press; 2019. Contributors Goodier S, Jones M, Tetrault L Authors’ Contributions 16. Ford JH. Chapter XXIV: Base hospitals: Base hospital No. 1. In: The medical department fi of the United States army in the World War, Vol. II Administration, American Expeditionary Mollie Marr participated in the critical review, drafting, and submission of the nal Forces [Internet]. Washington, DC: United States Government Printing Office; 1927. manuscript. Iris Dupanovic, MS, Victoria Sefcsik, MS, Nitisha Mehta, and Eliza Lo [cited 2020 Apr 1]. Available from: https://history.amedd.army.mil/booksdocs/wwi/ Chin, MD, MPH, participated in the critical review and drafting of the final adminamerexp/chapter24.html manuscript. All authors have given final approval to the manuscript. 17. Hocker E. Hocker Collection, Accession 2015.006, folder 19. Philadelphia, PA: Drexel University College of Medicine Legacy Center. 18. Report of Dr. Caroline M. Purnell. Womans Med J 1918 Dec;28(12):257. Available from: How to Cite this Article https://babel.hathitrust.org/cgi/pt?id=uc1.$c213852&view=1up&seq=29 Marr MC, Dupanovic I, Sefcsik VZ, Mehta N, Chin EL. They were there: American 19. Jessie Fisher diary. 1918 Jul 21. Fisher Family Archives. women physicians and the first world war. Perm J 2020;24:20.032. DOI: https:// 20. Korr M. 100 Years Ago-Dr. Harriet Alleyne Rice of Newport: The struggles of an doi.org/10.7812/TPP/20.032 African-American physician. Rhode Island Med J 2015 Jan;98(1):74. 21. Andrews-Koryta S. Dr. Olga Stastny, her service to Nebraska and the world. Nebr Hist 1987;68(1):20-7. Available from: https://history.nebraska.gov/sites/history.nebraska.gov/ fi References les/doc/publications/NH1987OlgaStastny.pdf 1. More E. Restoring the balance: Women physicians and the profession of medicine, 22. Sherer B. Home front heroes: A biographical dictionary of Americans during wartime. 1850-1955. Cambridge, MA: Harvard University Press; 1999: p 98-9. Vol 1. Westport, CT: Greenwood Press; 2007. 2. Application for examination for appointment in the Medical Reserve Corps, U.S. Army, 23. War work fatal to woman surgeon. Records of W/MCP: Registrar 1921-1975 (ACC-266) Form 149, W.D., S.G.O. (Revised May 3, 1917), US Army, US National Archives. [Internet]. Philadelphia, PA: Drexel University College of Medicine Legacy Center, Archives and Special Collections; 1923 Feb 5: p 543 [cited 2020 Apr 1]. Available from: 3. Bellafaire J, Graf MH. Women doctors in war. College Station, TX: Texas A&M University http://xdl.drexelmed.edu/viewer.php?object_id=1469&t=womanmd Press; 2009. 24. Purnell CM. The work of the American women’s hospitals in foreign service [Internet]. 4. Jensen K. Mobilizing Minerva: American women in the First World War. Champaign, IL: Philadelphia, PA: Drexel University College of Medicine Legacy Center, Archives University of Illinois Press; 2008 June. and Special Collections [cited 2020 Apr 5]. Available from: http://xdl.drexelmed.edu/ fi 5. Women doctors nd opportunity does not knock. Oregon J May 4, 1918. pdfs/r747_w82_1918_002.pdf 6. Calmes SH. A history of women in American anesthesiology. In: Eger EI, Saidman LJ, 25. Crenshaw K. Demarginalizing the intersection of race and sex: A black feminist critique of Westhorpe RN, eds. The wondrous story of anesthesia. New York, NY: Springer; 2014: antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chicago Legal p 185-203. Forum 1989(1):article 8. ’ 7. Medical Women s National Association. California resolution. Womans Med J 1917 Jun;27(6): 26. Barlow-Brown A. Wilmette public library local history collection. Letters from World War I, 141. Available from: https://babel.hathitrust.org/cgi/pt?id=uc1.$c213852&view=1up&seq=29 1917, 115 [Internet]. Wilmette, IL: Wilmette Public Library [cited 2020 Apr 1]. Available 8. Lovejoy EP. Certain Samaritans. New York, NY: Macmillan; 1933. from: http://history.wilmettelibrary.info/65159/page/149?n 9. Franzen T. Women in American history: Anna Howard Shaw: The work of woman 27. US Congress House Committee on Military Affairs. Appointment of female physicians suffrage. Champaign, IL: University of Illinois Press; 2014. and surgeons in the Medical Corps of the Army and Navy: Hearings before the 10. The clearing house for women’s war service. Woman Citizen 1917 Jun;1(3-26):87. United States House Committee on Military Affairs, Subcommittee No. 3 (Military Affairs), 11. Schneider D, Schneider CJ. Into the breach: American women overseas in World War I. 78th Cong, 1st Session, Mar 10, 11, 18 (1943). Washington, DC: US Government Printing New York, NY: Viking Press; 1991. Office; 1943: p 88.

6 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.032 n COMMENTARY Women Physicians and the Suffrage Movement

Eliza Lo Chin, MD, MPH1; Morgan S Levy, BS2; Alyssa D Brown, BS3; Mollie C Marr, BFA4; Prachi M Keni, BS5; Naveena Daram, BS6; Courtney A Chau7; Naseem Rangwala, BA8; Katarina Watson9 Perm J 2020;24:20.036 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.036

ABSTRACT for wearing masculine clothing, arguing that it made her Women physicians have a long history of advocacy, dating duties easier.1 She ran twice for Congress, albeit unsuccess- to the 19th century women’ssuffrage movement. As history re- fully,2 and ardently supported women’ssuffrage, although counts the work of the suffragists, many women physicians bear she felt that a constitutional amendment was unnecessary. mention. Some were leaders on the national scene, and others led Since the phrase, “We the People,” was not gendered, ff ff su rage e orts in their own state. In this article, we provide a she believed that the Constitution had already granted snapshot of 7 prominent suffragists who were also physicians: women the right to vote and instead argued for legislation Mary Edwards Walker, Mary Putnam Jacobi, Esther Pohl Lovejoy, 3 Marie Equi, Mattie E. Coleman, Cora Smith Eaton, and Caroline E. to allow women to exercise that right. Sadly, Dr Walker Spencer. In sharing their stories, we hope to better understand died in 1919, just 1 year before the passage of the 19th some of the challenges and struggles of the suffrage movement Amendment. and how their advocacy paved the way not only for women’s voting rights but also the role of women physicians as advocates Mary Putnam Jacobi (1842-1906): Champion for for change. Menstruating Women Dr Mary Putnam Jacobi was one of the preeminent INTRODUCTION women physicians of her generation and also a writer and suffragist. She obtained medical degrees in both the US is year marks the centenary of the 19th Amendment, and Paris, France, and became a professor at the Women’s granting women the constitutional right to vote. e first Medical College of the New York Infirmary. Her father, women’s rights convention took place in Seneca Falls, New the well-known publisher George Putnam, was wary of York, in 1848. is same period also marked the formal her pursuit of medicine but remained a staunch supporter entrance of women into the medical profession. In 1849, of her endeavors.4 In 1876, she won Harvard’s esteemed Dr Elizabeth Blackwell became the first woman to earn her Boylston Prize for her essay, “e Question of Rest for medical degree, from Geneva Medical College. e decades Women during Menstruation,” which debunked claims that followed would witness a growth in both movements. that menstruation rendered women unfit “for any respon- Many women physicians were active in the fight for suf- sible effort of mind, and … body also.”5 frage, and some even assumed leadership roles, devoting Dr Jacobi became active in the suffrage movement in their lives to the cause. As pioneers in a profession dom- 1893 when a women’ssuffrage amendment to the New inated by men, it is not surprising that these women ad- York State Constitution was proposed.6 Delivering a pow- vocated for equality on behalf of their own sex. Many were erful address at the Constitutional Convention, Dr Jacobi also proponents of temperance, public health reform, or argued that women should not be considered a “dependent reproductive rights. is article highlights a few of these class” given their work in many industries and their status trailblazing women and their varied paths to activism. as property owners, taxpayers, and professionals (including “ WOMEN PHYSICIAN SUFFRAGISTS physicians, teachers, and journalists). Why should not the Mary Edwards Walker (1832-1919): Civil War Surgeon Author Affiliations Dr Mary Edwards Walker was a surgeon, activist, and 1 American Medical Women’s Association, Schaumburg, IL, and University of California, San Francisco, San leading suffragist. She was the second woman to graduate Francisco, CA from Syracuse Medical College in 1855. She married a 2 University of Miami Miller School of Medicine, Miami, FL 3 fellow medical student and together they opened a prac- University of Louisville School of Medicine, Louisville, KY, and Mayo Clinic School of Biomedical Sciences, 1 Rochester, MN tice, but neither the marriage nor the practice were to last. 4 Department of Behavioral Neuroscience, Oregon Health & Science University, Portland, OR Dr Walker is best known for her work as a civilian contract 5 University of Illinois at Urbana-Champaign, Carle Illinois College of Medicine, Champaign, IL surgeon during the Civil War. While crossing enemy lines 6 Oakland University William Beaumont School of Medicine, Rochester, MI 7 University of California, Berkeley, Berkeley, CA to provide medical care to civilians, she was captured by 8 University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, CA Confederate forces and imprisoned for 4 months. For her 9 Georgetown University, Washington, DC heroism, she was awarded the Medal of Honor in 1865 and to date is the only woman to have received that honor.1 Corresponding Author Eliza Lo Chin, MD, MPH ([email protected]) Dr Walker also advocated for dress reform and was known Keywords: activism, female physicians, leadership, suffrage, voting rights, women in medicine The Permanente Journal·https://doi.org/10.7812/TPP/20.036 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 7 COMMENTARY Women Physicians and the Suffrage Movement

women have the right to speak for themselves, and by their own after 2 years serving on the Portland Board of Health, she mouths to make their own wants known?”7 Although the was elected as Portland’s City Health Officer.10 Dr Pohl suffrage amendment she pushed for failed to pass, an ex- Lovejoy’s public health and policy experiences informed her panded version of the address was published as a book, approach to women’ssuffrage. She believed that women’s “Common Sense” Applied to Woman Suffrage.7 Dr Jacobi con- suffrage was vital for the promotion of healthy communi- tinued to work for women’ssuffrage and that same year, ties because women were more likely to be concerned with she co-founded the League for Political Education. At the the health and well-being of families and children. In one time of her death, she had written more than 115 medical speech, she countered the argument about suffrage being articles and 9 books.6 So great was her dedication to medical outside the women’s sphere11: science that after being diagnosed with a brain tumor, she And now we come to the mooted question of Woman’s wrote an account of her symptoms, which was published Sphere. It is delightfully entertaining to listen to a gentleman posthumously, titled “Early Symptoms of the Meningeal anti-suffragist—especially if he happens to be a Doctor of Tumor Compressing the Cerebellum. From Which the Divinity—rhapsodize upon Woman’s Sphere. e woman Writer Died. Written by Herself.”7 that he conjures up is a poetic creation of the imagination. How she does rock the cradle! It’s a wonder her baby doesn’t Marie Equi (1872-1952): “Rebellious Soul” die of sea-sickness! She never washes dishes or peals [sic] Dr Marie Equi was a physician and radical political potatoes, or feeds the chickens, or goes to market or engages in activist who lived openly as a lesbian. She attended medical any gross and material occupation. She just rocks the cradle school at the University of Oregon in one of the first classes from morning until night! at is her strong suit. It is her one to admit women.8 After graduating in 1903, Dr Equi set up manifestation of life! She is a woman of one instinct—one a practice in Portland, Oregon, where she served working- idea—one possibility—and it is easy to believe any Right class women and children and became active in campaigns Reverend Doctor of Divinity who predicts that such a for birth control, women’ssuffrage, and overall improve- creature will forsake that over-worked cradle on the first ment in the rights of women. She viewed these issues as opportunity and rush to the polls with a ballot in her hand connected to a “larger class struggle, the end of which would be and vote and vote and vote and do nothing else for the rest the freedom, dignity, and health of working women and their of her life but vote.… But the normal woman in her nat- families.”8 Margaret Sanger, a fellow birth control advocate, ural sphere —the home—who lets her baby sleep while she described Dr Equi as a “rebellious soul.”8 does her house-work will find time on election day to vote Dr Equi worked alongside Abigail Scott Duniway, a for the things that will influence the welfare of that home suffrage leader in Oregon, and frequently found herself and that baby. A pure water and food supply if she lives in at odds with Dr Anna Shaw about the preferred tactics the city. for achieving suffrage.9 She also brought an awareness of As a leader in the Oregon suffrage movement, Dr Pohl marketing to the suffrage movement, once staging an “all- Lovejoy built coalitions between diverse suffrage groups. suffrage wedding” at which the bride “vowed to cherish Ultimately, she formed her own suffrage organization, rather than obey her future husband.”9 Finally, in 1912, Everybody’s Equal Suffrage League, with the goal of being Dr Equi saw Oregon pass women’ssuffrage after 5 failed “free from all cliques and class distinctions and open to all.”12 referendums.8 Despite her extensive leadership in the suffrage move- In 1914, the Congressional Union separated from the ment, Dr Pohl Lovejoy continued to work as a physician, National American Woman Suffrage Association with the maintaining a private practice in obstetrics and gynecology. goal of pressuring Congress to pass the federal amendment.9 She even incorporated a medical perspective into her suf- e chair of the Oregon branch of the Union excluded frage work, inviting members of suffrage organizations to Dr Equi as a delegate for the National Convention of a dinner with invitations “in the form of a prescription Women Voters because of her radical politics.9 Dr Equi signed by Dr Pohl.”12 After Oregon passed women’s suf- attended anyway. She was credentialed and granted a seat, frage in 1912, Dr Pohl Lovejoy served on the National but the Oregon contingent had her removed by vote. After American Woman Suffrage Association legislative com- the convention, Dr Equi sued the Oregon chair for slander mittee as the Oregon congressional representative. She and libel, “demanding a voice even for radical suffragists.”9 e traveled to France during World War I to study the needs lawsuit was ultimately dismissed. of women and children affected by war.13 In 1920, she ran (unsuccessfully) for Congress in Oregon’s ird District.12 Esther Clayson Pohl Lovejoy (1869-1967): Public Health Pioneer She then returned to war-related humanitarian work through Dr Esther Pohl Lovejoy was a leader in public health the American Women’s Hospitals, a program that she reform, politics, and suffrage in Portland, Oregon. In 1907, would lead for the next several decades.

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Mattie E. Coleman (1870-1943): “Building Biracial Alliances” doubt with the same determination and grit that fueled her Dr Mattie E. Coleman was one of Tennessee’s first leadership in the suffrage movement.18 In 1909, she joined a female physicians. She married a minister in the Colored group of suffragists to climb Mount Rainier and on reaching Methodist Episcopal Church in 1902 and subsequently the summit, raised a “Votes for Women” banner.18 is act graduated from Meharry Medical College in 1906. After embodies the passion and dedication that Dr Eaton brought receiving her medical degree, Dr Coleman opened her own to the cause for women’ssuffrage. practice and dedicated much of her effort to helping those in need, a reflection of her strong Christian beliefs. She was Caroline E. Spencer (1861-1928): Silent Sentinel elected President of the Clarksville District Missionary Dr Caroline E. Spencer was a physician activist who Society, through which she influenced others to do the same advocated for the elimination of the economic and political through “gospel work.”14 Dr Coleman took on an active inequalities American women faced. After graduating from role in the Colored Methodist Episcopal Church, even- the Woman’s Medical College of Pennsylvania in 1892, she tually becoming President of the Woman’s Connectional moved to Colorado, where she became a focal point of the Missionary Council, a position that she held for more than 2 state’ssuffragist movement. She helped found the Women’s decades. She empowered women of all colors to unite and Club of Colorado Springs in 1902 and the Civic League in work together. Known for “building biracial alliances,” which 1909.19 was unusual at the time, Dr Coleman worked with white As her prominence in political advocacy grew, Dr Spencer women leaders who supported social service programs for expanded her work to the national level, becoming a leader the African American community.15 In return, Dr Coleman in Alice Paul’s National Women’s Party, an organization helped secure a block of votes by influencing more than that employed militant tactics in its mission to achieve 2500 black women to vote in the 1919 Nashville, Tennessee, women’ssuffrage on a federal level.20 As one of the Silent municipal elections, the first time women in Tennessee Sentinels, a suffrage group organized by Alice Paul and were granted the right to vote in municipal elections.15 the National Women’s Party, she picketed in front of the White House during the years 1917 to 1919.21 In 1919, she Cora Smith Eaton (1867-1939): Climbing for Equity also demonstrated at the Watch Fires for Justice, where Dr Cora Eaton’s participation in the suffrage movement President Wilson’s speeches were burned.21 Dr Spencer’s began at a young age when she followed in the footsteps banner during one of President Wilson’s speeches read, of her mother, a women’s rights advocate. In 1890, she and “Mr. President, what will you do for women’ssuffrage?”21 her mother were among the first women to vote in a local She was arrested 3 times and sent to prison twice, once for election in Grand Forks, North Dakota, a state which 7 months because of repeat offenses for her protesting.21 allowed women limited voting rights in a special school After the successful passage of the 19th Amendment, election.16 Two years later, Dr Eaton became the first li- Dr Spencer continued her advocacy with the National censed female physician in North Dakota and in 1895 Women’s Party to pass the Equal Rights Amendment and became the President of the North Dakota Suffrage As- continued in this line of work until her death in 1928.19 sociation. e following year, she moved to Minneapolis, where she served as a surgeon at the Minneapolis Mater- ONE CENTURY LATER nity Hospital and President of the Minnesota Suffrage e women’ssuffrage movement marks a pivotal time in Association.17 American history in the promotion of autonomy and equal- Eventually, Dr Eaton moved to Washington State, where ity for American women. Female physicians played an im- she played a major role in the successful 1910 state suffrage portant role in these efforts. Familiar with the challenges ratification campaign. She established the National Council of being among the first in their field, they were courage- of Women Voters, a nonpartisan group composed of wo- ous, passionate advocates and leaders with deep conviction. men from voting states, separate in organization and goals ese women demonstrated flexibility and creativity, adapt- from the National American Woman Suffrage Association. ing their strategies to address the changing concerns of their She was also the physician of Alice Paul, one of the most communities, each drawing from her own personal back- prominent leaders in the suffrage movement. When Paul ground and strengths. Yet the history of suffrage is not was imprisoned for picketing at the White House, Dr Eaton without controversy. Although biracial alliances existed in helped smuggle notes in and out of the infamous Occoquan Tennessee, most efforts remained largely segregated, and Workhouse prison.18 sometimes the tactics included racist or anti-immigrant While practicing in the Pacific Northwest, Dr Eaton took rhetoric. on yet another challenge: mountaineering. She was the first As we celebrate the hundredth anniversary of the 19th woman to climb the East Peak of Mount Olympus, no Amendment, we should remember that our success as a

The Permanente Journal·https://doi.org/10.7812/TPP/20.036 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 9 COMMENTARY Women Physicians and the Suﬀrage Movement

society lies in embracing diversity—learning from and 6. Jacobi MP. “Common sense” applied to woman suffrage: A statement of the reasons which justify the demand to extend the suffrage to women, with consideration of the giving voice to groups that have historically been silenced. arguments against such enfranchisement, and with special reference to the issues And just as suffrage leaders shifted from quiet discourse to a presented to the New York State Convention of 1894. New York, NY: G.P. Putnam’s Sons; 1915: p 223. Available from: babel.hathitrust.org/cgi/pt?id=uc2.ark:/13960/ rallying cry to achieve their goals, so too must we join with t2n58fp7q&view=1up&seq=3 allies to achieve equity for our patients and for ourselves. 7. Jacobi MP. Description of the early symptoms of the meningeal tumor compressing the cerebellum, from which the author died. Written by herself. In: Jacobi MP A pathfinder in May we learn from their history even as we work in this medicine, The Women’s Medical Association of New York City, editor. New York, NY: G. P. century to advance women’s leadership at all levels of Putnam’s Sons; 1925: p 501-4. v 8. Changing the Face of Medicine: Dr Marie Diana Equi [Internet]. Bethesda, MD: US healthcare and in society at large. National Library of Medicine, National Institutes of Health; 2003 Oct 14. Updated 2015 Jun 3 [cited 2020 Jan 28]. Available from: https://cfmedicine.nlm.nih.gov/physicians/ Disclosure Statement biography_103.html The author(s) have no conflicts of interest to disclose. Funding sources: none. 9. Helquist M. Marie Equi: Radical politics and outlaw passions. Corvallis, OR: Oregon State University Press; 2015. 10. Jensen K. Oregon’s doctor to the world: Esther Pohl Lovejoy and a life in activism. Seattle, Acknowledgments WA: University of Washington Press; 2012. ’ We would like to thank Kimberly Jensen, PhD, and Jacqueline Antonovich, PhD, 11. Jensen K. Part II of Esther Pohl Lovejoy s speech to the Milwaukie, Oregon Grange. Kimberly Jensen’s blog [Internet]; 2012 Aug 26 [cited 2020 Jan 28]. Available from: http:// for review of the manuscript. Source material for this article was taken from kimberlyjensenblog.blogspot.com/2012/08/part-ii-of-esther-pohl-lovejoys-speech.html ’ materials gathered for the American Medical Women s Association online 12. Jensen K. ‘Neither head nor tail to the campaign’: Esther Pohl Lovejoy and the Oregon exhibition, Women Physician Suffragists (www.amwa-doc.org/women-physician- woman suffrage victory of 1912. Oregon Historical Q Fall 2007;108(3):350-83. Available suffragists). at: https://www.jstor.org/stable/20615762 Kathleen Louden, ELS, of Louden Health Communications performed a primary 13. Jensen K. Esther Pohl Lovejoy, M.D., the First World War, and a feminist critique of copyedit. wartime violence. In: The women’s movement in wartime. Fell AS, Sharp I, editors. London, UK: Palgrave Macmillan; 2007: p 175-93. 14. Aaseng N. African-American religious leaders: A-Z of African American religious leaders. Authors’ Contributions New York, NY: Facts on File, Inc; 2003: p 4. All authors participated in reviewing the literature and preparing the manuscript. 15. Goodstein AS. A rare alliance: African American and white women in the Tennessee All authors have given final approval to the manuscript. elections of 1919 and 1920. J South Hist 1998 May;64(2):219-46. DOI: https://doi.org/ 10.2307/2587945 16. Bloomberg KM. Cora Smith Eaton and North Dakota woman suffrage. In: Equality at the How to Cite this Article ballot box: Votes for women on the Northern Great Plains. Lahlum LA, Rozum MP, editors. Chin EL, Levy MS, Brown AD, Marr MC, Keni PM, Daram N, Chau CA, Rangwala Pierre, SD: South Dakota State Historical Society Press; 2019: p 309-40. N, Watson K. Women physicians and the suffrage movement. Perm J 2020;24: 17. The suffragists of North Dakota [Internet]. Bismarck, ND: North Dakota Studies Program, 20.036. DOI: https://doi.org/10.7812/TPP/20.036 State Historical Society of North Dakota [cited 2020 Jan 28]. Available from: www.ndstudies.gov/sites/default/files/PDF/suffragist%20biographies.pdf 18. Ware S. Climbing mountains for the right to vote: On the 1909 National American Woman Suffrage Association convention in Seattle [Internet]. In: Why they marched: The untold References stories of the women who fought for the right to vote. Ware S, editor. Boston, MA: Harvard 1. Graf M On the field of mercy: Women medical volunteers from the Civil War to the First University Press; 2019 May 13 [cited 2020 Jan 28]. Available from: https://lithub.com/ World War. Amherst, NY: Humanity Books; 2010: p 73-78. climbing-mountains-for-the-right-to-vote/. 2. Alexander KL. Mary Edwards Walker [Internet]. Alexandria, VA: National Women’s History 19. Nicholl C. Dr Caroline Spencer and Colorado Springs’ radicals for reform. In: Museum [cited 2020 Jan 28]. Available from: www.womenshistory.org/education- Extraordinary women of the Rocky Mountain West. Blevins T, Daily D, Nicholl C, Otto CP, resources/biographies/mary-edwards-walker Sturdevant KS, editors. El Paso County, CO: Pikes Peak Library District; 2010: p 245-89. 3. Dr Mary Edwards Walker. Washington, DC: National Park Service, US Department of the 20. Historical overview of the National Woman’s Party [Internet]. Women of protest: Interior [cited 2020 Jan 28]. Available from: www.nps.gov/people/mary-walker.htm Photographs from the records of the National Woman’s Party collection. Washington, DC: 4. Jacobi MP. Life and letters of Mary Putnam Jacobi. New York, NY: G.P. Putnam’s Sons; Library of Congress [cited 2020 Jan 28]. Available from: www.loc.gov/collections/women- 1925: p 70. of-protest/articles-and-essays/historical-overview-of-the-national-womans-party/ 5. Jacobi MP. The question of rest for women during menstruation. New York, NY: G.P. 21. Gillmore IH. The story of the Woman’s Party. New York, NY: Harcourt, Brace, 1921: Putnamʼs Sons; 1877: p 4-5. Available from: http://resource.nlm.nih.gov/67041010R p 181-396.

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Connie Newman, MD1,2; Kim Templeton, MD2,3; Eliza Lo Chin, MD, MPH4 Perm J 2020;24:20.024 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.024

ABSTRACT Joan of Arc was motivated by political and religious consid- Gender inequities date back thousands of years, with women erations, but Joan’s perceived gender transgressions (dress- expected to be caregivers at home and men expected to be ing as a male, having a male haircut, and leading soldiers in leaders with occupations outside the home. In more recent history, battle) were also accusations that had an important role in women have trained in various professions, including medicine. condemning her (Figure 1).2 Although the number of female physicians has risen consistently During the ensuing centuries, few women had the op- over the past several decades and half of US medical students portunity or were allowed to participate in the workforce, now are women, gender inequities persist and are due, at least in part, to implicit (unconscious) biases held by doctors, other health greatly limiting possibilities for leadership roles. Women care professionals, and patients and their families. Implicit biases were impeded by limited access to schools and higher edu- negatively affect women in their medical careers and contribute cation, company policies against hiring married women, to slower advancement, less favorable evaluations, underrepre- restrictive federal and state policies, and state work bans sentation in leadership positions, fewer invited lectures, lower for married women.3 Educational opportunities for women salaries, impostor syndrome, and burnout. Despite efforts to ad- in the US began to improve in the 1820s with the estab- dress gender biases, studies in academic medical centers indicate lishment of women seminaries and academies and in the no major change over a 20-year span. Management of implicit 1860s and 1870s with the founding of colleges for women.4 gender bias at the organizational level is imperative. Strategies However, the higher education of women was justified as a ff include implicit bias training for doctors and other sta ; devel- means of preparing women to educate their children.4 State opment of a transparent and equitable compensation plan; and work ban laws for married women began in the late 19th transparent processes for promotion and hiring, mentorship, and sponsorship of women physicians for grand rounds, lectureships, century. Before the Great Depression, 9 states had laws that committees, leadership positions, and awards. Achievement of prohibited married women from working, and this number 3 equity for women physicians requires effort and ultimately a increased to 26 states in the 1930s. culture change. Gender equity in the medical profession will lead Limited education and workforce opportunities, includ- to improved physician wellness, retention of women physicians, ing in the professions,4 reflected in part the societal ex- and improved access to and quality of health care. pectation of women as mothers and caregivers with little interest in roles outside the home.4 Medicine, like other HISTORICAL OBSERVATIONS professions, has traditionally been dominated by men and structured to accommodate them. When Elizabeth Gender inequity and bias date back thousands of years Blackwell, the first woman physician in the US, attended to long-standing societal beliefs that men are superior to medical school in the 1840s, she shocked the community of women in strength and intellect and thus more suited for Geneva, New York; women stared at her and the wives of work outside the home, and that women exist for the pur- doctors refused to talk to her.5 She was excluded from some pose of bearing children and raising a family. In this social of the anatomy demonstrations for her class because of her construct, men are seen as powerful and strong leaders, sex. Furthermore, Dr Blackwell had difficulty finding whereas women are regarded as warm, nurturing, and un- training after graduation, despite having graduated at the suited for leadership. top of her class. is was a common problem for other Archaeologic findings show evidence of gender role dif- women medical school graduates later in the 1800s. ferences more than 5000 years ago in the fourth millennium BC.1 More men than women had evidence of inflicted violence likely due to their roles as warriors, and rock art Author Affiliations shows gender differences: more male than female figures are 1 Division of Endocrinology and Metabolism, Department of Medicine, New York University Grossman School of depicted as archers. Female figures are generally not shown Medicine, New York, NY fi  fi 2 Past President, American Medical Women’s Association, Schaumburg, IL in hunting or ghting scenes. ese ndings support a 3 Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS societal role for men distinct from that of women, and the 4 American Women’s Association, Schaumburg, IL, and University of California, San Francisco, San Francisco, CA emergence of the powerful male stereotype. ese early gender-based roles contributed to social Corresponding Author Connie Newman, MD ([email protected]) complexity. In medieval times, the famous trial in 1431 of Keywords: gender bias, implicit bias, inequities, women in medicine, women physicians The Permanente Journal·https://doi.org/10.7812/TPP/20.024 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. 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Figure 1. The painting by Louis Maurice Boutet de Monvel, entitled “The Trial of Joan of Arc (Joan of Arc Series: VI).” Courtesy National Gallery of Art, Washington. The painting is from the National Gallery collection and accessible at https://images.nga.gov/en/search/do_quick_search.html?q=Joan+of+Arc+trial.

When the US entered World War I in 1917, women By the latter part of the 20th century, the numbers of doctors who applied for commissioned service in the army women studying medicine began to improve. In 1965 to were rejected on account of their sex. Dr Rosalie Slaughter 1966, women comprised 9.3% of matriculating students Morton (founding Chair of the War Service Committee of in medical schools.8 After the passage of Title IX in 1972 the American Medical Women’s Association), Dr Esther (which prohibited discrimination based on sex in all fed- Pohl Lovejoy, and others, however, refused to stay “home.” erally funded educational programs or activities), the num- ey organized American Women’s Hospitals, which ber of matriculating women medical students increased provided funding for ambulances, hospitals, and treatment from 11% in the academic year 1970 to 1971, to 29% in centers in Europe, where women doctors served as civilians 1980 to 1981, 38.5% in 1990 to 1991, and 46% in 2000 to both during and after the war.6 2001. In 2019, women comprised, for the first time, more In the first half of the 20th century, the number of women than 50% of all medical student in the US.9 Achieving physicians remained limited. Often only a handful were ac- a robust pipeline of women entering medicine has been a cepted at each medical school because of established quotas. major achievement. Yet despite these gains, women in When Dr Helen Brooke Taussig, expressed her desire to medicine still find lack of acceptance, marginalization, and study medicine in 1921, her father encouraged her to study differential treatment compared with men, largely due to public health, which he considered a more appropriate gender bias. In addition, recruitment and acceptance of career for women.7 In Dr Taussig’s interview at Harvard women in some areas of medicine, such as general surgery University, the Dean of Public Health was quoted as saying, and surgery subspecialties, continue to be an issue.10 ere “[W]e will permit women to study but we will not admit also remain society’s gendered expectations of women re- them as candidates for degrees.”7 So instead, she studied garding care of children and duties at home; these expec- anatomy at Boston University School of Medicine and ap- tations can be at odds with a health care system whose plied to Johns Hopkins Medical School, which accepted framework and compensation models were traditionally more women than other schools did. Admitted to the class developed by and for men, despite the increased influx of of 1923 as 1 of 10 women in a class of 70, Dr Taussig women into the profession. became a renowned pediatric cardiologist, co-developing In addition to biological sex, factors that contribute to (with Dr Arthur Blalock and Vivian Leigh) the opera- inequality for women in the medical profession include race, tion that saved babies with “blue baby syndrome,” which ethnicity, sexual orientation, and nonbinary gender. One was usually caused by a congenital heart defect such as of the first examples was the experience of Dr Rebecca Lee Tetralogy of Fallot. She was later instrumental in estab- Davis Crumpler, the first black woman physician, who lishing thalidomide as a teratogen causing congenital limb applied to medical school at a time when all women doctors deformities. in the US (300 of the approximately 55,000 physicians in

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1860) were white.11 After graduation, Dr Crumpler prac- advancement of women in academic medicine, with fewer ticed in the post-Civil War South. Although appreciated by women at each successive level of career promotion, may be her patients, she was treated without respect by her male related to gender bias in the promotion process itself or in colleagues and by pharmacists, who did not want to fill her the various steps required for promotion. For example, prescriptions.12 e issues of intersectionality for women professional medical societies give more awards to men,22 physicians continue to this day. and women receive fewer invitations to speak at grand rounds.23 In 2015, women constituted 34% of the physician PREVALENCE OF GENDER BIAS IN ACADEMIC MEDICINE workforce, although only 15% of presidents of professional Similar studies in 1995 and 2014 demonstrated that gen- medical societies were women.24 Gender bias also affects der bias in academic medical settings affects women more how people refer to physicians and other professionals. Both than men and substantially affects women’s careers. Regret- men and women scientists are more likely to call men, but fully, the prevalence of gender bias did not change during the not women, by their surname, including introductions for interval of 20 years between these studies.13,14 e earlier grand rounds25 or other important lectures. ese differ- study, which surveyed 1979 faculty from 24 medical schools,13 ences in forms of address were found to reinforce the per- found that gender bias affecting professional advancement ception that men are leaders in the field and more deserving was experienced by 60% of women and 9% of men. Sim- of awards, recognition, and promotion.26 ilarly, the 2014 survey of 1066 physicians who were recipients Analysis of physician-patient communication shows that of career development awards found that 66% of women women doctors in general have different communication and about 10% of men perceived personal gender bias.14 styles than their male colleagues.27 Women physicians are reported to be caring and empathic, and ask more psy- IMPACT OF GENDER BIAS ON WOMEN PHYSICIANS chosocial questions, speak more positively, and spend more Biases based on gendered stereotypes can negatively affect time with each patient.27,28 Patients, however, have gen- the careers of women in science and medicine.15,16 Biases dered expectations of physicians that affect the way they per- that are explicit and recognized by the individual are eas- ceive communication styles in female and male doctors.29 ier to identify and fortunately are becoming less common. Physicians with the same behavior may receive different More challenging are implicit or unconscious biases, which patient ratings based on their sex, with women doctors can affect interactions and decisions without awareness.17 A not always receiving a good rating for patient-centered systematic review of 42 studies that evaluated biases among behavior.29 In addition, even if the communication of health care professionals, including more than 12,000 women physicians is scored highly by patients, this style of physicians, found evidence in 35 studies for implicit biases, providing more “warmth” can also come with lower scores largely based on race-ethnicity and sex, which were similar in the area of competence,30 reflecting the societal view of to what is seen in the general population.17 As implicit women as nurturers but not necessarily as knowledgeable biases are largely unknown to the person holding them, they physicians. Given the increased emphasis on assessing the can be much harder to identify. Both men and women can metrics of patient experiences, negative patient satisfaction harbor implicit gender biases against women.18,19 A study 20 years ago found that women viewed self-promoting women Negative Impact of Gender Bias on Women Physicians as competent but less socially attractive and thus would prefer to hire men. In contrast, men viewed self-promoting Career Advancement 18 women favorably and were willing to hire them. Amore · Underrepresentation in leadership positions15,20,23,24 recent study, in 2007, found that women and men had a · Slower academic promotion37 negative bias toward women who were successful in male- · Fewer professional awards22 associated jobs.19 However, this negative reaction was di- · Fewer grand rounds or national lectures23,26 minished when the women seeking employment conformed · Attrition45 to societal expectations in their roles as mothers. Financial Considerations Numerous studies have shown that implicit bias nega- Less research funding46 tively affects women in academic medical careers and may · Lower salaries37,39 limit opportunities or hinder professional advancement15,20 · (see Sidebar: Negative Impact of Gender Bias on Women Psychological challenges Physicians). Recent data from the Association of American · Harassment13,14,43 Medical Colleges show that women comprise 59% of fac- · Impostor Syndrome47,48 ulty at the instructor level, 47% at assistant professor, 38% at · Burnout32,34,47 associate professor, and 25% at full professor.21 e slower

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ratings could potentially hinder the advancement of women strategies for improving inequities can be developed. ese in the medical profession.29 strategies may include the following: Women physicians frequently adopt the empathic style · increasing awareness of both unconscious and conscious of interaction (the “mother transference”) because of their gender bias through implicit bias training for physicians tendency to be more nurturing, which may be a learned trait and other staff, as well as training to help individuals (related to social or cultural influences), as well as an in- manage their biases nate biological characteristic.31 In the Physician Work Life · development of a compensation plan, designed for pay Study of 2326 physicians (32% women), women doctors re- equity, that compensates for the position, not the qual- ported having more psychosocially complex patients, fewer ities of the individual resources, and the need to spend more time with their · safe, clear reporting processes for those who experience patients to provide high-quality care.32 If health care models or witness bias do not provide extra time to interact with these patients, this · transparent hiring procedures and requirements for excessive workload can lead to long hours and burnout.33 As promotion noted by Dahlke et al34 in 2018 when discussing female · commitment to advancing the careers of both women surgeons, the “motherly approach to patient care is likely to and men be best for the patient, but perhaps could be personally · provision of family leave for women at all stages of their “draining” to female [surgeons] over time.” careers · sponsorship of women physicians by encouragement ASSESSMENT OF BIAS of their nomination for leadership positions, important Implicit (unconscious) gender bias can be assessed by committees at the institution and elsewhere, editorial the Implicit Association Test,35 which measures the time boards, grand rounds speakers, and invited lectureships it takes for an individual to associate specific words, such · support for development of leadership skills in women by as woman, man, home, career, or pictures, with each other. providing funding and coverage for leadership programs Salles et al20 reviewed data from the Gender-Career Implicit and making time available for them to fully participate in Association Test and compared responses of approximately these programs 43,000 health care professionals, largely women (80%), and · transparency about the organization’s commitment to about 900,000 people who were not health care profes- equity and the policies involved. sionals. Both groups associated men with career and women To achieve equity, a variety of approaches are needed. with family, although the implicit bias score was slightly Underpinning many of these is the need for the support of higher in health care professionals. Implicit bias scores of male colleagues, sometimes referred to as “male allies”; this women health care professionals were higher than their support is critical and will likely accelerate progress. Studies male counterparts. Health care professionals of both sexes on intergroup relations (outside the medical profession) also had explicit biases. Using a Gender-Specialty Implicit have found that women who advocate for gender equity Association Test developed by the authors, 131 surgeons appreciate support from men provided that this support is (34% women) associated men with surgery and women with autonomy oriented, rather than domineering, because the family medicine, and responses were similar in men and latter would reinforce stereotypical male roles.36 women. However, on the explicit bias test, women were Although data are limited, studies of interventions to less likely to associate men with surgery and women with achieve equity suggest benefits to women faculty at aca- family medicine, reinforcing the need to evaluate uncon- demic medical institutions. Results of one of the earliest scious biases, which are a result of societal and professional reports, by Fried et al,37 found that multiple interventions stereotypes. between 1990 and 1995 in the Department of Medicine at a single medical center, Johns Hopkins, had positive MANAGING GENDER BIAS IN THE MEDICAL PROFESSION effects on retention and promotion of both women and With the increasing number of women in medicine, men faculty, including a 5.5-fold increase in promotion of addressing gender bias in the workplace has become a women to associate professor. Essential to this success was national imperative. Unfortunately, larger societal change the commitment by leadership (in this case, the department eliminating gender bias is unlikely, at least in the short term. Chair) to career equity. Interventions included communi- Managing implicit bias so that women in medicine are cations from the department Chair, problem assessment, treated equitably begins at the organizational level. One of leadership development, salary adjustment, education about the first steps is assessment of the magnitude of the prob- gender bias/discrimination in academic medicine, effective lem, by evaluating leadership positions, salaries, rank, and mentoring, annual curriculum vitae review of each female new hires, by sex. Based on the results of this assessment, faculty member, and later male faculty, to identify gaps

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for promotion and strategies to remedy them. In addition, depends on organizational commitment. A system of ac- meetings previously held on weekends and after 5 pm were countability is needed, for example, a departmental “equity rescheduled so that women with family responsibilities report card” that is public and accessible to all.41 could participate. At a 3-year assessment, both women and e #MeToo movement in medicine has revealed how men faculty reported more timely promotions, reduction in sexual harassment can negatively affect women’s careers in signs of gender bias, improved access to information about medicine.42 In 2018, the National Academies of Science, promotion, greater inclusion, greater degree of equity in Engineering, and Medicine published the seminal report, pay, and better mentoring experiences, with women report- Sexual Harassment of Women: Climate, Culture, and Con- ing significantly greater improvements in these outcomes sequences in Academic Sciences, Engineering, and Medicine, compared with men, with the exception of mentoring. which revealed that more than 50% of women faculty and Evaluation of a leadership program for women faculty at the staff report having been harassed.43 eeffect on a woman’s same medical institution from 2010 to 2013 found self- academic career can be substantial, depending on the power reported improvement in 9 of 11 leadership skills in 134 dynamics involved, thus having an impact on academic women faculty (95% at the assistant professor level) in the promotion and leadership advancement opportunities. Departments of Medicine and Surgery.38 at same year, Time’s Up Healthcare was founded to Pay equity has been found to be achievable using a ensure safety and equity in the health professions. e structured compensation model in which physicians reach foundation’s Signatory Program invites medical centers, a target salary for the specialty after 5 years, without taking universities, hospitals, and other health care organizations into consideration relative value units, duration of service, to uphold 3 principles: 1) prevention of sexual harassment and academic rank or tenure.39 In 2017, evaluation of sal- and gender inequity and protection and assistance for aries at the Mayo Clinic, which has used a structured model those who are targets; 2) equitable opportunity, support, for 40 years, found equitable compensation by sex, race, and and compensation for every employee; and 3) measure- ethnicity.39 Exceptions were noted for those in leadership ment and tracking of sexual harassment and gender-based positions, usually men, who received higher compensation; inequities.44 in addition, higher compensation was seen for those in some specialties that are predominantly male. is demonstrates CONCLUSION the need for continued support and sponsorship for women Implicit and explicit gender biases have existed for cen- to achieve leadership roles and to enter all specialties of turies and are rooted in gender norms that date back thou- medicine as part of approaches to reach pay equity. sands of years. e more complex a society or organization Changing or controlling implicit bias can be difficult but becomes, the more likely that biases will be present. Fully is possible through training. A workshop to reduce implicit addressing implicit gender bias in the medical profession gender bias has been evaluated in a pair-matched, single- requires changing both the culture of medicine and the blind, cluster-randomized controlled study of faculty in sociopolitical milieu in which medicine is practiced. Only medicine, science, or engineering at one institution.40 e then will it be possible to achieve full equity for women objectives of the 2.5-hour interactive workshop were to physicians, a reality that will translate into improved phy- increase awareness of gender bias and its detrimental effects, sician wellness, retention of women physicians in the work- provide education about various forms of stereotype-based force, and improved access to and quality of health care. v gender bias, and discuss evidence-based behavioral strategies for individuals to practice. ree months after the Disclosure Statement The author(s) have no conflicts of interest to disclose. workshop, surveys found improvement in self-efficacy to adopt behaviors that promoted gender equity, a requirement Acknowledgments for behavioral change. When 25% or more of the depart- Kathleen Louden, ELS, of Louden Health Communications performed a primary ment faculty attended the workshop, self-reported actions copyedit. to promote gender equity increased at 3 months. Leadership development programs specifically tailored to How to Cite this Article ff Newman C, Templeton K, Chin EL. Inequity and women physicians: Time to meet the needs of women physicians are currently o ered by change millennia of societal beliefs. Perm J 2020;24:20.024. DOI: https://doi.org/ a number of organizations, both locally and nationally. e 10.7812/TPP/20.024 Association of American Medical Colleges’ Early Career Women Faculty Leadership Development Seminar and References Drexel University College of Medicine’s Executive Lead- 1. Cintas-Peña M, García Sanjuan´ L. Gender inequalities in Neolithic Iberia: A multi-proxy approach. Eur J Archaeol 2019 Nov;22(4):499-522. 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Gendered expectations: Do they contribute to high burnout among Nov 15 [cited 2020 Jan 28]. Available from: www.aamc.org/system/files/2019-11/2019_ female physicians? J Gen Intern Med. 2018 Jun;33(6):963-5. DOI: https://doi.org/10.1007/ FACTS_Table_A-9.pdf s11606-018-4330-0 10. Association of American Medical Colleges. AAMC 2019 report on residents table B3 number of 34. Dahlke AR, Johnson JK, Greenberg CC, et al. Gender differences in utilization of duty- active residents, by type of medical, school, GME specialty, and sex [Internet]. Washington, hour regulations, aspects of burnout, and psychological well-being among general DC: Association of American Medical Colleges; 2019 [cited 2020 Jul 15]. Available from: surgery residents in the United States. Ann Surg 2018 Aug;268(2):204-11. DOI: https:// https://www.aamc.org/data-reports/students-residents/interactive-data/report-residents/2019/ doi.org/10.1097/SLA.0000000000002700 table-b3-number-active-residents-type-medical-school-gme-specialty-and-sex 35. Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit 11. Women in Medicine Legacy Foundation. Dr Rebecca Crumpler: The first black woman cognition: The Implicit Association Test. J Pers Soc Psychol 1998 Jun;74(6):1464-80. physician [Internet]. Royersford, PA: Women in Medicine Legacy Foundation; 2019 Jul 3 DOI: https://doi.org/10.1037/0022-3514.74.6.1464 [cited 2020 Mar 3]. Available from: www.wimlf.org/blog/dr-rebecca-crumpler-the-first- 36. Wiley S, Dunne C. Comrades in the struggle? Feminist women prefer male allies black-woman-physician who offer autonomy- not dependency-oriented help. Sex Roles 2019 Oct;80:656-66. 12. Outstanding women doctors. John H. Johnson Ebony; Johnson Publishing Company; DOI: https://doi.org/10.1007/s11199-018-0970-0 1964 May;19(7):68. 37. Fried LP, Francomano CA, MacDonald SM, et al. Career development for women in 13. Carr PL, Ash AS, Friedman RH, et al. Faculty perceptions of gender discrimination and academic medicine: Multiple interventions in a department of medicine. JAMA 1996 Sep; sexual harassment in academic medicine. Ann Intern Med 2000 Jun;132(11):889-96. DOI: 276(11):898-905. DOI: https://doi.org/10.1001/jama.1996.03540110052031 https://doi.org/10.7326/0003-4819-132-11-200006060-00007 38. Levine RB, Gonzalez-Fern´ andez´ M, Bodurtha J, Skarupski KA, Fivush B. Implementation 14. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual harassment and evaluation of the Johns Hopkins University School of Medicine leadership program for and discrimination experiences of academic medical faculty. JAMA 2016 May;315(19): women faculty. J Womens Health 2015 May;24(5):360-6. DOI: https://doi.org/10.1089/ 2120-1. DOI: https://doi.org/10.1001/jama.2016.2188 jwh.2014.5092 15. Kaatz A, Carnes M. Stuck in the out-group: Jennifer can’t grow up, Jane’s invisible, and 39. Hayes SN, Noseworthy JH, Farrugia G. A structured compensation plan results in Janet’s over the hill. J Womens Health 2014 Jun;23(6):481-4. DOI: https://doi.org/10. equitable physician compensation. Mayo Clin Proc 2020 Jan;95(1):35-43. DOI: https://doi. 1089/jwh.2014.4766 org/10.1016/j.mayocp.2019.09.022 16. Institute of Medicine. Beyond bias and barriers: Fulfillling the potential of women in 40. Carnes M, Devine PG, Baier Manwell L, et al. The effect of an intervention to break the academic science and engineering. Washington, DC: National Academies Press; 2007. gender bias habit for faculty at one institution. Acad Med 2015 Feb;90(2):221-30. DOI: DOI: https://doi.org/10.17226/11741 https://doi.org/10.1097/acm.0000000000000552 17. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: A systematic review. BMC 41. D’Armiento J, Witte SS, Dutt K, Wall M, McAllister G; Columbia University Senate Med Ethics 2017 Mar;18(1):19. DOI: https://doi.org/10.1186/s12910-017-0179-8 Commission on the Status of Women. Achieving women’s equity in academic medicine: 18. Rudman LA. Self-promotion as a risk factor for women: The costs and benefits of Challenging the standards. Lancet 2019 Feb;393(10171):e15-6. DOI: https://doi.org/10. counterstereotypical impression management. J Pers Soc Psychol 1998 Mar;74(3): 1016/S0140-6736(19)30234-X 629-45. DOI: https://doi.org/10.1037/0022-3514.74.3.629 42. Choo EK, Byington CL, Johnson N-L, Jagsi R. From #MeToo to #TimesUp in health care: 19. Heilman ME, Okimoto TG. Why are women penalized for success at male tasks?: The Can a culture of accountability end inequity and harassment? Lancet 2019 Feb; implied communality deficit. J Appl Psychol 2007 Jan;92(1):81-92. DOI: https://doi.org/10. 393(10171):499-502. DOI: https://doi.org/10.1016/s0140-6736(19)30251-x 1037/0021-9010.92.1.81 43. National Academies of Sciences, Engineering, and Medicine. Sexual harassment of women: 20. Salles A, Awad M, Goldin L, et al. Estimating implicit and explicit gender bias among Climate, culture, and consequences in academic sciences, engineering, and medicine. health care professionals and surgeons. JAMA Netw Open 2019 Jul;2(7):e196545. DOI: Washington, DC: National Academies Press; 2018. DOI: https://doi.org/10.17226/24994 https://doi.org/10.1001/jamanetworkopen.2019.6545 44. Interested in becoming a signatory? [Internet]. Time’s Up Foundation [cited 2020 Mar 15]. 21. Association of American Medical Colleges. Table 9: Medical school faculty by sex and Available from: https://timesupfoundation.org/work/times-up-healthcare/interested-in- rank, 2019 [Internet]. Washington, DC: Association of American Medical Colleges; 2020 becoming-a-signatory/ [cited 2020 Jan 28]. Available from: www.aamc.org/system/files/2020-01/2019Table9.pdf 45. Cropsey KL, Masho SW, Shiang R, Sikka V, Kornstein SG, Hampton CL; Committee on 22. Silver JK, Slocum CS, Bank AM, et al. Where are the women? The underrepresentation of the Status of Women and Minorities, Virginia Commonwealth University School of women physicians among recognition award recipients from medical specialty societies. Medicine, Medical College of Virginia Campus. Why do faculty leave? Reasons for PM&R 2017 Aug;9(8):804-15. DOI: https://doi.org/10.1016/j.pmrj.2017.06.001 attrition of women and minority faculty from a medical school: Four-year results. J Women 23. Boiko JR, Anderson AJM, Gordon RA. Representation of women among academic grand Health (Larchmt) 2008 Sep;17(7):1111-8. DOI: https://doi.org/10.1089/jwh.2007.0582 rounds speakers. JAMA Intern Med 2017 May;177(5):722-4. DOI: https://doi.org/10.1001/ 46. Oliveira DFM, Ma Y, Woodruff TK, Uzzi B. Comparison of National Institutes of Health jamainternmed.2016.9646 grant amounts to first-time male and female principal investigators. JAMA 2019 Mar; 24. Silver JK, Ghalib R, Poorman JA, et al. Analysis of gender equity in leadership of 321(9):898-900. DOI: https://doi.org/10.1001/jama.2018.21944P physician-focused medical specialty societies, 2008-2017. JAMA Intern Med 2019 Mar; 47. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: Issues 179(3):433-5. DOI: https://doi.org/10.1001/jamainternmed.2018.5303 faced by women physicians. National Academy of Medicine Discussion Paper. 2019 May 25. Files JA, Mayer AP, Ko MG, et al. Speaker introductions at internal medicine grand 28. DOI: https://doi.org/10.31478/201905a rounds: Forms of address reveal gender bias. J Womens Health 2017 May;26(5):413-9. 48. LaDonna KA, Ginsburg S, Watling C. “Rising to the level of your incompetence”:What DOI: https://doi.org/10.1089/jwh.2016.6044 physicians’ self-assessment of their performance reveals about the imposter syndrome in 26. Atir S, Ferguson MJ. How gender determines the way we speak about professionals. Proc medicine. Acad Med 2018 May;93(5):763-8. DOI: https://doi.org/10.1097/acm. Natl Acad Sci USA 2018 Jul;115(28):7278-83. DOI: https://doi.org/10.1073/pnas.1805284115 0000000000002046

16 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.024 n COMMENTARY Discovering and Reﬂecting on Bias: A Discussion about Challenges and Beneﬁts of Culturally Centered Patient Care with Women Physicians of the East Bay

Chelsea Gong, MD1; Carroll-Anne Heins, DO1 Perm J 2020;24:20.031 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.031

ABSTRACT pressure control in African Americans.… I think patients are Implicit or unconscious bias is a lens through which we see our concerned about things like experimentation, which are real world based on our past experiences and learned stereotypes. concerns … [because] for some of my patients, Tuskegee hap- Within health care, this lens of bias has typically had a negative pened in their lifetime.” impact on patient care, particularly for marginalized populations. e Tuskegee experiment, conducted from 1932 to 1972, We sat down with 3 physicians within Kaiser Permanente East Bay studied the effects of untreated syphilis in African American to learn about their personal experiences of bias in patient care. men. e prospective study was formally titled “Tuskegee We also discuss the importance of acknowledging bias and ” practicing cultural humility in order to best ally with our patients. Study of Untreated Syphilis in the Negro Male. However, We are hopeful our conversation with these physicians will inspire the participants of the study had agreed to examination and  more of the same, leading to improved health care for those that treatment. ey were not informed that the intent was to have suffered from bias in the past. observe untreated disease and ultimately included with- holding effective treatment once penicillin was determined to be curative treatment and the standard of care in 1946.2 INTRODUCTION is overtly biased study ended more than 50 years ago. Physicians, although often proud of their foundation in fi However, we still see disparity imparted by a more implicit evidence-based, objective, and scienti c care, cannot re- bias against African Americans and Latinx (Latino/Latina) move the unique vantage point that is created by our ex- communities resulting in poorer outcomes for those with dia- periences, environments, and learned stereotypes. We each betes, hypertension, and other chronic conditions.3 Results view our world from a unique vantage point that is created of multiple studies, such as those evaluated in a meta- by our experiences, environments, and learned stereotypes. analysis by Meghani et al,4 also show that black patients ese perspectives or implicit biases live in our subconscious  were consistently less likely to receive any pain medications and inform our everyday actions. ey create a lens through compared with white patients in a similar situation. which we see our world and ultimately affect our choices, 1 Maternal and child health care has seen some of the often resulting in unintended consequences. We spoke to bleakest outcomes of implicit bias in medicine. Dr Williams 3 physicians from the Kaiser Permanente (KP)-East Bay “ ff knows these numbers well. ere are huge disparities that service area about how these lenses a ect their patient in- have been revealed in maternal health.… [T]he risk of death teractions and how acknowledging our own implicit biases and major disability, (or near-misses, is 2 times higher in can improve the care we provide individually and as a health African American women compared to white women, and the care system. ”  risk of death is 3 to 4 times the rate. A recent article in the Nailah ompson, DO; Patricia Castañeda-Davis, MD; Journal of Clinical Obstetrics and Gynecology discusses these and Amanda Williams, MD, are physicians who are leaders statistics along with noting that these disparities have in local conversations about recognition of implicit bias and existed for centuries and have increased in the past 100 cultural humility in the health care system. However, to lead years.5 Specifically, black women experienced the fastest these conversations about steps to move forward through growing rate of maternal mortality between 2007 and these challenges, we must have an understanding and an 2014.5 Ethnic minorities such as African American women appreciation of the history of bias in health care. are also less likely to receive minimally invasive hysterec- HISTORY OF BIAS IN HEALTH CARE tomies compared with open abdominal hysterectomies for benign indications.6,7 Dr ompson, who leads a blood pressure clinic for African American patients, highlights how history plays an Author Affiliations integral role in her daily care: “I started the African American 1 Kaiser Permanente Oakland Medical Center, Oakland, CA blood pressure clinic to bridge the gap between the great job Kaiser [Permanente] was doing with blood pressure control Corresponding Author Chelsea Gong, MD ([email protected]) across the nation and the discrepancy of suboptimal blood Keywords: bias, culturally centered patient care, cultural humility, physician, race The Permanente Journal·https://doi.org/10.7812/TPP/20.031 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 17 COMMENTARY Discovering and Reflecting on Bias: A Discussion about Challenges and Benefits of Culturally Centered Patient Care with Women Physicians of the East Bay

CULTURAL HUMILITY provider with the conversation, it has been picked up and Understanding the history of bias and racism in medicine sensed by the patient.” She notes that just as patients can and its subsequent effects on community health is part of a sense discomfort, they also easily sense respect and when crucial foundation in developing methods to mitigate health a physician sees them without judgment. She continued, disparities. However, the topics of racial and social ineq- “If you don’t understand what’s going on in their life, you make uities and the problems they create in health care can be an effort and try to.… It’s about rebuilding that trust and overwhelming, and although many institutions are work- making sure patients know why, and what our motivation is, ing to incorporate these conversations, finding the most that we’re trying to prevent heart attack and stroke and really effective way can be challenging. Dr Castañeda-Davis re- get their blood pressure under control and help them live their flected on her experience when she first started leading these healthiest life.” discussions 13 years ago. She said, “[T]hey asked me to work on cultural humility and essentially ‘address all health dis- ALLYSHIP parities’.… I think they only gave me 1 hour a week to identify is effort to understand and humble yourself to the and address everything. I think it’s well intended, but often- patient’s perspective is the first step in becoming an ally to times people are unaware of how to tackle this big problem.” your patient and providing equitable health care. Allyship e conversation acknowledging the ill effects of implicit is defined as a lifelong process of building relationships bias is growing in hospitals and medical institutions. Pre- based on trust, consistency, and accountability with mar- viously, organizations tried to address implicit bias through ginalized individuals and/or groups of people.9 Dr Williams concepts such as cultural competency. However, there is explained how effective allyship exists only with recognition now a shift from “competency” to “humility.” Cultural hu- of implicit bias. mility focuses on the individual needs and stories of patients I think one of the best ways to fight implicit bias is to and their communities to start reducing the larger prob- intentionally make yourself uncomfortable.… You cannot be a lem of implicit bias. Most importantly, cultural humility is good ally until you confront your own implicit bias… People acknowledging the impossibility of being fully competent in have to deal with the bias and the privilege first and then they all cultures and knowing this does not diminish respect for are more equipped to be a good ally. Your positive intent does the patient and his/her perspective. e focus of this hu- not negate your painful impact that you might have. And mility is ultimately asking the physician to acknowledge that we’re responsible for both and we have to figure out when we the patient is alone the expert of his/her personal cultural do offend or we do hurt someone, how do we remedy that and identity. is relinquishing of power from the physician re- make it better and commit ourselves to doing something quires acknowledgment of personal implicit biases and having differently. the tools to overcome how they can create disparate care.8 Dr Williams underscores that ultimately allyship is not self-defined and that our efforts must be recognized by ACKNOWLEDGING PERSONAL IMPLICIT BIAS those with whom we ally. All 3 physicians shared some of Dr Castañeda-Davis shared the following: “I have my their experiences of advocacy and allyship and reflected how own personal bias specifically related to [maternal-child health]. this adds passion and fulfillment to their careers. I realized I subconsciously thought African American women Dr Castañeda-Davis told us about her time working in were more likely not to breastfeed, but I assumed a Latina mom California Congresswoman Barbara Lee’soffice as a staffer would be breastfeeding and therefore biased my counseling to- specializing in health care issues. wards that. So I saw my individual bias is what was leading to My proudest moment in any of my careers was working as an individual health disparity.” She then reflected how she con- her staffer. An African American teenager came into her office. tinues to perform the difficult task of internal reflection regard- He had been at the wrong place at the wrong time and had ing her own biases. “Part of cultural humility is checking in with been injured in the stomach by a bullet. Before his injury, he yourself on things that you’re doing when you’re in an uncom- was a straight A student and was on his way to college. Due fortable situation. Cultural humility poses questions that walk to his injury, he couldn’t digest food and lived mostly on TPN you through your own biases, like ‘How often am I having to [total parenteral nutrition]. His insurance company wanted change my automatic response? What is my bias? Why do I have to do a cadaver transplant but a facility in Chicago this bias and what can I do about it? Have I ever been sur- approached him about doing a living donor transplant. His prised? What kind of detrimental things is the bias leading to?’” brother was a perfect match but the insurance company rough our conversation with Dr ompson, she em- wouldn’t allow it because the Chicago facility was out of phasized that although acknowledging our bias can be awk- network. He fought them for a year and couldn’t get it done ward, ignoring it often creates a much more uncomfortable and he came into our office, told us his story, and gave us the patient interaction. She said, “If you are not comfortable as a information.

18 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.031 COMMENTARY Discovering and Reﬂecting on Bias: A Discussion about Challenges and Beneﬁts of Culturally Centered Patient Care with Women Physicians of the East Bay

an interest in Latino and African American children and the stereotypes and health disparities they face. Her career has also been enriched by working as a congressional staﬀer in California Con- gresswoman Barbara Lee’soﬃce, where she focused, among other things, on health care issues in her district.

Nailah Thompson, DO, is an African American internal medicine physician at Kaiser Permanente Oakland Medical Center with expertise in preventive medicine. Dr Thompson played basketball throughout her academic studies and started her college education as an electrical engineering major. She transitioned to the medical ﬁeld when she saw her sister and others struggle with diabetes. After completing her internal medicine residency at Highland General Amanda Williams, MD, is an African American obstetrician and Hospital, Oakland, California, she went on to study preventive gynecologist and is currently the chief of the OB/GYN Department at medicine and obtain her master’s in public health degree at Co- Kaiser Permanente Oakland Medical Center. She was born and raised lumbia University, New York, New York. Since returning to the Bay in Washington, DC, and received her undergraduate degree from Area, she continues to work fervently serving the underserved Harvard University in Cambridge, Massachusetts. She subsequently population in East Bay communities with a goal of addressing their moved to Atlanta, Georgia, where she received both her medical health before chronic conditions can manifest. degree and master’s in public health degree from Emory University. Finally, she made her way to California for her internship and res- Patricia Castañeda-Davis, MD, was born to a Mexican mother and idency in obstetrics and gynecology at the University of California, Jamaican father, and with this background, started acknowledging San Francisco Medical Center, San Francisco, California. Since she bias and racism at a young age. She followed in her father’s footsteps joined Kaiser Permanente Oakland Medical Center, she has been to become a physician, and with a passion for children, it was an easy involved in addressing racial health disparities in the realm of OB/ choice for her to pursue pediatrics. She completed a pediatric GYN through her individual practice as well as through outreach via residency at Children’s Hospital of Oakland, Oakland, California, social media. where she was able to care for a diverse patient population. She has

The Permanente Journal·https://doi.org/10.7812/TPP/20.031 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 19 COMMENTARY Discovering and Reﬂecting on Bias: A Discussion about Challenges and Beneﬁts of Culturally Centered Patient Care with Women Physicians of the East Bay

She reflects on the impact of simply being a physician LOOKING TO THE FUTURE in the political arena. “I called the insurance company and I is trust building is an integral part of creating an eq- introduced myself as Dr Castañeda-Davis from Congress- uitable health care system. Dr Castañeda-Davis acknowl- woman Barbara Lee’soffice.… [A]t first the woman at the edges that simply starting to have these conversations about insurance [company] wanted to try to explain the procedure to bias is a major step forward. me, and I was able to tell her that ‘I’m a practicing medical While these discussions focus on some of the big challenges doctor, I know the medicine. I don’t understand why you won’t that we are currently dealing with as individuals, as an pay for this.’ And then, within 3 months, he had the surgery; organization, and as a country, the fact that we are even they had flown him into Chicago, [had] done the surgery. e exploring these issues is something that wasn’t happening insurance approved it and paid for everything.” years ago. ere is more and more legislation regarding some Dr Williams is also known for going beyond the role of of these issues around inclusion and diversity, which also is physician by using her voice in social media. “It’sadifferent incredibly hopeful. e fact that we have an Equity, In- way of approaching people and trying to connect with them clusion, and Diversity Committee here at Kaiser [Perma- around their health. [Using social media is] a piece of the puz- nente] that is working to educate individuals and identify zle for me and I love it.… When you sit in your academic circle, gaps is noteworthy. We have much work to do, and at the you go over all of the details of the paper/study, but to use social same time, we are moving forward and we always have hope. media lets you think about how something applies to peoples’ ese discussions are essential as we continue to engage lives.… I think it’s an avenue for me to express and connect in research that shows we are making strides to combat with like-minded colleagues and patients, women, and people of these internalized stereotypes. Already, Dr Williams has differing opinions.” been encouraged by the work she has seen in the integrated She views both her passion for social media and women’s health care system of KP Northern California, described health as being avenues of connecting more deeply with in a recent study by Zaritsky et al10 in December 2019, patients. who found that there were no longer racial-ethnic dis- As a physician, I’m not scared to engage. I think when you parities among the patients who receive minimally invasive prioritize meeting the patient where they are; you can’tbe hysterectomies. afraid to deal with some of the cultural issues, because those Dr ompson’s African American blood pressure clinic is issues are there and influencing what’s happening to your an exemplary model of how conversations about bias, hu- patient, no matter what you do. Prescribing a 4-times-daily mility, and allyship can turn into a different model of pa- medication for a new mother is going to be hard for her to tient care. When speaking about her culturally concordant manage. You have to think about the totality of peoples’ African American blood pressure clinic, she regards these circumstances. When you engross yourself in this type of work, visits as “a time to slow down and help the patient[s] really around bias, around justice, around looking at people as their understand their disease, their medications, and help them see full selves, it really allows you to be a better clinician. how they can be most engaged.” Dr ompson extends her role of physician outside the Patient-centered care and conversations result in patients clinic walls and advocates for patients by meeting them in feeling more cared for and more confident in the quality their own communities. of their health care. A study by Traylor et al11 demonstrated We can definitely make differences with our patients one higher rates of cardiac medication adherence in culturally on one, but a lot things we do need to have an effect on en- concordant provider-patient relationships. is finding is tire communities, like making sure there is access to healthy promising in that these practices of acknowledging bias and food and that [it] is safe to go for a walk for your exercise and cultural humility could provide an opportunity for margin- people have clean water.… We recognize that everyone is alized populations to feel more comfortable seeking health not comfortable within our walls, so we go out into the places care, and they could be healthier for it. where our patients are and do education and screenings It is exciting to hear how these women physicians paved there, like blood pressure checks and glucometer testing.… new pathways and started novel conversations in their ca- We can also tie [our health events] to celebrating the cul- reers about implicit bias and cultural humility. It is our hope ture such as Black History Month. We have a Chinatown that these conversations continue to not only reduce and street fair too; we do different care-beyond-our walls events eliminate bias in health care but also provide physicians the at different places of worship around town in African- fuel and model of how to continue leading and paving new American, Spanish-speaking, and Filipino communities, so paths for a better health care system. v that’s another great way that we can again address those health disparities by building trust by being present in the Disclosure Statement community. The author(s) have no conflicts of interest to disclose.

20 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.031 COMMENTARY Discovering and Reﬂecting on Bias: A Discussion about Challenges and Beneﬁts of Culturally Centered Patient Care with Women Physicians of the East Bay

3. Quiñones AR, Botoseneanu A, Markwardt S, et al. Racial/ethnic differences in Acknowledgments multimorbidity development and chronic disease accumulation for middle-aged adults. Kathleen Louden, ELS, of Louden Health Communications performed a primary PLoS One 2019 Jun;14(6):e0218462. DOI: https://doi.org/10.1371/journal.pone.0218462 copyedit. 4. Meghani SH, Byun E, Gallagher RM. Time to take stock: A meta-analysis and systematic review of analgesic treatment disparities for pain in the United States. Pain Med 2012 Feb; 13(2):150-74. DOI: https://doi.org/10.1111/j.1526-4637.2011.01310.x Authors’ Contributions 5. Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Chelsea Gong, MD, participated in the collection of background research and Gynecol 2018 Jun;61(2):387-99. DOI: https://doi.org/10.1097/GRF.0000000000000349 the drafting, critical review, and submission of the final manuscript. Carroll-Anne 6. Alexander AL, Strohl AE, Rieder S, Holl J, Barber EL. Examining disparities in route of Heins, DO, participated in the collection of background research and the drafting surgery and postoperative complications in black race and hysterectomy. Obstet Gynecol and critical review of the final manuscript. Both authors have given final approval to 2019 Jan;133(1):6-12. DOI: https://doi.org/10.1097/AOG.0000000000002990 the manuscript. 7. Pollack LM, Olsen MA, Gehlert SJ, Chang S-H, Lowder JL. Racial/ethnic disparities/ differences in hysterectomy route in women likely eligible for minimally invasive surgery. J Minim Invasive Gynecol 2020 Jul;27(5):1167-77. DOI: https://doi.org/10.1016/ How to Cite this Article j.jmig.2019.09.003 fl Gong C, Heins C-A. Discovering and re ecting on bias: A discussion about 8. Tervalon M, Murray-García J. Cultural humility versus cultural competence: A critical challenges and benefits of culturally centered patient care with women physicians distinction in defining physician training outcomes in multicultural education. J Health Care of the east bay. Perm J 2020;24:20.031. DOI: https://doi.org/10.7812/TPP/20.031 Poor Underserved 1998 May;9(2):117-25. DOI: https://doi.org/10.1353/hpu.2010.0233 9. Allyship [Internet]. Anti-Oppression Network [cited 2020 Apr 1]. Available from: https:// theantioppressionnetwork.com/allyship/ References 10. Zaritsky E, Ojo A, Tucker L-Y, Raine-Bennett TR. Racial disparities in route of 1. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: How doctors may hysterectomy for benign indications within an integrated health care system. JAMA Netw unwittingly perpetuate health care disparities. J Gen Intern Med 2013 Nov;28(11): Open 2019 Dec;2(12):e1917004. DOI: https://doi.org/10.1001/jamanetworkopen.2019.17004 1504-10. DOI: https://doi.org/10.1007/s11606-013-2441-1 11. Traylor AH, Schmittdiel JA, Uratsu CS, Mangione CM, Subramanian U. 2. US public health service syphilis study at Tuskegee [Internet]. Atlanta, GA: Centers for Adherence to cardiovascular disease medications: Does patient-provider Disease Control and Prevention website; last reviewed 2020 Mar 2 [cited 2020 Apr 1]. race/ethnicity and language concordance matter? J Gen Intern Med 2010;25(11):1172-7. Available from: www.cdc.gov/tuskegee/index.html DOI: https://doi.org/10.1007/s11606-010-1424-8

Jessie L Werner, MD1; Resa E Lewiss, MD2; Gita Pensa, MD1; Alyson J McGregor, MD, MA1 Perm J 2020;24:19.241 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/19.241

INTRODUCTION every medical specialty has produced a podcast.9 To recount Since the early 2000s, podcasting, or audioblogging, has a more personal vignette, on a recent work shift with one been gaining popularity as an easy and inexpensive way to of the authors of this commentary, a resident suggested disseminate information.1 In medicine, podcasts are increas- esmolol for a case of refractory ventricular fibrillation. When ingly used as an education tool, both in graduate medical asked what source he had used, he answered: a podcast. education and for continuing medical education (CME).2 With so many people listening to podcasts both in and e 2019 Infinite Dial study found that the total number of out of medicine, the importance of diversity should be clear. Americans aged 12 or older who have ever listened to a e beauty of a podcast is the freedom a host has in pro- podcast exceeded 50% for the first time ever.3 ducing its content. Without diverse representation behind Despite this rise in podcast consumption, there are still the microphone, we are missing out on unique perspectives, important sex-based differences between podcast hosts and narratives, and learning points. listeners. e2019Infinite Dial study also found that among monthly podcast listeners, women lag behind men, with TRADITIONALLY A MAN’SGAME 46% of listeners identifying as women and 54% identifying Podcasting, an amalgam of “iPod” (Apple Inc, Cuper- as men.4 Similarly, the role of podcast host has traditionally tino, CA) and “broadcast,” began in the early 2000s when a been held by white men and has been slow to change.5 In software developer and a video jockey from MTV (Music fact, in 2017, only about one-third of the top 100 podcasts Television Network; Viacom International Inc, New York, on Apple were hosted or co-hosted by women.6 NY) collaborated to create a new form of audio media is commentary explores sex and gender differences in distribution.10 e rudimentary technology developed at a podcasting, including why it matters to have diverse rep- time when broadband Internet was not yet widely available. resentation, sociocultural barriers to acquiring technological e podcast directories we use today, such as Apple’siTunes, expertise, the impact of voice preference, and future directions which allows users to stream, download, and subscribe to for women entering the podcasting sphere. In researching podcasts, also did not exist.11 In fact, the only way to access this commentary, the authors found a relative dearth of podcasts was to search for specific content, then listen to it information regarding women in the podcasting space, on your computer or wait for it to download to your iPod. specifically regarding medical podcasts. is furthers the e act of creating a podcast was even more complex and idea that more investigation into this topic needs to be done required multiple, specialized steps to record and distribute and is a possible area for future research. content. As Melissa Kiesche, Edison Research senior vice president, notes, “it was a tech heavy ask for people.… [I]t WHYSHOULDWECARE? makes sense that this was an industry born from the depths Podcasts have influence. In the mainstream, this is evi- of male tech culture.”4 denced by the massive rise of advertisers using podcasts for Unfortunately, women still are playing catch-up. It is profit. A study by the Interactive Advertising Bureau reports difficult to say if women’s underrepresentation on Apple’s that podcast advertising is expected to exceed $1 billion by top 100 podcasts is because women are not hosting as many the year 2021.7 podcasts or because they are not receiving recognition for In medicine, residents and young physicians are increas- their podcasts. A possible deterrent from women creating ingly using knowledge gained from podcasts to inform their podcasts is that the mechanical process of producing a practice. In a 2017 study, Riddell et al8 found that of the podcast requires knowledge and experience with recorders, residents surveyed, 88.8% listen to a podcast at least once microphones, and computerized editing software—a realm a month, and 72.2% said podcasts changed their clinical that has been historically associated with maleness.12 A practice. Another study published in 2020 found that nearly recent article in Forbes argued that women are not involved in technology and entrepreneurship because “society teaches ffi girls to focus on perfecting rather than building, abiding by Author A liations ”13 1 Department of Emergency Medicine, The Warren Alpert School of Medicine, Brown University, Providence, RI rules rather than breaking them. 2 Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA VOICE MATTERS Corresponding Author Another bias that may be limiting women’s access to Alyson J McGregor, MD ([email protected]) equal success in podcasting is voice pitch. Studies show that Keywords: education, gender equity, podcasting, sex and gender 22 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/19.241 COMMENTARY Women in Podcasting: We Should Tune In

both women and men prefer lower-pitched voices. In an gender associations become more established the more that article by Tigue et al,14 “Voice Pitch Influences Voting we are exposed to them. However, there is research to sug- Behavior,” the researchers modified recorded audio to make gest that implicit bias may be malleable on the basis of a lower-pitched and a higher-pitched version of each. ey social cues.23 Changing the context in which we see or hear then assessed associations that study participants had with something may help to change our prior perceptions.24 voice pitch for a number of traits, including level of at- What the authors of this commentary would like to suggest tractiveness, dominance, intelligence, and leadership abil- is that rather than expecting women to adjust their voices to ities. e study found that favorable personality traits were sound more masculine, perhaps promoting women’s voices associated with lower-pitched voices.14 Similarly, previous by increasing their representation in podcasting will help work found that people with lower-pitched voices are to deconstruct this prejudice. By hearing more women as perceived as more competent and equipped to lead than podcast hosts, in positions of authority, we may change our people with higher voices.15 Both men and women per- idea of what a leader should sound like. ceived those with lower vocal pitch to be more dominant As noted earlier, women’s podcast listenership ap- than those with higher voices.16,17 proaches that of men but lags slightly behind. A recent Artificial intelligence such as Alexa (Amazon, Seattle, study by Edison Research found that 61% of women would WA) and Siri (Apple) may further undermine the per- listen to podcasts if there were topics they were interested ceptions of women when it comes to voice. A recent United in.25 Increasing the visibility of women-hosted podcasts Nations report discussed the problems of having a virtual would likely introduce more topics relevant to female assistant with a woman’s voice and a submissive identity. It listeners. notes that “people like the sound of a male voice when it is making authoritative statements, but a female voice when it WHAT ELSE CAN WE DO? is being helpful.”18 As these female virtual assistants become As podcasting has become more prevalent and lucrative, more ubiquitous, they perpetuate a gender stereotype of initiatives have started to address the underrepresentation “woman” as “assistant.” e report goes on to explain that of women. Current editing software such as GarageBand “this demonstrates that powerful technology can not only (Apple Inc), Adobe Audition (Adobe Systems, San replicate gender inequalities, but also widen them.”18 Jose, CA), Hindenburg (Hindenburg Systems, Hvidovre, It is not too far a stretch, then, to suggest that women, Denmark), and others, as well as hosting platforms such as who generally have higher-pitched voices than men, may Apple and Libsyn (Liberated Syndication, Pittsburgh, PA), be at a disadvantage when podcasting. Not only may their have made it easier than ever to create, publish, distribute, voices be less popular, but they may be perceived as having and listen to podcasts. Spotify (Stockholm, Sweden) and less authority on a topic simply because they do not speak as Google (Mountain View, CA) offer training programs and deeply as a male counterpart. access to podcasting mentors. New York City public radio, ere are important sex-based biological differences that WNYC, hosts an annual festival specifically for women in contribute to voice pitch, which is primarily determined by podcasting called “Werk It!” which similarly provides in- the vibratory rate of the vocal folds. Longer vocal folds tend structive courses and networking opportunities.26 to vibrate at a lower frequency, which we interpret as a Long-established male leaders in the field with large lower pitch. When testosterone levels rise during puberty in audiences of their own are creating platforms to highlight males, the vocal folds undergo hypertrophy. As a conse- female podcast hosts. Roman Mars from Radiotopia started quence, men’s vocal folds are approximately 60% longer a Kickstarter campaign to fund 3 new podcasts for the than women’s and have a vibratory frequency 5 standard network, each specifically hosted by women.27 Ira Glass, deviations lower.19 Over the years, women have tried to of is American Life, similarly seeks to highlight female compensate for this inherent difference. Margaret atcher, hosts to continue the momentum. In the world of medical former British Prime Minister, famously underwent voice podcasting, Mel Herbert, MD, of Emergency Medicine coaching to sound more powerful.20 Reviews and Perspectives (EM:RAP), a major CME pod- is preference for lower voices makes one wonder that cast for emergency physicians, stepped down as co-host and perhaps what is at play in the gender disparity of podcasting hired a female emergency medicine doctor, Jan Shoenberger, is a form of unconscious (implicit) bias. Unconscious bias is a MD, to replace him.28 Hippo Education, another major prejudice or preference outside a person’s awareness. It is an medical CME podcast, has a female physician, Mizuho automatic, quick judgment that happens in the brain based Morrison, DO, as editor-in-chief.29 Despite those gestures, on people’s own culture, experiences, and environment.21 we still have a long way to go in bridging the gender divide. Calvin Lai, who researches unconscious bias at Harvard A quick search of the top 25 medical podcasts reveals that University, suggests with coauthor Mahzarin Banaji22 that only 2 are hosted by women.30

The Permanente Journal·https://doi.org/10.7812/TPP/19.241 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 23 COMMENTARY Women in Podcasting: We Should Tune In

A groundbreaking podcast for female hosts, and for the 7. PricewaterhouseCoopers LLP. IAB FY 2018 Podcast Ad Revenue Study: A detailed analysis of the US podcast advertising industry. New York, NY: field in general, was the true-crime podcast, “Serial,” which Interactive Advertising Bureau; 2019 Jun [cited 2020 Jul 9]. Available from: www.iab.com/ came out in 2014 and had a million listeners within 1 month wp-content/uploads/2019/06/Full-Year-2018-IAB-Podcast-Ad-Rev-Study_6.03.19_  vFinal.pdf. of its launch. is highly successful podcast series was 8. Riddell J, Swaminathan A, Lee M, Mohamed A, Rogers R, Rezaie S. A survey of created, produced, and hosted by women: host Sarah emergency medicine residents’ use of educational podcasts. West J Emerg Med 2017 31 Jan;18(2):229-34. DOI: https://doi.org/10.5811/westjem.2016.12.32850 Koenig co-created and co-produced with Julie Snyder. 9. Little A, Hampton Z, Gronowski T, Meyer C, Kalnow A. Podcasting in medicine: A review is demonstrated that women have what it takes to create of the current content by specialty. Cureus 2020 Jan;12(1):e6726. DOI: https://doi.org/ exceptional, popular content regardless of voice pitch. 10.7759/cureus.6726 10. Team Sounder. Everything you need to know about the history of podcasts.Medium 2019 Koenig has become a role model for women podcasters, and Jun 18 [cited 2020 Jul 9]. Available from: https://medium.com/sounder-fm/everything-you- her work likely opened the door for other women to achieve need-to-know-about-the-history-of-podcasts-6af334f13a0e. 11. Pot J. The evolution of the podcast—how a medium was born [geek history]. MakeUseOf success in the field. 2013 Aug 23 [cited 2020 Jul 9]. Available from: www.makeuseof.com/tag/the-evolution-of- We are on the right track, but this commentary is meant the-podcast-how-a-medium-was-born-geek-history/. 12. Cheryan S, Master A, Meltzoff AN. Cultural stereotypes as gatekeepers: Increasing girls’ as a call to action. It has become clear that podcasts have interest in computer science and engineering by diversifying stereotypes. Front Psychol power. ey carry economic weight, and they can influence 2015 Feb;6:49. DOI: https://doi.org/10.3389/fpsyg.2015.00049 13. Wang L. The surprising reason girls are not getting into tech. Forbes 2018 Dec 8 [cited our thinking in the public sphere and in our medical 2020 Jul 9]. Available from: www.forbes.com/sites/lisawang/2017/12/08/the-surprising- practice. e voices we hear matter, and gender diversity is reason-girls-are-not-getting-into-tech/. imperative for representing a breadth of viewpoints and 14. Tigue CC, Borak DJ, O’Connor JJM, Schandl C, Feinberg DR. Voice pitch influences voting behavior. Evol Hum Behav 2012 May;33(3):210-6. DOI: https://doi.org/10.1016/ experiences. Feminist allies need to provide mentorship and j.evolhumbehav.2011.09.004 sponsorship for female hosts. As listeners, we should am- 15. Borak CA, Anderson RC, Peters S. Sounds like a winner: Voice pitch influences perception of leadership capacity in both men and women. Proc R Soc B 2012 Mar; plify women’s voices by actively seeking out podcasts created 279(1738):2698-704. DOI: https://doi.org/10.1098/rspb.2012.0311 and hosted by women. v 16. Feinberg DR, DeBruine LM, Jones BC, Little AC. Correlated preferences for men’s facial and vocal masculinity. Evol Hum Behav 2008 Jul;29(4):233-41. DOI: https://doi.org/ 10.1016/j.evolhumbehav.2007.12.008 Disclosure Statement 17. DeBruine BC, Feinberg DR, DeBruine LM, Little AC, Vukovic J. A domain-specific The author(s) have no conflicts of interest to disclose. Dr Werner is a podcast opposite-sex bias in human preferences for manipulated voice pitch. Anim Behav 2010 host for EMRA*Cast. Dr Lewiss is the host and creator of the Visible Voices Jan;79(1):57-62. DOI: https://doi.org/10.1016/j.anbehav.2009.10.003 ’ podcast. Dr Pensa is the host and creator of Doctors and Litigation: The L Word. 18. UNESCO. I d blush if I could. 8 Jan 2020, Available from: en.unesco.org/Id-blush-if-I- could. Dr McGregor has no conflicts of interest to disclose. 19. Aung T, Puts D. Voice pitch: A window into the communication of social power. Curr Opin Psychol 2020 Jun;33:154-61. DOI: https://doi.org/10.1016/ Acknowledgments J.COPSYC.2019.07.028 20. Lee C. Here’s how the sound of your voice can hold you back in your career. Forbes 2016 Kathleen Louden, ELS, of Louden Health Communications performed a primary Dec 28 [cited 2020 Jul 9]. Available from: www.forbes.com/sites/break-the-future/2016/12/ copyedit. 28/heres-how-the-sound-of-your-voice-can-hold-you-back-in-your-career/. 21. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: ’ Where do we go from here? Perm J. 2011 April;15(2):71-8. http:// Authors Contributions www.thepermanentejournal.org/issues/2011/spring/736-health-disparities.html Jessie L. Werner, MD, and Alyson J. McGregor, MD, contributed background 22. Lai CK, Banaji MR. The psychology of implicit intergroup bias and the prospect of literature review and initial drafting of the manuscript. Resa E. Lewiss, MD, and change. In: Allen D, Somanathan R, editors. Difference without domination: Pursuing Gita Pensa, MD, contributed to critical review, editing and manuscript preparation. justice in diverse democracies. Chicago, IL: University of Chicago Press; 2019. Available All authors have given final approval to the manuscript. from: https://wappp.hks.harvard.edu/files/wappp/files/lai_banaji_-_the_psychology_of_ implicit_intergroup_bias_and_the_prospect_of_change.pdf. 23. Blair IV. The malleability of automatic stereotypes and prejudice. Pers Soc Psychol Rev How to Cite this Article 2002;6(3):242-61. DOI: https://doi.org/10.1207/s15327957pspr0603_8 Werner JL, Lewiss RE, Pensa G, McGregor AJ. Women in podcasting: We should 24. Lai CK, Hoffman KM, Nosek BA. Reducing implicit prejudice. Soc Personal Psychol 2013 tune in. Perm J 2020;24:19.241. DOI: https://doi.org/10.7812/TPP/19.241 May;7(5):315-30. DOI: https://doi.org/10.1111/spc3.12023 25. Lazovick M. Women podcast listeners: Closing the listening gender gap. 2018 Dec 20 [cited 2020 Jul 9]. Available from: www.edisonresearch.com/women-podcast-listeners- References closing-the-listening-gender-gap/. 1. Quah N. The three fundamental moments of podcasts’ crazy rise. Wired 2017 Oct 4 [cited 26. Kinnie R. The growth of women in podcasting. Podcast Business J 2019 Feb 26 [cited 2020 Jul 9]. Available from: www.wired.com/story/podcast-three-watershed-moments/. 2020 Jul 9]. Available from: https://podcastbusinessjournal.com/the-growth-of-women-in- 2. Cho D, CosiminiM, Espinoza J. Podcasting in medical education: a review of the literature. podcasting/. Korean J Med Educ 2017 Dec;29(4):229-39. DOI: https://doi.org/10.3946/kjme.2017.69 27. Madison A. In the male-dominated world of podcasts, more women are 3. Edison Research. The infinite dial 2019. 2019 Mar 6 [cited 2020 Jul 9]. Available from: claiming the mic. Bitch Media 2015 Feb 23 [cited 2020 Jul 9]. Available from: www.edisonresearch.com/infinite-dial-2019/. www.bitchmedia.org/post/women-are-making-headway-in-the-male-dominated- 4. Edison Research. SheListens: Insights on women podcast listeners. 2019 Nov 14 [cited world-of-podcasts. 2020 Jul 9]. Available from: www.edisonresearch.com/shelistens-insights-on-women- 28. About EM:RAP. Emergency medicine reviews and perspectives. [cited 2020 Jul 9]. podcast-listeners/. Available from: www.emrap.org/about. 5. Kerpen C. The power of podcasting to fight the patriarchy. Forbes 2018 Mar 13 [cited 2020 29. Hippo Education. Meet our world-class faculty. [cited 2020 Jul 9]. Available from: Jul 9]. Available from: www.forbes.com/sites/carriekerpen/2018/03/13/the-power-of- www.hippoed.com/pa/faculty. podcasting-to-fight-the-patriarchy/#1edb7a5f6b94. 30. CareCloud. Top 25 medical podcasts for healthcare professionals. [cited 2020 Jul 9]. 6. Taylor L. Thomson Reuters Foundation. Podcasts are dominated by male voices, these Available from: www.Carecloud.com/continuum/top-25-medical-podcasts/. women want to change that. World Economic Forum 2018 Dec 7 [cited 2020 Jul 9]. 31. Hamedy S. The ’Serial’ podcast producers have a new show, and you can binge it. Available from: www.weforum.org/agenda/2018/12/podcasts-are-dominated-by-male- Mashable 2017 Feb 1 [cited 2020 Jul 9]. Available from: https://mashable.com/2017/02/ voices-these-women-want-to-change-that/. 01/serial-spinoff-series-production-company/.

24 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/19.241 n COMMENTARY Preinvisible: An Early-Career Perspective on a Midcareer Phenomenon

Chen He, MD1; Alyson J McGregor, MD, MA2; Resa E Lewiss, MD3 Perm J 2020;24:20.001 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.001

ABSTRACT had faced greater discrimination decades ago than I had. In this commentary, a female early-career academic physician And perhaps not enough time had passed for my larger reflects on her experiences with microinequities in the workplace. cohort of women physicians to take on these leadership Using a recent publication describing the experience of midcareer roles. After all, the opportunities seemed boundless in academic women physicians as a launching point, the author my first few years as an attending physician. ere were discusses the experiences that early-career women in medicine teaching fellowships and awards geared specifically for commonly have. In training and early career, women are exposed early-career physicians. Many departmental faculty sought to subtle barriers, aggressions, and inequities, which build over time. By midcareer, some women leave medicine or if they remain to engage me in research projects and medical school ed- fi in medicine, they have likely not reached the salary or promo- ucation initiatives. How surprised I was to nd that the tion levels of men. Ultimately, the author questions if trainees abundance of these opportunities would not sustain. I began and early-career women in academic medicine are simply in a to see that maybe the culture of academic medicine had “preinvisible” phase of their careers. Ways to address the micro- not changed. inequities are offered. e article by Lewiss et al introduced me to the concept of microinequities. Unlike macroinequities, which are blatant and observable, microinequities often stem from uncon- INTRODUCTION 9 I recently read an article by Lewiss et al1 titled “Is scious bias. Macroinequities, such as promotion and salary Academic Medicine Making Mid-Career Women Physi- disparities, are measurable and well documented. Micro- ”  inequities, on the other hand, are less frequently described cians Invisible? . e piece described a phenomenon where-  ffi by female midcareer academic physicians become invisible yet no less prevalent. ey are subtler, more di cult to because of various barriers, aggressions, and inequities. e measure, and unfortunately dismissed as the complaints of intentional support and professional attention that women oversensitive women. Yet they are real. And these micro- physicians may receive early in their careers wane as they disparities accumulate as women transition from training to advance to midcareer, making these women invisible. e early career to midcareer. article offered surprising insights into my own early-career What struck me as I read about these concepts was the applicability to my own experiences. inking back, I re- experiences. If midcareer is a time when some women realize fi that they have become invisible, perhaps I should evaluate called rsthand examples of microaggressions that led to my own trajectory. Am I on that path? Am I “preinvisible”? microinequities, and I was nowhere near midcareer. I realized that they start in training and early career. I realized In 2010, I graduated from medical school. At that time, “ ” women comprised 48.3% of allopathic medical school that I was in a preinvisible stage. graduates2 and just over 40% of residents and fellows in EXAMPLES OF MICROINEQUITIES emergency medicine programs accredited by the Accredi- See Me by My Title tation Council for Graduate Medical Education.3 At the I am an Asian American woman in my 30s. Every day, my time, some authors were positing that there were too many 4 patients assume that I am their nurse, even though I in- female medical graduates. Women seemed to be making “ ” progress, and concerns about gender inequities were not on troduce myself as Doctor. Once, a neighbor in my apart- my radar. ment building, seeing me in scrubs, asked if I was the home health aide for an elderly resident of the building. Patients But, in 2019, although women comprise greater than fi fi 75% of the health care workforce,5 they continue to face call me by my rst name (found on my identi cation card), disparities in compensation, promotion, and leadership. ey are less likely than men to hold the rank of associate or Author Affiliations 1 Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY full professor, despite adjustments for relevant contributing 2 Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI 6,7 factors. Perhaps more telling, women continue to receive 3 Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA less compensation than men for the same job.8 Still, I attrib- uted the glaring disparities in gender equity within lead- Corresponding Author Chen He, MD ([email protected]) ership positions to the fact that senior women physicians Keywords: early career, gender equity, invisibility, leadership, midcareer The Permanente Journal·https://doi.org/10.7812/TPP/20.001 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 25 COMMENTARY Preinvisible: An Early-Career Perspective on a Midcareer Phenomenon

even though I never introduce myself that way. Somehow later referenced, even if they are the same ones made by the the “MD” on the same card remains invisible. Meanwhile, female speaker or female faculty members. my male colleagues, who introduce themselves by their first Additionally, I have seen residents go to male attending names, have a contrasting experience. Patients naturally tag physicians for a “second opinion” about how to manage a “Doctor” onto their names without prompting. Some pa- patient they share with a woman attending. ere is almost tients comment on my youthful appearance, ask me my age, a reverence that medical students and residents hold for and question how long I have been a doctor. Other patients the words and opinions of my male colleagues. I rarely see comment about my nice accent (I am American; I grew up in this applied to female faculty members. It comes as no Oklahoma), ask if I’m Korean (no, Chinese), and question surprise, then, that men are far more visible when it comes whether I went to medical school in the United States to winning awards and accolades.11,12 (um—yes). To be clear: I am not offended by being identified as a nurse, called by my given name, complimented Let Jennifer Grow Up about my appearance, or asked about my heritage. My I also relate to the “Jennifer” phenomenon referenced frustration lies in the persistence of the biases that these in the article by Carnes and Bigby13 in 2007. e term was seemingly harmless inquiries bely. And I am not alone. originally coined in Barbara Gordon’s14 1988 book, Jennifer Esther Choo, MD, MPH,10 wrote about her experiences Fever: Older Men/Younger Women. Jennifer was the most with racial-ethnic and gender bias in a Twitter thread that popular girl’s name at that time, and Gordon used it to went viral.10 represent younger women who attracted the attention of Society is more interested in defining me (and other older men. e analogy to academic medicine is essentially women or individuals of color) by sex, age, and race than by where trainees and early-career women, or “Jennifers,” re- accomplishments and professions. If my patients do not see ceive more professional attention and development by their me as an academic physician, how can I expect my insti- more senior (and often male) superiors. tution to do so? ese are the microinequities that lead to ese opportunities all but disappear by midcareer. invisibility, and serve as daily reminders of how far little has Whereas my early career opportunities seemed abundant, changed for women. the path into midcareer is murkier. As a resident, I looked to many women attendings for inspiration and as role models. Follow the Woman Leader Now 6 years into being an emergency medicine attending, Another common experience: I bring a male medical I recognize the dearth of women in leadership roles ahead student with me to see a patient or to speak with a con- of me. Where do I see myself in 5 or 10 years? Am I to sulting physician. ere is an automatic assumption that my assume this is the pinnacle of my academic career? After all, medical student is the team leader. Patients direct their women represent only 22% of full professors, 18% of de- questions to the medical student, look at him when I am partment chairs, and 18% of medical school deans.15 No speaking, and even seek confirmation that he agrees with women have held presidential leadership positions among my plan of care. is often happens despite clear intro- 10 major medical specialty societies in the last decade.16 ductions and delineation of roles. It even happens after I tell I am reminded again of the often-referenced quotation by the patient that I am going to teach my student how to do a activist Marian Wright Edelman: “you can’t be what you basic medical examination, and then proceed to do so in an can’t see.” intentional way. It is as if knowledge and competence pale in comparison The Baby “Problem” to a woman’s sex. e assumption that men are in charge, When I recently became pregnant, I thought about how men are the team leaders, and men are the doctors is deeply this life change would affect my professional trajectory. ingrained in society. Although I do not anticipate being any less ambitious, wanting any less salary, or submitting promotion paper- Louder Is Not Better work in a delayed fashion, medicine may see me differently. As an emergency medicine attending and medical edu- I knew that having children has disproportionately nega- cator, I have noticed a disproportionate number of teaching tively affected the academic careers of women.17 awards and accolades bestowed to men. During our de- I recently reviewed the family leave policy benefits at my partment’s weekly residency conference, we often have large hospital system: paid maternity leave with conditions larger discussions that involve the faculty members in at- and fathers were given one paid day off. Women must file tendance. If something is debated, I notice that students for short-term disability before they are then asked to use and residents often listen to the male voices; they resonate vacation days they have earned for the year, to make up their more loudly. e points made by male faculty members are maternity leave. If women want any additional time, it is

26 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.001 COMMENTARY Preinvisible: An Early-Career Perspective on a Midcareer Phenomenon

considered unpaid leave. is is a rather antiquated policy in discriminatory practices. Pregnancy is not a disability. We light of the recently updated Goldman Sachs family leave should demand fair universal parental policies instead of policy, which allows 20 weeks of paid leave to all parents, making women feel guilty for their needs. e approach regardless of the parent’s sex or caregiver status.18 It is in- must be top-down, initiated at the level of the government credibly disheartening that Wall Street takes care of its or institution (eg, with Goldman Sachs), instead of reliant bankers better than hospitals take care of their doctors. A on colleagues to “pick up the slack.” e microinequities are woman who is required to use all of her vacation days to take real; they are not a figment of our minds. We need more care of her newborn, while her male colleagues are allowed men to step up, speak up, and serve as allies. We need more to take only one day off with pay, is at a disadvantage. Not women to be sponsored and selected to serve as chairpersons only is she inarguably being asked to delay her career tra- and deans. We need more objective and transparent ad- jectory compared with her male counterparts, she is also vancement criteria to promote the many qualified women to often seen as needing special accommodations. “She wants full professor. to work fewer nights.”“She’s not being flexible about the Although the examples given here are my own experi- lack of space for a lactation room.” ese are comments I ences, they are likely relatable to many early-career women have heard in reference to women physicians. physicians. As I look forward to midcareer, I see the in- e truth is that female physicians are more likely to bear visibility looming. I want to make it end. v high-risk pregnancies, undergo infertility therapy, and experience miscarriage during their reproductive years com- Disclosure Statement fl pared with the general female population.19 e risk of The author(s) have no con icts of interest to disclose. miscarriage increases for women physicians who work night 20  Acknowledgments shifts during pregnancy. e accommodations are not Kathleen Louden, ELS, of Louden Health Communications performed a primary special; they are merely humane. copyedit.

CONSEQUENCES OF GENDER INEQUITIES Authors’ Contributions Although initially just irksome, I have come to recognize Although this commentary is written from the perspective of Chen He, MD, “ ” Alyson J McGregor, MD, MA and Resa E Lewiss, MD contributed significantly to that these inequities are just the preinvisible and sentinel the concept, design and critical revision of this manuscript. events that lead to the midcareer invisibility about which 1 Lewiss et al wrote. e daily interactions of feeling dis- How to Cite this Article respected, of not being heard, and of not being seen worsen He C, McGregor AJ, Lewiss RE. Preinvisible: An early-career perspective on a feelings of “imposter syndrome,” in which a person doubts midcareer phenomenon. Perm J 2020;24:20.001. DOI: https://doi.org/10.7812/ TPP/20.001 her accomplishments and carries a persistent fear of being exposed as a “fraud.” Women already experience this psychological pattern more commonly than men. In a survey References 1. Lewiss RE, Silver JK, Bernstein CA, Mills AM, Overholser B, Spector ND. Is academic of 3000 adults in the United Kingdom, women were 18% medicine making mid-career women physicians invisible? J Womens Health 2020 Feb; more likely than their male counterparts to experience 29(2):187-92. DOI: https://doi.org/10.1089/jwh.2019.7732 2. Association of American Medical Colleges. Total enrollment by U.S. medical school and imposter syndrome, with two-thirds of women respondents sex, 2010-2011 through 2013-2014. Washington, DC: Association of American Medical having feelings consistent with the syndrome in the past Colleges; 2019 [cited 2020 Jul 7]. Available from: https://www.aamc.org/system/files/ 21  2019-11/2019_FACTS_Table_B-2.1.pdf 12 months. ese worsened feelings of imposter syn- 3. Center for Workforce Studies. 2012 physician specialty data book. Washington, drome cause women to take even less ownership over their DC: Association of American Medical Colleges; 2012 Nov; p 29 [cited 2020 Jul 7].  Available from: https://www.aamc.org/system/files/2019-08/ knowledge and accomplishments. e vicious cycle ulti- 2012physicianspecialtydatabook.pdf mately results in the perception that women are less con- 4. McKinstry B. Are there too many female medical graduates? Yes. BMJ 2008 Apr; fident and less suited to lead. And with few women role 336(7647):748. DOI: https://doi.org/10.1136/bmj.39505.491065.94 5. Day JC, Christnacht C. Women hold 76% of all health care jobs, gaining in higher-paying models in leadership, it is no surprise that women physicians occupations. Washington, DC: United States Census Bureau; 2019 Aug [cited 2020 Jul 13]. become disillusioned. Available from: https://www.census.gov/library/stories/2019/08/your-health-care-in- womens-hands.html#:~:text=Women%20Hold%2076%25%20of%20All,Gaining%20in% 20Higher%2DPaying%20Occupations&text=The%20number%20of%20full% ADDRESSING MICROINEQUITIES 2Dtime,Census%20Bureau’s%20American%20Community%20Survey 6. Carr PL, Raj A, Kaplan SE, Terrin N, Breeze JL, Freund KM. Gender differences in Am I at the preinvisible stage? Is early career merely a academic medicine. Acad Med 2018 Nov;93(11):1694-9. DOI: https://doi.org/10.1097/ preview and a prelude to the inevitable invisibility of mid- acm.0000000000002146  7. Bennett CL, Raja AS, Kapoor N, et al. Gender differences in faculty rank among academic career medicine? ere is no doubt that we can do better. emergency physicians in the United States. Acad Emerg Med 2019 Mar;26(3):281-5. We need more data, literature, and policy to change DOI: https://doi.org/10.1111/acem.13685 8. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public the culture and to improve the disparities for women in medical schools. JAMA Intern Med 2016 Sep;176(9):1294-304. DOI: https://doi.org/10. medicine. rough advocacy, we need to consciously fight 1001/jamainternmed.2016.3284

The Permanente Journal·https://doi.org/10.7812/TPP/20.001 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 27 COMMENTARY Preinvisible: An Early-Career Perspective on a Midcareer Phenomenon

9. Silver JK, Rowe M, Sinha MS, Molinares DM, Spector ND, Mukherjee D. Micro-inequities in 16. Silver JK, Ghalib R, Poorman JA, et al. Analysis of gender equity in leadership of medicine. PM&R 2018 Oct;10(10):1106-14. DOI: https://doi.org/10.1016/j.pmrj.2018.08.382 physician-focused medical specialty societies, 2008-2017. JAMA Intern Med 2019 Mar; 10. Choo E. We’ve got a lot of white nationalists in Oregon. So a few times a year, a patient in 179(3):433-5. DOI: https://doi.org/10.1001/jamainternmed.2018.5303 the ER refuses treatment from me because of my race. Twitter 2017 Aug 13 [cited 2020 17. Adesoye T, Mangurian C, Choo EK, Girgis C, Sabry-Elnaggar H, Linos E. Perceived Jul 7]. Available from: https://twitter.com/choo_ek/status/896850427408293888?lang=en discrimination experienced by physician mothers and desired workplace changes. JAMA 11. Krzyzaniak SM, Rowe M, Parsons M, Rocca N, Chan TM. What emergency medicine Intern Med 2017 Jul;177(7):1033-6. DOI: https://doi.org/10.1001/jamainternmed.2017. rewards: Is there implicit gender bias in national awards? Ann Emerg Med 2019 Dec; 1394 74(6):753-8. DOI: https://doi.org/10.1016/j.annemergmed.2019.04.022 18. Gross EL. Goldman Sachs has upped the ante for paid parental leave on Wall Street. 12. Abbuhl S, Bristol MN, Ashfaq H, et al. Examining faculty awards for gender equity and Forbes 2019 Nov 5 [cited 2020 Jul 7]. Available from: https://www.forbes.com/sites/ evolving values. J Gen Intern Med 2010 Jan;25(1):57-60. DOI: https://doi.org/10.1007/ elanagross/2019/11/05/goldman-sachs-has-upped-the-ante-for-paid-parental-leave-on- s11606-009-1092-8 wall-street/#333fa7d31ca2 13. Carnes M, Bigby J. Jennifer fever in academic medicine. J Womens Health 2007;16(3): 19. Gyorffy Z, Dweik D, Girasek E. Reproductive health and burn-out among female 299-301. DOI: https://doi.org/10.1089/jwh.2007.e072 physicians: Nationwide, representative study from Hungary. BMC Womens Health 2014 14. Gordon B. Jennifer fever: Older men/younger women. New York, NY: Harper & Row; Oct;14:121. DOI: https://doi.org/10.1186/1472-6874-14-121 1988. 20. Begtrup LM, Specht IO, Hammer PEC, et al. Night work and miscarriage: A Danish 15. Association of American Medical Colleges. The state of women in academic medicine. nationwide register-based cohort study. Occup Environ Med 2019;76(5):302-308. DOI: Washington, DC: Association of American Medical Colleges [cited 2020 Jul 13]. Available https://doi.org/10.1136/oemed-2018-105592 from: https://www.aamc.org/data-reports/data/2018-2019-state-women-academic- 21. Higginbottom K. Two-thirds of women in UK suffer from imposter syndrome at work. medicine-exploring-pathways-equity Forbes July 29, 2018.

28 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.001 n COMMENTARY Been There, Tried That, Learned This: Two Physicians’ Life-Care List for Colleagues

Linda Hawes Clever, MD, MACP1; Sharon Krejci Mowat, MD, FAAP2 Perm J 2020;24:20.027 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.027

INTRODUCTION consuming all my thoughts.” Conversations led to adjustments. We wish to provide philosophical foundations and prac- Her husband was happy to assume the responsibility of tical “life-care” guidelines for women—and men—physicians taking the children to the dentist, school transportation, so they and their families can lead whole, healthy lives, just and more. Suddenly, with just a couple of shifts, she had a as we hope for our patients. Frankly, when the opportunity smaller checklist to manage. at made a huge difference. came along to write this commentary, we grabbed it. Both of It was a perfect example of RENEW’s “fatigue prescrip- us have been fascinated by the world of health care and by tion”: “Awareness → Reflection → Conversation → Plan the brave and vulnerable clinicians who inhabit it. We have and Act.”3 spent years in that world, trying to figure out how our own 2. Take some big breaths. Breathe in for 4 counts, hold care of patients could be more pleasant, efficient, and ef- for 7, breathe out for 8 and do this 3 times. This will help fective. At the same time, we have been deeply involved settle your amygdala, that boiling area of your brain that with our communities outside of medicine. We also feel manages other “A” words such as anxiety and anger. You can strongly that, devoted as we are to our calling, we and those then focus on your personal values. Values that people list close to us should not suffer just because we practice the often include, for example, honesty, kindness, excellence, profession we love. hard work, faith, and family. Reconnecting with your own Everyone knows that our work and our lives interact. is values will help you set priorities about ways to spend your mix may be silky smooth; it sometimes feels more like a time. at is essential, because all you have is time, and time rolling catastrophe, however. Women are at special risk for is love. distress because of our many roles: professional, daughter, 3. Know that you are not alone. Seek out good company sister, family chief executive officer, friend, community to go beyond the “BMW” (Bitch, Moan, and Whine) volunteer, parent, and more. And what about ourselves? syndrome so you can develop strategies and solutions. Seek ere are no quick fixes, of course, to the sometimes out like-minded friends to lift and inspire you. It takes allies baneful complexities of caring for patients as well as our to contend with the gender bias, microaggressions, and home and personal lives plus community responsibilities. sexual harassment that still affect us all as female physicians. is is especially true now and whenever we see that our Being a female physician can bring daily stresses: patients environment may be beyond our control. Nonetheless, if we wanting to see the “doctor” when you are standing right want to have professional and personal fulfillment, we need there; others (men) taking credit for your (women’s) ideas; to set actionable goals and move forward. not reaching for a new opportunity because you think you Before we started to write this commentary, we reflected have a lack of experience or skills. Working together with on references,1 resources,2 conversations, and our own val- your allies, you can a make a positive difference. ues and experience. We asked others for their suggestions. 4. Get help! Whether you need counseling, child care, or We wanted to stretch beyond “satisfaction.” We hope that a hand with an older parent or housekeeping, spend some our list of 14 suggestions both support and lift your life and money and get that help. Your time is better spent with that adopting some of them will change it for the better. family, your partner, or yourself instead of doing laundry, unless laundry gives you true, boundless joy, and not just the THE LIST feeling that your mother would approve. 1. Put yourself first. Make time for yourself. It is not 5. Meet your leaders. Get your leader’s ear by going selfish to take care of yourself. It is self-preservation, so beyond complaints. Have some ideas about ways to solve you can do what you want to do and what you need to do. Reflect on your hopes, dreams, circumstances, and resources. A leader we know hesitated to take on additional Author Affiliations 1 Department of Medicine, California Pacific Medical Center, San Francisco, CA professional responsibilities even though her spouse and 2 Department of Pediatric Hospital Medicine and Physician in Chief, The Permanente Medical Group, Diablo children supported her doing so. She finally realized that Service Area, Kaiser Permanente Medical Center, Antioch, CA managing everything all the time was exhausting her. Work, home, and parenting were always on her mind no matter Corresponding Author Linda Hawes Clever, MD, MACP ([email protected]) where she was. “It was the constant follow-up that was Keywords: guide, health, physician, women The Permanente Journal·https://doi.org/10.7812/TPP/20.027 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 the Author(s). Published by PNAS. 29 COMMENTARY Been There, Tried That, Learned This: Two Physicians’ Life-Care List for Colleagues

challenges. Be a partner in improving policies and work- usually dwell only on what is wrong or deficient. We, flows. Follow your passion and let your leaders help and therefore, actually need to campaign against our dark side mentor you. Don’t be afraid to network with people. It is to become continuously improving beings. We can move important for others to know what interests you have and ahead—as long as we work together, accentuate the posi- where your passion lies. tive, and do not get stuck trying to make every outcome 6. Do your own checkup.4 Women can be woefully perfect. neglectful when it comes to our own health. Have you had 10. What’s good for physicians and their families is your screening tests? Your annual flu shots? And shingles good for patients and their families and vice versa. If shots, if you’re the right age? In addition to these “body” you do something smart and healthy, this will carry over to checks, do a “sense of humor” check (only if you have—or your patients. If your patients are thriving, so can you. Being had—one, of course). A sense of humor can get you through smart and healthy may mean being organized at work and at a great deal. Viktor Frankl, a psychiatrist who survived the home. Try different methods—apps, paper calendar books, Holocaust when his whole family was killed, wrote Man’s alarm clocks, and so on—and use what works for you. Search for Meaning.5 He led “sense of humor” workshops Another good practice is decluttering. Decluttering at home in the death camps and observed that if you can laugh at and work can declutter your mind and make you more something, it changes everything. It lifts you out of the effective and fulfilled wherever you are. muck. e loss of a sense of humor means the loss of a major 11. Keep on learning. Do this in your professional and defense mechanism and is a sign of trouble. Pay attention to personal lives. What continuing medical education course the results of your entire checkup, including your laughs, will you take? What new friend or cookie recipe will you and follow up on your findings (see item 4). make? What will you do to confront professional, personal, 7. Attitude counts and shows. Viktor Frankl5 also and civic challenges, such as bias? Engage in work, life, pointed out that your attitude is a choice. Indeed, he said relationships, and continual learning to enhance your that choosing your attitude is the last human freedom. at brain’s plasticity and vitality so it doesn’t dwell on gloom and means you can choose to be a victim—or the opposite. You offenses. More importantly, being involved and engaged can choose to approach family and work with compassion, will reinvigorate your purpose in your career and your life. empathy, and curiosity. is puts you in a forward-moving 12. Nurses and other health care professionals can be state and emphasizes what you can contribute and grow, your new best friends. These clinicians may know more rather than shrink, shrivel, and resent. about particular patients than you do, because they usually 8. Do something you love. One always busy, hard- spend more time with them. They are teachers, advocates, pressing woman physician said her husband and child and care coordinators. They may know techniques that can pointed out that she never did anything fun. She said, “My supplement yours, such as massage, acupuncture, aroma- husband has music; my daughter has theater. What did I do? I therapy. We all know that taking good care of patients— really had to explore what was fun for me. I am still exploring, and ourselves—is a team game, not solitaire. but I have done horseback riding, thus making exercising more 13. Be professional. We all profess—take an oath—to act fun vs a chore. I also added nights out with friends and made it appropriately. Part of this means that we must take care of a priority [before COVID-19’s shelter in place]. Just the each other as well as ourselves. at requires being aware, process made me generally happier and not so resentful.” If you noticing when trouble looms, and then intervening. We are love being with others, what might you do if you cannot get on the front lines of primum non nocere for ourselves, our together in person? Try a video chat platform such as Skype, colleagues, our families, patients, and more. FaceTime, or Zoom. Read a book (not work-related) and 14. Know that you do have the answers. Developing the chat online to review it. Sort pictures and make a family answers and solutions will take pausing, looking around, album once you’ve joined forces to figure out who’s who. finding allies, listening and learning, holding conversations Get out into nature. When you can bring family and friends (not just texting and posting), experimenting (remember along, laughter, activity, and community come together for that having no errors means you didn’t try), polishing, and a memorable experience. then, yes, celebrating success. 9. ink appreciative inquiry.6 is approach to building an effective workplace can also be used at home. It CONCLUSION posits that if an organization, clinic, or classroom is doing As you consider these life-care guidelines, consider your well, that means at least some procedures, equipment, and own situation. What would you add to the list? What would people must be doing well. Look for what is succeeding you remove? What are your values and your dear ones’ and then emphasize, copy, and expand them. is is not values? How will you define success? What will you do that intuitive since our reptilian-like, negatively biased brains is new, renewing, refreshing? What will you do first? What

30 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 the Author(s). Published by PNAS. The Permanente Journal·https://doi.org/10.7812/TPP/20.027 COMMENTARY Been There, Tried That, Learned This: Two Physicians’ Life-Care List for Colleagues

will you do next? How will you reward yourself? You do How to Cite this Article deserve a reward, you know. e best reward is your own Clever LH, Mowat SK. Been there, tried that, learned this: Two physicians’ life-care good health. You have chosen a noble profession, and you list for colleagues. Perm J 2020;24:20.027. DOI: https://doi.org/10.7812/TPP/ must care for yourself so you can be there for your patients 20.027 and communities, as well as for the family and friends about v whom you also care. References 1. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout Disclosure Statement issues facing women physicians [Internet]. NAM Perspectives 2019 May 30. The author(s) have no conflicts of interest to disclose. DOI: https://doi.org/10.31478/201905a 2. National Academy of Medicine. National Academy of Medicine clinician resilience resources [Internet]. Washington, DC; National Academy of Acknowledgments Medicine [cited 2020 Jan 29]. Available from: https://nam.edu/search-results/? The authors thank Eliza Lo Chin, MD, MPH, Executive Director of the American keywords=NAM+Action+Collaborative+on+Clinician+Well-Being+and+ Women’s Medical Association for her ideas, review, and encouragement. Resilience&searchpage=0 Kathleen Louden, ELS, of Louden Health Communications performed a primary 3. Clever LH. The fatigue prescription: Four steps to renewing your energy, health and life. copyedit. Berkeley, CA: Viva Editions; 2010:65-81. 4. Renew-O-Meter [Internet]. Portola Valley, CA: RENEW [cited 2020 Jul 22]. ’ Available from: https://renewnow.org/r-o-m/ Authors Contributions 5. Frankl VE. Man’s search for meaning. New York, NY: Simon & Schuster; 1984. Linda Hawes Clever, MD, MACP, and Sharon Krejci Mowat, MD, FAAP, 6. Cooperrider DL Jr, Sorenson PF, Yaeger TF, Whitney D, eds. Appreciative participated in the drafting and submission of the final manuscript. Both authors inquiry: Foundations in positive organization development. Chicago, IL: Stipes have given final approval to the manuscript. Publishing; 2005.

The Permanente Journal·https://doi.org/10.7812/TPP/20.027 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 the Author(s). Published by PNAS. 31 n ORIGINAL RESEARCH ARTICLE Assessment of Burnout: A Pilot Study of International Women Physicians

Farzanna S Hafﬁzulla, MD, FACP, FAMWA1,2; Connie Newman, MD, FACP, FAHA, FAMWA3; Shivani Kaushal, BS2; Caitlin A Williams, MS2; Anisa Hafﬁzulla4; Patrick Hardigan, PhD2; Kim Templeton, MD, FAAOS, FAOA, FAMWA5 Perm J 2020;24:20.028 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.028

ABSTRACT Numerous studies have established the presence of burnout Introduction: Physician burnout, wellness, and resilience have worldwide and in various individual countries. However, become increasingly important topics of discussion worldwide. most studies evaluate burnout among physicians in high- While studies have assessed burnout globally in various individual income countries, with much less data regarding those in countries, few studies directly compare or analyze gender-based developing countries, and there are few existing studies ff physician burnout among di erent global regions. directly comparing physician burnout rates among different Methods: Female physicians attending the Medical Women’s countries or regions.1 International Association (MWIA) Centennial Congress completed the Copenhagen Burnout Inventory (CBI) which evaluates Burnout results from constant overtaxing that reduces the personal-, work-, and patient-related burnout using a scale of 0 to ability to meet physical or psychological demands at work or  100. Results were analyzed using descriptive statistics and 1-way home. e most common instrument used to assess burnout ANOVA to compare burnout scores amongst women physicians is the Maslach Burnout Inventory (MBI), which evaluates 3 from different global regions. domains: emotional exhaustion (EE), depersonalization, and Results: Of 100 physicians invited to participate, 76 provided sense of lack of accomplishment.2 Other measures of burn- responses and 71 met the inclusion criteria. Mean burnout scores out include shortened versions of the MBI, the Copenhagen were highest amongst women from Africa in all categories. Mean Burnout Inventory (CBI), and the Oldenburg Burnout work-related, patient-related, and personal-related burnout scores Inventory.3 Although most studies have used the MBI or fi were signi cantly lower for physicians in Europe compared to a shortened version, the MBI has been criticized because it Africa (p = 0.05) when evaluated using a 1-way ANOVA, with no does not distinguish between nonpatient-focused work, and statistically significant differences between other regions. patient-focused work.4 Discussion: The data suggests that there may be regional fi differences in the prevalence of burnout in women physicians. Burnout is more common in the health care eld than Various factors could play a role in explaining the higher burnout it is in other professions, noted among medical students, 5 scores in female physicians in Africa, including younger average residents, and practicing physicians. Internationally, almost age, establishing practice during childbearing years, and signif- half of physicians have reported symptoms of burnout icant physician shortage. Through this study, we have begun to sometime in their career.6 Sex-based differences in preva- explore the cultural and geographical context related to women’s lence of burnout have been reported in some studies, with mental and physical wellbeing in the medical field. Further re- women often noted to be more affected than men.7 e fi search should focus on the gender-speci c contributors to coronavirus disease 2019 (COVID-19) pandemic may ex- ff burnout among di erent global regions, so that methods can be acerbate this problem because women comprise a greater implemented on a systemic level to alleviate burnout. proportion of essential health care workers and are likely providing even more child care than usual.8 INTRODUCTION Resilience, which represents the ability to “bounce back,” Physician burnout, wellness, and resilience have become adapt, or recover from difficult circumstances is a trait increasingly important topics of discussion worldwide. that may help physicians prevent or overcome symptoms of burnout. Resilience can be measured by a variety of methods.9 A survey assessing resilience and burnout among US physicians found an inverse association between resil- Author Affiliations 1 Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL ience and burnout symptoms but also found substantial 2 Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, FL burnout rates even among physicians with the greatest 3 New York University Robert I. Grossman School of Medicine, New York, NY resilience, indicating that physician resilience alone does 4 American Heritage School, Plantation, FL 5 University of Kansas Medical Center, Kansas City, KS not prevent burnout. In addition, moral distress or injury is being increasingly identified as a major contributor to Corresponding Author burnout symptoms, especially for physicians working in Farzanna S Haffizulla, MD, FACP, FAMWA (fhaffi[email protected]) areas with limited resources or in which previously ade- ffi Keywords: burnout, Copenhagen burnout index, gender, global health, international, medical, physician, quate resources are no longer su cient, such as during a women 32 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.028 ORIGINAL RESEARCH ARTICLE Assessment of Burnout: A Pilot Study of International Women Physicians

pandemic.10 Interventions hypothesized to improve resil- of the commonly used MBI, which may be due to its fun- ience and well-being include psychosocial skills training, damental construct.4 Although systematic reviews have been stress management training, discussion groups, and edu- performed to assess existing research on burnout among cation in mindfulness and/or communication. However, physicians from various countries, these reviews used mul- evidence for long-term effectiveness of these methods in tiple burnout inventories and did not investigate differences, physicians after training is limited and does not effectively such as sex-based cross-cultural burnout data, among phy- address the underlying causes of burnout.11 sicians from different countries. Factors associated with burnout in the US include youn- No known prior original research studies have addressed ger age, work-home conflict, female sex, excessive work, international differences in burnout risk factors and prev- low level of autonomy, and lack of support at work.12 alence among female physicians. Given the impact of Burnout also varies by specialty. Higher risks of burnout burnout, the increasing number of women in medicine, and in resident physicians in the US were associated with train- the different systems and societies in which they work, it ing in urology, neurology, emergency medicine, and general is important to identify region-specific prevalence and risk surgery.13 Physician burnout is a worldwide phenomenon. factors and to seek methods to strengthen resilience and In a comprehensive review of 182 studies of physician burn- well-being. e objective of this pilot study was to obtain out in 45 countries, the estimated prevalence of burnout, preliminary data regarding burnout in women physicians assessed using the MBI in most studies, was 72%.4 One attending an international meeting and examine the data by meta-analysis that correlated physician burnout across re- global region to identify areas for additional research. gions worldwide noted that EE was negatively associated with autonomy, positive work attitudes, and quality and METHODS safety culture. Emotional exhaustion was positively asso- All physicians attending the “Work-Life Balance/ ciated with constrained organizational structure, conflicts/ Preventing Burnout” session at the Medical Women’s incivility/violence, and contributors to poor mental health.14 International Association (MWIA) Centennial Congress is same analysis pointed out that physicians in the (in New York City in July 2019) were invited in person Americas experienced higher EE when work-life conflict to complete the CBI. e CBI was chosen to assess burn- was strong and coping strategies were ineffective. European out because of the limitations of the MBI, discussed physicians experienced lower EE when they had positive previously. Inclusion criteria included a terminal medical work attitudes. In fact, a culture of quality and safety, career degree (MD, DO, or international equivalent); active work development opportunities, and problem-focused coping cor- in health care or academia; female and aged 18 years or related with decreased EE in physicians in the Americas.14 older; and ability to read, understand, and speak English. Most prior studies have focused on burnout among phy- Retired physicians and medical/premedical students were sicians in high-income countries, with much less data re- excluded. garding those in developing countries.1 In addition, many of Women physicians who met the inclusion criteria were these studies have not disaggregated data by sex and thus asked to complete an anonymous hard-copy survey about cannot provide a sex-based analysis of global burnout, as- their demographics as well as the CBI. is inventory eval- sociated risk factors, and effective prevention and/or coping uates personal-, work-, and patient-related (related to one’s strategies. Although studies of burnout specifically in women work with patients) burnout using a scale of 0 to 100. physicians are rare, there are a few studies that highlight Results were analyzed using descriptive statistics and 1-way the scope of burnout in women globally. One study of ANOVA. is study was approved by the institutional 2414 women physicians in Hungary, using the MBI, found review board at Nova Southeastern University, Fort Lau- moderate to severe levels of EE in 51%, sense of lack of derdale, Florida. personal accomplishment in 68%, and depersonalization in 38%.15 A study of 1345 physicians (62.5% women) in RESULTS Portugal, using the CBI, found scores of 48.6 and 42.5 for Of the 100 physicians invited to participate, 76 (76%) pro- personal-related and work-related burnout, respectively, and vided responses, and 71 met the inclusion criteria. Because 24.1 for patient-related burnout.16,17 In the CBI, a score of only 1 participant was from South America, her data were 50% indicates the response “sometimes or somewhat” to the not included in the analysis. Demographic data and mean question. burnout scores related to work, patients, and personal life Rotenstein et al,4 in their systematic review on physician are shown in Tables 1 and 2. burnout, uncovered marked global variability in prevalence Mean work-related, patient-related, and personal burn- estimates, burnout definitions, and assessment methods. out scores were significantly lower for physicians in Europe Moreover, this comprehensive review affirmed limitations compared with Africa (p = 0.05) when evaluated using a

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Table 1. Demographics for study participants and years after medical schoola Geographic region Characteristic Total Africa Asia Australia Europe North America Number (%) 70 (100) 22 (31.0) 5 (7.0) 3 (4.2) 14 (19.7) 26 (36.6) Mean age (range), y 54 (22-89) 46.48 63.00 62.33 57.43 56.12 Years after medical school, percent of participants < 10 14 14 20 0 14 15 10-20 28 55 0 0 14 23 > 20 58 32 80 100 71 62 a Totals may not equal 100% because of rounding.

affect development of burnout in this area.1 Pentecost and Table 2. Mean burnout scores by geographical region in 70 19 women physicians Cousins describe the distressing socioeconomic conditions and the competing demands of doctors in Africa and suggest Mean burnout score (SD)a using the framework of endurance as opposed to resilience. Number Work- Patient- Personal- ff Region (% of total) related related related According to the authors, endurance invites a di erent Africa 22 (31.0) 45 (24.5) 39 (25.0) 51 (22.0) relationship of the self and takes into account social and ff Asia 5 (7.0) 26 (24.0) 32 (17.0) 35 (20.5) historical factors. Despite regional di erences, an endurance framework is relevant to clinical context globally.19 Australia 3 (4.2) 45 (15.5) 31 (14.0) 50 (23.0) fi Europe 14 (19.7) 25 (11.0) 18 (9.2) 32 (11.5) Our ndings of lower burnout levels in older, female, European participants align with data from the European North America 26 (36.6) 41 (22.0) 30 (23.5) 47 (19.0) a General Practice Research Network Burnout Study Group Score of ≥ 50 on the Copenhagen Burnout Inventory indicates a high level of burnout.  SD = standard deviation. showing that older female doctors had less burnout. is study found that job satisfaction, country of residence in Europe, substance abuse disorder, male sex, and younger 1-way ANOVA. No other significant differences between age were strongly associated with burnout.20 regions were identified. A possible explanation of the differences in burnout seen for women in Europe compared with Africa and the US DISCUSSION may be that local health care systems across regions have In this pilot study, patient-related, personal, and work- varying cultural expectations and policies for a women’s role related burnout scores for women physicians were highest in as a caretaker and for accommodating women’s roles out- those practicing in Africa and were lowest in Europe. Scores side medicine.21-24 Expectations of the woman as primary for women physicians in North America were also lower caretaker for the family may play a role by creating a con- compared with Africa. ese data suggest that regional flict between work and the home.21-24 In contrast to some differences in the prevalence of burnout in women doctors European cultures, in African cultures, the woman is ex- may exist. pected to care for children and for aging or ill family High scores of burnout among physicians from Africa, members. Caregivers of Asian and Hispanic heritage have particularly in the personal burnout domain, could reflect also described strong cultural prescriptions for women to younger average age, attempt to establish practice during have a caregiving role in their families, whereas those of childbearing years, or substantial physician shortage. ese European heritage face somewhat different cultural expec- findings are consistent with those from a 2019 systematic tations.25 ese can be broad generalizations, however, review of physician burnout in Sub-Saharan Africa.1 Up to because some countries in Europe provide varying lengths 80% of physicians in the included African countries re- of mandatory and nonmandatory maternity leave for ported burnout, and many of the studies found differences physicians, but other countries, including the US, do not in prevalence based on sex.1 edifferences found in the have specific policies.26 Physician mothers in the US have present study may be explained by varying work environ- noted insufficient time off after childbirth and limitations in ments and resources in these regions. African countries, for necessary accommodations and support after returning to example, make up the majority of countries with health work.27 e impact of these factors requires further study to worker shortages reported by the World Health Organi- determine if implementing policies that increase maternity zation.18 Workload, lack of institutional support, and in- leave and support mothers after they return to work would terpersonal and professional conflicts have been found to affect the risk of burnout. In addition, women’s expected

34 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.028 ORIGINAL RESEARCH ARTICLE Assessment of Burnout: A Pilot Study of International Women Physicians

caretaking roles are lifelong.28 Further studies should focus considerably to physician burnout, whereas value congruence on how cultural expectations of women to provide career and a focus on humanism substantially predicts professional long family support have an impact on patient care and efficacy in addition to the well-being of physicians.41-43 physician well-being across countries, with an emphasis on In addition, given the inconsistent relationship between the role of career long family leave. resilience and burnout, the focus on improving rates of Differing compensation models in various countries may burnout must be on institutional and societal change, rather also affect the risk of burnout. Models that focus on pro- than individual interventions for physicians. ductivity have been identified as risk factors for burnout On the basis of the observations from this initial pilot in men and women, with higher risk of burnout among study, further research could address the causes and se- physicians who are compensated and valued on the basis of verity of burnout in women physicians by geographical the number of patients seen or procedures performed.29 e region. Specifically, research should evaluate the impact impact of various compensation models on risks of burnout of physician-underrepresented minority status (race and and their impact on addressing student debt also needs lesbian, gay, bisexual, transgender, and queer) and the re- investigation and analysis by sex because medical school lationship of burnout to factors such as age, cultural ex- costs vary by country, with some countries having medical pectations, years of practice, clinical specialty, hospital or schools that are free of charge.30,31 outpatient practice, hours worked, caretaking, and other Patient-related burnout scores in our pilot study were gendered responsibilities at home. Other areas of potential lowest among the CBI categories in all regions except Asia. investigation include the relationship of resilience and en- e predominance of low patient-related burnout is con- durance to burnout, physician-patient dynamics, the impact sistent with many international studies of CBI-assessed of humanism on burnout and well-being, differences in burnout in Africa, Asia, and North America and the main- international health care systems, and the effects of the tenance of feelings of professional accomplishment among COVID-19 pandemic. physicians despite other indicators of burnout.32-38 is finding can be used to reimagine health care delivery and CONCLUSION restructure health care systems to return the emphasis to the Given the increasing number of women in medicine, patient-physician interaction, rather than clerical and work- global physician shortages, and the impact of burnout on force concerns, in order to reduce burnout and promote physician wellness and patient care, solutions tailored to physician well-being. geographical region and culture must be developed to re- Limitations of this pilot study include the small sample duce physician burnout. e international dialogue must size and the selected population. Because this investigation be continued to assess strategies that have been successful was intended as a pilot study, no conclusions can be drawn in various countries, and methods must be tailored to regarding prevalence or causes of burnout. In fact, a sys- implement them within the health care system in each area tematic comparison was not possible especially given the of the globe. v heterogeneity of data available and complexity surrounding burnout globally. However, the results identify some dif- Disclosure Statement fl ferences around the world and point to the need for further The author(s) have no con icts of interest to disclose. research in a larger population of women doctors. Acknowledgments As with any public health issue, we must take a preventive We are grateful for the support of MWIA President Eleanor Nwadinobi MBBS, approach to burnout. We must focus on change in orga- EMA, FAAC and Prof Gabrielle Casper, BSc (Hons) MBBS FRANZCOG who nizational structure/process, ensure adequate health care served as co-chairs with Farzanna Haffizulla, MD, FACP, FAMWA, at the session “ ” resources, return some degree of practice autonomy to titled Work-Life Balance/Preventing Burnout held at the MWIA Centennial Congress in New York, New York, in July 2019. In addition, American Medical physicians, tailor professional development programs that Women’s Association (AMWA) Executive Director Eliza Chin, MD, MPH, and align with individual physicians’ needs and practice envi- Nitisha Mehta, a medical student from the University of South Florida and a student ronment, and eliminate bias and harassment, along with member of AMWA, contributed during the writing of this report. We are also deeply ff grateful to Malekha Mohamed for her dedicated support throughout this research e orts at building resilience and encouraging stress reduc- process. tion, mindfulness-based strategies, and health-promoting Kathleen Louden, ELS, of Louden Health Communications performed a primary behaviors.39 copyedit. Health care professionals’ stress and burnout interfere with therapeutic relationships, detract from the patient Authors’ Contributions Farzanna S. Haffizulla, MD, FACP, FAMWA, served as principal investigator for experience and quality of care, and risk increased attrition this study and participated in every aspect of the study and manuscript preparation 40 from the physician workforce. Incongruence between per- inclusive of study design, data collection, data analysis, critical review, drafting and sonal and health system values and work overload contribute editing of the manuscript, and submission of the final manuscript. Connie B.

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Newman, MD, FACP, FAHA, FAMWA, participated in study design, data analysis, 19. Pentecost M, Cousins T. ‘The Good Doctor’: The Making and unmaking of the physician critical review, and drafting and editing of the final manuscript. Shivani A. Kaushal self in contemporary South Africa. J Med Humanit 2019 Aug 5-10. DOI: https://doi.org/ participated in data analysis and review and editing of the final manuscript. Caitlin 10.1007/s10912-019-09572-y A. Williams, MS, participated in data analysis and review and editing of the final 20. Soler JK, Yaman H, Esteva M, et al. Burnout in European family doctors: The EGPRN fi study. Fam Pract 2008 Aug;25(4):245-65. DOI: https://doi.org/10.1093/fampra/cmn038 manuscript. Anisa S. Haf zulla participated in the overall study and survey design, 21. Jang S-N, Avendano M, Kawachi I. Informal caregiving patterns in Korea and European data analysis, critical review, and drafting and editing of the final manuscript. Patrick countries: A cross-national comparison. Asian Nurs Res 2012 Mar;6(1):19-26. DOI: Hardigan, PhD, participated in data analysis and review and editing of the final https://doi.org/10.1016/j.anr.2012.02.002 manuscript. Kim Templeton, MD, FAAOS, FAOA, FAMWA, participated in study 22. Jefferson L, Bloor K, Maynard A. Women in medicine: historical perspectives and recent design, data analysis, critical review, and drafting and editing of the final trends. Br Med Bull 2015 Jun;114(1):5-15. DOI: https://doi.org/10.1093/bmb/ldv007 manuscript. All authors have given final approval to the manuscript. 23. Treas J, Lui J. Studying housework across nations. J Fam Theory Rev 2013 Jun;5(2): 135-49. DOI: https://doi.org/10.1111/jftr.12006 24. Asiedu EEA, Annor F, Amponsah-Tawiah K, Dartey-Baah K. Juggling family and How to Cite this Article professional caring: Role demands, work-family conflict and burnout among registered Haffizulla FS, Newman C, Kaushal S, Williams CA, Haffizulla A, Hardigan P, nurses in Ghana. Nurs Open 2018 Jul;5(4):611-20. DOI: https://doi.org/10.1002/nop2.178 Templeton K. Assessment of burnout: A pilot study of international women 25. Pharr JR, Francis CD, Terry CC, Clark MC. Culture, caregiving, and health: Exploring the fl physicians. Perm J 2020;24:20.028. DOI: https://doi.org/10.7812/TPP/20.028 in uence of culture on family caregiver experiences. ISRN Public Health. 2014. DOI: https://doi.org/10.1155/2014/689826 26. Strang L, Broeks M. Maternity leave policies: Trade-offs between labour market demands and health benefits for children. Santa Monica, CA: RAND Corporation; 2016. References 27. Juengst SB, Royston A, Huang I, Wright B. Family leave and return-to-work experiences 1. Dubale BW, Friedman LE, Chemali Z, et al. Systematic review of burnout among of physician mothers. JAMA Netw Open 2019;2(10):e1913054. DOI: https://doi.org/ healthcare providers in sub-Saharan Africa. BMC Public Health 2019 Sep;19(1):1247. 10.1001/jamanetworkopen.2019.13054 DOI: https://doi.org/10.1186/s12889-019-7566-7 28. Templeton K, Nilsen KM, Walling A. Issues faced by senior women physicians: A national 2. Maslach C, Jackson SE. The measurement of experienced burnout. J Organiz Behav survey. J Womens Health 2020 Jul;29(7):980-8. DOI: https://doi.org/10.1089/ 1981 Apr;2(2):99-113. DOI: https://doi.org/10.1002/job.4030020205 jwh.2019.7910 3. National Academy of Medicine. Valid and reliable survey instruments to measure burnout, 29. Dillon EC, Tai-Seale M, Meehan A, et al. Frontline perspectives on physician burnout and well-being, and other work-related dimensions [Internet]. Washington, DC: National strategies to improve well-being: Interviews with physicians and health system leaders. J Academy of Medicine [cited 2020 Jul 26]. Available from: https://nam.edu/valid-reliable- Gen Intern Med 2020 Jan;35(1):261-7. DOI: https://doi.org/10.1007/s11606-019-05381-0 survey-instruments-measure-burnout-well-work-related-dimensions/ 30. Wolff EN, Baumol WJ, Saini AN. A comparative analysis of education costs and 4. Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians. outcomes: The United States vs. other OECD countries. Econ Educ Rev 2014 Apr;39: JAMA 2018 Sep;320(11):1131-50. DOI: https://doi.org/10.1001/jama.2018.12777 1-21. DOI: https://doi.org/10.1016/j.econedurev.2013.12.002 5. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance 31. Zavlin DT, Jubbal KG, Noé J, Gansbacher B. A comparison of medical education in among US physicians relative to the general US population. Arch Intern Med 2012 Oct; Germany and the United States: From applying to medical school to the beginnings of 172(18):1377-85. DOI: https://doi.org/10.1001/archinternmed.2012.3199 residency. Ger Med Sci 2017 Sep;15:Doc15. DOI: https://doi.org/10.3205/000256 6. West C. Physician burnout & work-life balance. Physician’s Weekly 2013. 32. Stassen W, Nugteren BV, Stein C. Burnout among advanced life support paramedics in 7. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: Issues Johannesburg, South Africa. Emerg Med J 2013 Apr;30(4):331-4. DOI: https://doi.org/ faced by women physicians. NAM Perspectives 2019 May. DOI: https://doi.org/10.31478/ 10.1136/emermed-2011-200920 201905a 33. Stein C, Sibanda T. Burnout among paramedic students at a university in Johannesburg, 8. Guille DP, Jena AB. Sex differences in time spent on household activities and care of South Africa. Afr J Health Prof Educ 2016 Sep;8(2):193. DOI: https://doi.org/10.7196/ children among US physicians, 2003-2016. Mayo Clin Proc 2018 Oct;93(10):1484-7. DOI: ajhpe.2016.v8i2.626 https://doi.org/10.1016/j.mayocp.2018.02.018 34. Fernando BMS, Samaranayake DL. Burnout among postgraduate doctors in Colombo: 9. Connor KM, Davidson JRT. Development of a new resilience scale: The Connor-Davidson Prevalence, associated factors and association with self-reported patient care. BMC Med Resilience Scale (CD-RISC). Depress Anxiety 2003 Sep;18(2):76-82. DOI: https://doi.org/ Educ 2019 Dec;19(1):1-4. DOI: https://doi.org/10.1186/s12909-019-1810-9 10.1002/da.10113 35. Chou L-P, Li C-Y, Hu SC. Job stress and burnout in hospital employees: Comparisons of 10. West CP, Dyrbye LN, Sinsky C, et al. Resilience and burnout among physicians and the different medical professions in a regional hospital in Taiwan. BMJ Open 2014 Feb;4(2): general US working population. JAMA Netw Open 2020 Jun;3(7):e209385. DOI: https:// e004185. DOI: https://doi.org/10.1136/bmjopen-2013-004185 doi.org/10.1001/jamanetworkopen.2020.9385 36. Jacobs LM, Nawaz MK, Hood JL, Bae S. Burnout among workers in a pediatric health 11. Venegas CL, Nkangu MN, Duffy MC, Fergusson DA, Spilg EG. Correction: care system. Workplace Health Saf 2012 Aug;60(8):335-44. DOI: https://doi.org/10.1177/ Interventions to improve resilience in physicians who have completed training: A 216507991206000803 systematic review. PloS One 2019 Jan;14(1):e0210512. DOI: https://doi.org/10.1371/ 37. Wright JG, Khetani N, Stephens D. Burnout among faculty physicians in an academic journal.pone.0214782 health science centre. Paediatr Child Health 2011 Aug;16(7):409-13. DOI: https://doi.org/ 12. West CP, Dyrbye LN, Shanafelt TD. Physician burnout: Contributors, consequences and 10.1093/pch/16.7.409 solutions. J Intern Med 2018 Jun;283(6):516-29. DOI: https://doi.org/10.1111/joim.12752 38. Walters JE, Brown AR, Jones AE. Use of the Copenhagen Burnout Inventory with social 13. Herrin J, Dyrbye LN. Notice of retraction and replacement. Dyrbye et al. Association of workers: A confirmatory factor analysis. Hum Serv Organ Manag Leadersh Gov 2018 Oct; clinical specialty with symptoms of burnout and career choice regret among US resident 42(5):437-56. DOI: https://doi.org/10.1080/23303131.2018.1532371 physicians. JAMA. 2018;320(11):1114-1130. JAMA 2019 Mar;321(12):1220-1. DOI: 39. Kumar S. Burnout and doctors: Prevalence, prevention and intervention. Healthcare https://doi.org/10.1001/jama.2019.0167 (Basel) 2016 Jun;4(3):37. DOI: https://doi.org/10.3390/healthcare4030037 14. Lee RT, Seo B, Hladkyj S, Lovell BL, Schwartzmann L. Correlates of physician burnout 40. Montgomery A, Panagopoulou E. Improving quality and safety in the hospital: across regions and specialties: A meta-analysis. Hum Resour Health 2013 Sep;11:48. Organizational culture, burnout, and quality of care. PsycEXTRA Dataset 2013 Sep;18(3): DOI: https://doi.org/10.1186/1478-4491-11-48 656-62. DOI: https://doi.org/10.1037/e589922013-001 15. Gy}orffy Z, Dweik D, Girasek E. 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Advances in patient safety from research to implementation. Vol 17. Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen Burnout 3, Implementation issues. Rockville, MD: Agency for Healthcare Research and Quality Inventory: A new tool for the assessment of burnout. Work & Stress 2005 Feb;19(3): (AHRQ); 2005 [cited 2020 Aug 7]. AHRQ Publication no. 05-0021-3. Available from: 192-207. DOI: https://doi.org/10.1080/02678370500297720 www.ncbi.nlm.nih.gov/books/NBK20564/ 18. Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context – global 43. Leiter MP, Frank E, Matheson T. Values, demands, and burnout: Perspectives from shortages and international migration. Glob Health Action 2014 Feb;7(1):23611. DOI: national survey of Canadian physicians. PsycEXTRA Dataset 2009;55(12): https://doi.org/10.3402/gha.v7.23611 1224-25.e12256. DOI: https://doi.org/10.1037/e604522009-001

36 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.028 n ORIGINAL RESEARCH ARTICLE Let’s Get Personal: Academic Ofﬁce Displays and Gender

Katelyn Moretti, MD, MS1; Andrew Musits, MD, MS1; Alyson McGregor, MD, MA1; Adam Aluisio, MD, MSc1 Perm J 2020;24:19.237 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/19.237

ABSTRACT professional credentials because they show qualifications to Introduction: Differential standards in academic medicine visiting patients. In academic medicine, the office is often based on gender have been described for self-promoting used to meet students, colleagues, and supervisors, and, in behavior. this case, it demonstrates a level of accomplishments. Self- ff ffi Objective: To explore di erences in o ce display of profes- promotion may be instrumental for managing a competent sional and personal items between male and female academic impression, yet women who self-promote may suffer social physicians as a proxy for self-promotion. reprisals for violating gender prescriptions to be modest, Methods: A university hospital’s faculty was invited to participate in a study on office setup. Participants were blinded to the whereas men are often pressured to conform to masculine fi 4 study aim. Investigators evaluated offices to assess the number of norms and stereotypes of con dence and ambition. ff professional and personal displays. De-identified data on par- Women and men are exposed to di erent working en- ticipant characteristics and office physical characteristics were vironments and different types of demands and tensions, recorded. Correlations with the number of items displayed were even when they work in the same profession. We wondered analyzed by univariable and multivariable Poisson regression. how these factors might affect outward displays of profes- Results: Forty-eight physicians participated: 23 (47.9%) from sional and personal identity in the work office environment. emergency medicine, 9 (18.8%) from surgery, and 16 (33.3%) from e goal of this study was to determine whether there were internal medicine. The median number of professional displays differences in office displays of professional and personal was 5.0 for women (interquartile range [IQR] = 3.0-9.0) and 6.0 for items between male and female academic physicians. Asso- men (IQR = 2.0-12.0). Controlling for specialty and academic rank, fi ff ciations with age, academic rank, medical specialty, and no signi cant di erence existed in professional display rates by ffi women (incidence rate ratio = 1.1, 95% confidence interval = 0.8- o ce characteristics were also explored. 1.4). The median number of personal displays was 14.5 items for women (IQR = 8.0-25.0) and 6.0 items for men (IQR = 3.0-15.0), METHODS with a significantly different rate (incidence rate ratio = 1.4, 95% Study Design, Setting, and Population confidence interval = 1.2-1.7) when we controlled for specialty, Academic faculty from the Departments of Emergency generation, rank, and office characteristics. Medicine, Surgery, and Internal Medicine at a large uni- Conclusion: Women displayed more personal items than did versity hospital were invited via email to participate in a men, with no difference in professional display rates. Future study on academic office setup between February 2017 and ff studies should examine this di erence to understand its cause, March 2017. Participants were blinded to the study aim ff which may be linked to di erences in academic promotion be- but were informed that researchers were investigating office tween men and women. arrangement. Faculty with more than 1 office were asked to identify their primary, nonclinical office for analysis. INTRODUCTION Offices were located across the academic campus and were Evidence that supports ongoing stereotypes is clear and not used for patient care, but for academic endeavors in- fervent in the world of academic medicine.1 Men are often cluding meetings with colleagues and trainees. An ethical ’ expected to be confident and aggressive and are not highly review was completed through our university s institutional criticized for putting work ahead of family. Women are review board, and all faculty from whom data were collected more likely to be praised for being good wives and mothers; consented to participation. they often perceive that they have to make greater efforts to prove their worth compared with male colleagues, which Data Collection ’ ffi can be a cause of greater stress in the work environment.2 Research personnel evaluated the participants o ces to However, women generally have greater emotional involve- assess the number of professional and personal items on fi ment in social relationships and increased aptitude toward display. Professional items were de ned as diplomas, expressing emotions as a form of self-care than do men.3  fl is could re ect social conventions about gender-appropriate Author Affiliations behavior in academic office settings. 1 Department of Emergency Medicine at Brown University, Providence, RI Customarily, the office setting is about transparency and tradition: derived out of establishing credibility as a Corresponding Author Katelyn Moretti, MD, MS ([email protected]) qualified professional. Most licensed professionals display Keywords: academic medicine, gender differences, office setup, self-promotion The Permanente Journal·https://doi.org/10.7812/TPP/19.237 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 37 ORIGINAL RESEARCH ARTICLE Let’s Get Personal: Academic Office Displays and Gender

Table 1. Characteristics of population and offices documents of merit-based recognition, or awards, whereas personal items were defined as items indicative of life out- Characteristic Frequency, no. (%) side academics (eg, photographs of family, drawings from Sex children). Items or collages within 1 frame or discrete unit Male 26 (54.2) were counted once. Office physical characteristics recorded Female 22 (45.8) included the presence or absence of a window and a shared Generation vs private space. De-identified data on the participant’s Millennial (age < 37 y) 6 (12.5) gender implied by name and appearance, age, academic Generation X (37-52 y) 32 (66.7) rank, and medical specialty were also recorded. Baby boomer (> 52 y) 10 (20.8) Academic rank Data Analysis Clinical instructor/assistant professor 24 (50.0) Data analysis was performed using statistical software Associate professor 16 (33.3) (Stata version 15.0; StataCorp, College Station, TX). Aca- Professor 8 (16.7) demic rank was categorized as clinical instructor/assistant Specialty professor, associate professor, or full professor. Age was Emergency medicine 23 (47.9) categorized by generations as seen in previous research on Internal medicine 9 (18.8) work attitudes5,6: millennials (age < 37 years), generation X Surgery 16 (33.3) members (37-52 years), and baby boomers (> 52 years). Presence of a window Some physicians may be general “displayers,” hanging up Yes 41 (85.4) both personal and professional items in equal numbers, No 7 (14.6) whereas others may display a majority of either classifica- Occupancy tion. To control for the propensity of a physician to gen- Private 34 (70.8) erally display items in his/her office, a personal-professional Shared 14 (29.2) display index (PPDi) was calculated (the number of personal

Figure 1. Displayed professional and personal items stratiﬁed by gender. Dot = outlier values; error bars = range; solid line inside box = median; box= interquartile range.

38 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/19.237 ORIGINAL RESEARCH ARTICLE Let’s Get Personal: Academic Oﬃce Displays and Gender

fi items minus professional items), which further classi ed the Table 2. Professional and personal displays by physician and predominant type of items on display. office characteristics  ffi e count and percentage of participant and o ce char- Median professional Median personal acteristics were calculated. Given the nonparametric data, Characteristic displays (IQR) displays (IQR) the median number of awards and personal items with Physician characteristics interquartile ranges (IQRs) were calculated. Sex Univariable poisson regressions were performed for par- Female 5.0 (3.0-9.0) 14.5 (8.0-25.0) ffi ff ticipant or o ce characteristics to assess for di erences in Male 6.0 (2.0-12.0) 6.0 (3.0-15.0) the display rate of professional and personal items. Corre- Generation ffi lations of participant or o ce characteristics with the PPDi Millennial (< 37 y) 3.0 (1.0-5.0) 6.0 (4.0-11.0) were analyzed by univariable linear regression. Backward Generation X (37-52 y) 5.0 (3.0-10.5) 11.0 (5.0-18.0) stepwise analysis with an inclusion threshold of p = 0.05 and Baby boomer (> 52 y) 7.5 (5.0-12.0) 19.5 (8.0-25.0) exclusion threshold of p = 0.1 was performed for multi- Academic rank variable models. Clinical instructor/ 3.5 (2.0-7.0) 7.5 (4.5-14.5) Multivariable poisson regression of the correlation of the assistant professor participant’s gender with the display rate of professional Associate professor 7.0 (3.5-12.5) 9.5 (5.0-16.5) items controlled for specialty and academic rank on the basis Professor 8.5 (6.5-10.0) 22.5 (14.5-29.5) of inclusion and exclusion thresholds. Poisson regression of Specialty the correlation of gender with the display rate of personal Emergency medicine 6.0 (3.0-14.0) 6.0 (3.0-15.0) items controlled for specialty, generation, rank, and the Internal medicine 5.0 (3.0-11.0) 16.0 (2.0-29.0) presence of a window. Linear regression of the correlation of Surgery 5.0 (2.0-7.0) 12.0 (7.0-23.0) gender with the PPDi controlled for the presence of a Office characteristics window and specialty. Presence of a window No 9.0 (3.0-10.0) 6.0 (2.0-8.0) RESULTS Yes 5 (2.0-10.0) 12.0 (6.0-21.0) A total of 48 physicians participated in the study, with 23 Occupancy physicians from emergency medicine (47.9%), 9 physicians Shared 4.5 (2.0-9.0) 8.0 (5.0-14.0) from surgery (18.8%), and 16 physicians from internal Private 5.5 (3.0-11.0) 11.5 (5.0-21.0) medicine (33.3%). Approximately half of the cohort was IQR = interquartile range. male (54.2%) and clinical instructors/assistant professors (50%), and 66.7% were generation X (66.7%; Table 1). Overall, the median number of professional items dis- internal medicine and surgery specialists had a lower rate played was 5.0 (IQR = 2.5-10.0) and of personal items was of professional items displayed compared with emergency 11.0 (IQR = 5.0-20.0). e median number of professional medicine (IRR = 0.7, IRR = 0.6; Table 3). ere was no items displayed was 5.0 for women (IQR = 3.0-9.0) and 6.0 significant difference between the internal medicine and sur- items for men (IQR = 2.0-12.0; Figure 1). In univariable gery specialties. Associate and full professors also displayed analysis, there was no statistically significant difference in professional items at a higher rate (IRR = 1.8, IRR = 1.8, the rates of professional display by women compared with respectively; Table 3) with no significant difference between men (incidence rate ratio [IRR] = 0.9, 95% CI = 0.7-1.1) associate and full professors. (Table 2). e median number of personal displays was 14.5 Specialty, rank, generation, and the presence of a win- items for women (IQR = 8.0-25.0) and 6.0 items for men dow were all correlated with the rate of personal item (IQR = 3.0-15.0), resulting in a significant difference in the display. Physicians in internal medicine and surgery dis- rates of personal displays by women compared with men played personal items at a higher rate compared with (IRR = 1.7, 95% CI = 1.4-1.9, p < 0.001; Table 3) emergency medicine physicians (IRR = 1.5, IRR = 1.6, In multivariable Poisson regression, these relationships respectively; Table 4). ere was no difference between were maintained with no significant difference in the rate of internal medicine and surgery. Full professors displayed professional displays (IRR = 1.1, 95% CI = 0.8-1.4) but a personal items at a higher rate than assistant or associate significant increase in the display rate of personal items by professors (IRR = 1.6; Table 4). Generation X members women (IRR = 1.4, 95% CI = 1.2-1.7, p < 0.001). For the and baby boomers displayed personal items at a higher rate PPDi, there was no significant difference between genders. compared with millennials (IRR = 2.2, IRR = 2.2; Table 4). Specialty and rank were significantly correlated with the Individuals whose office had a window also displayed number of awards displayed in the studied offices. Both personal items at a higher rate than those without a

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Table 3. Univariable regression analyses Professional display Personal display PPDi Characteristic IRR (95% CI) p Value IRR (95% CI) p Value RR (95% CI) p Value Participant characteristics Male 1 [Reference] — 1 [Reference] — 0 [Reference] — Female 0.9 (0.7-1.1) 0.2 1.7 (1.4-1.9) < 0.001 7.5 (1.3-13.7) 0.02 Generation Millennial (< 37 y) 1 [Reference] — 1 [Reference] — 0 [Reference] — Generation X (37-52 y) 2 (1.3-3.1) 0.003 1.9 (1.4-2.6) < 0.001 2.7 (-7.4 to 12.8) 0.17 Baby boomer (> 52 y) 2.3 (1.4-3.7) 0.001 2.4 (1.7-3.4) < 0.001 5.3 (-6.5 to 17.0) 0.18 Academic rank Clinical instructor/assistant professor 1 [Reference] — 1 [Reference] — 0 [Reference] — Associate professor 1.9 (1.5-2.4) < 0.001 0.9 (0.8-1.1) 0.5 -4.8 (-11.8 to 2.2) 0.17 Professor 1.7 (1.3-2.4) < 0.001 1.8 (1.5-2.2) < 0.001 6 (-2.8 to 14.9 0.18 Specialty Emergency medicine 1 [Reference] — 1 [Reference] — 0 [Reference] — Internal medicine 0.8 (0.6-1.1) 0.1 2.0 (1.6-2.4) < 0.001 11.0 (2.8-19.1) 0.009 Surgery 0.6 (0.5-0.8) < 0.001 1.6 (1.3-1.9) < 0.001 8.7 (2.0-15.5) 0.012 Office characteristics No window 1 [Reference] — 1 [Reference] — 0 [Reference] — Presence of a window 0.9 (0.7-1.3) 0.6 2.8 (2.0-4.0) < 0.001 9.8 (0.98-18.6) 0.03 Shared office 1 [Reference] — 1 [Reference] — 0 [Reference] — Private office 1.2 (0.9-1.5) 0.2 1.4 (1.2-1.7) < 0.001 3.3 (−3.7 to 10.5) 0.4 CI = confidence interval; IRR = incidence rate ratio; PPDi = personal professional display index; RR = rate ratio.

Table 4. Multivariable regression analyses Professional display Personal display PPDi Characteristic IRR (95% CI) p Value IRR (95% CI) p Value RR (95% CI) p Value Male 1 [Reference] — 1 [Reference] — 0 [Reference] — Female 1.1 (0.8-1.4) 0.6 1.4 (1.2-1.7) < 0.001 3.4 (-3.1 to 9.9) 0.3 Generation Millennial (< 37 y) ——1 [Reference] —— Generation X (37-52 y) ——2.2 (1.5-3.1) < 0.001 —— Baby boomer (> 52 y) ——2.2 (1.5-3.3) < 0.001 —— Specialty Emergency medicine 1 [Reference] — 1 [Reference] — 0 [Reference] — Internal medicine 0.7 (0.5-0.9) 0.03 1.5 (1.2-1.9) 0.001 9.6 (1.4-17.8) 0.02 Surgery 0.6 (0.5-0.8) 0.01 1.6 (1.3-2.0) < 0.001 8.1 (1.0-15.2) 0.03 Academic rank Clinical instructor/assistant professor 1 [Reference] — 1 [Reference] ——— Associate professor 1.8 (1.4-2.4) < 0.001 0.9 (0.7-1.1) 0.2 —— Professor 1.8 (1.3-2.5) < 0.001 1.6 (1.2-2.1) 0.001 —— No window ——1 [Reference] — 1 [Reference] — Presence of a window ——2.9 (2.0-4.1) < 0.001 9.7 (1.5-17.9) 0.02 CI = conﬁdence interval; IRR = incidence rate ratio; PPDi = personal professional display index; RR = rate ratio.

window (IRR = 2.9; Table 4). Similarly, those with a win- DISCUSSION dow had a higher PPDi (rate ratio [RR] = 9.7; Table 4), as As an underrepresented group in science, technology, did internal medicine specialists (RR = 9.6) and surgery engineering, and mathematics and speciﬁcally in the higher faculty (RR = 8.1). ranks of academic medicine, women, it has been argued,

40 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/19.237 ORIGINAL RESEARCH ARTICLE Let’s Get Personal: Academic Oﬃce Displays and Gender

should be encouraged to display their diplomas as a way windows have been shown to increase job satisfaction.17 to provide validation to those they mentor and to coun- Although causal associations cannot be determined in this teract imposter syndrome.7 In fact, contemporary culture study, we postulate that this increased satisfaction leads to illustrates this, as demonstrated on Twitter by #hangup- increased personalization of the office space. yourdiplomas. In this convenience sample at a single aca- e current study was a single-center convenience sample demic institution, men and women displayed their academic and, as such, the findings may not be generalizable to other achievements at equal rates, suggesting either a shift in institutions or specialties not included in this analysis. In current acceptable female behavior or a push against social addition, gender, treated as a binary variable, was assumed expectations.8 on the basis of the participant’s name and appearance and However, women displayed personal items at a higher consequently may not reflect the individual’s true gender; rate compared with men. is finding is consistent with transgender and agender were not identified. findings of workers in other office-based industries.9 Higher rates of personal displays have also been suggested to lead to CONCLUSION higher levels of wellness.10 Although cause and effect cannot As the first of its kind, this study provides preliminary be determined from this study, the gender difference seen in results for hypothesis generation and self-reflection regard- personal displays may reflect a coping mechanism by female ing gender differences in the display of personal and pro- physicians to improve wellness as they shoulder increased fessional items in medical faculty offices. Although we offer home-life demands in addition to academic careers.11-13 several hypotheses for the findings in this study, these are Alternatively, it may be reflective of the work/family nar- not exhaustive, and other, unidentified reasons may be the rative pervasive throughout our society, demonstrating the cause. social expectation that women focus more on family, whereas Future studies should correlate gender, physician well- men focus primarily on work, despite both genders having ness, and office characteristics. In fact, we encourage you to equal work-home demands.14 In future studies researchers look around your office and reflect: What is hanging on may want to examine the correlation between rates of per- your wall? Why is it there? How does it affect you and those sonal displays with physician wellness in academic medicine. with whom you interact? v ose participants at a higher academic rank displayed more professional items. Most logically, those who have Disclosure Statement fl reached the level of associate or full professor have also The author(s) have no con icts of interest to disclose. earned more degrees and awards. However, it may also be Acknowledgments that those who self-promote via office displays of their Kathleen Louden, ELS, of Louden Health Communications performed a primary achievements are more likely to get promoted. Future copyedit. studies may examine the offices of assistant professors and prospectively follow up with them through the promotion Authors’ Contributions  ff Katelyn Moretti, MD, and Andrew Musits, MD, MS, participated in study design, process. ere were also di erences observed between gen- data collection, critical review, analysis of the data, and drafting and submission of erations, perhaps consistent with previous work in the social the final manuscript. Alyson McGregor, MD, MA, and Adam Aluisio, MD, MSc, sciences that has identified generational differences in work- participated in data analysis and drafting and submission of the final manuscript. place values.6 Qualitative evaluation of attitudes in office All authors have given final approval to the manuscript. displays compared across generations may also help to ex- ff How to Cite this Article plain di erences observed, especially in light of previously Moretti K, Musits A, McGregor A, Aluisio A. Let’s get personal: Academic office documented shifting work attitudes between generations, displays and gender. Perm J 2020;24:19.237. DOI: https://doi.org/10.7812/TPP/ with work identified as less central and younger generations 19.237 focusing on work-life balance earlier.6 Higher display rates of professional items were found in References emergency medicine physicians’ offices compared with those 1. Morgan AU, Chaiyachati KH, Weissman GE, Liao JM. Eliminating gender-based bias in academic medicine: More than naming the “Elephant in the Room”. J Gen Intern Med in internal medicine and surgery. As first point of contact, 2018 Jun;33(6):966-8. DOI: https://doi.org/10.1007/s11606-018-4411-0 emergency medicine physicians have described feeling 2. Carnes M, Bartels CM, Kaatz A, Kolehmainen C. Why is John more likely to become 15,16 department chair than Jennifer? Trans Am Clin Climatol Assoc 2015 Jan;126:197-214. critiqued through a “retrospectascope.” Professional dis- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530686/ plays may represent an adaptive response to their work 3. Rivera-Torres P, Araque-Padilla R, Montero-Simó M. Job stress across gender: The fl importance of emotional and intellectual demands and social support in women. Int J environment or may re ect the personality types generally Environ Res Public Health 2013 Jan;10(1):375-89. DOI: https://doi.org/10.3390/ represented in each specialty. ijerph10010375 4. Moss-Racusin CA, Phelan JE, Rudman LA. When men break the gender rules: Status In addition, higher rates of personal displays were seen incongruity and backlash against modest men. Psychol Men Masc 2010 Apr;11(2): in offices with windows. In previous research, offices with 140-51. DOI: https://doi.org/10.1037/a0018093

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5. Colby S. Talkin’‘bout our generations: Will millennials have a similar impact on America’s 12. Carr PL, Ash AS, Friedman RH, Szalacha L, Barnett RC, Palepu A, Moskowitz MM. institutions as the baby boomers? Washington, DC: US Census Bureau; 2015 May 4 Faculty perceptions of gender discrimination and sexual harassment in academic [cited 2020 Jul 6]. Available from: https://www.census.gov/newsroom/blogs/research- medicine. Ann Intern Med 2000 Jun;132(11):889-96. DOI: https://doi.org/10.7326/0003- matters/2015/05/talkin-bout-our-generations-will-millennials-have-a-similar-impact-on- 4819-132-11-200006060-00007 americas-institutions-as-the-baby-boomers.html. 13. Ash DL, Newbill SL, Cardinali G, Morahan PS, Chang S, Magrane D. Narratives of 6. Twenge JM. A review of the empirical evidence on generational differences in work participants in national career development programs for women in academic medicine: attitudes. J Bus Psychol 2010 Feb;25(2):201-10.DOI: https://doi.org/10.1007/s10869-010- Identifying the opportunities for strategic investment. J Women’s Health 2016 Mar;25(4): 9165-6 360-70. DOI: https://doi.org/10.1089/jwh.2015.5354 7. Beamer P. Why you should display your diploma. Time 2016 May 16 [cited 2020 Jul 6]. 14. Ely RJ, Padavic I. What’s really holding women back?Harvard Business Review 2020 Available from: https://time.com/4330143/hang-up-your-diploma/. Mar-Apr [cited 2020 Jul 6]. Available from: https://hbr.org/2020/03/whats-really-holding- 8. Eagly AH, Karau SJ. Role congruity theory of prejudice toward female leaders. Psychol women-back. Rev 2002 Jul;109(3):573-98. DOI: https://doi.org/10.1037/0033-295x.109.3.573 15. Louie TA, Rajan MN, Sibley RE. Tackling the Monday-morning quarterback: Applications 9. Wells MM. Office clutter or meaningful personal displays: The role of office of hindsight bias in decision-making settings. Soc Cog 2007 Feb;25(1):32-47. DOI: https:// personalization in employee and organizational well-being. J Environ Psychol 2000 Sep; doi.org/10.1521/soco.2007.25.1.32 20(3):239-55. DOI: https://doi.org/10.1006/jevp.1999.0166 16. Peth HA. High-risk presentations in emergency medicine. Emerg Med Clin North Am 2003 10. Becker F, Steele F. The total workplace. Facilities 1990 Mar;8(3):9-14. DOI: https://doi.org/ Feb;21(1):xv-xvii. DOI: https://doi.org/10.1016/s0733-8627(02)00088-3 10.1108/eum0000000002099 17. Dravigne A, Waliczek TM, Lineberger RD, Zajicek JM. The effect of live plants and 11. Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent window views of green spaces on employee perceptions of job satisfaction. HortScience on parenting and domestic responsibilities by high-achieving young physician-researchers. 2008 Feb;43(1):183-7. DOI: https://doi.org/10.21273/hortsci.43.1.183 Ann Intern Med 2014;160(5):344-53. DOI: https://doi.org/10.7326/m13-0974

42 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/19.237 n SPECIAL REPORT Proceedings from the American Medical Women’s Association Graduate Medical Education Symposia: The First Three Years, 2018-2020

Perm J 2020;24:20.030 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.030

INTRODUCTION share best practices, and focus on issues relevant to women e American Medical Women’s Association in medicine. ere are also few organizations that facilitate (AMWA), founded in 1915, is the oldest national this collaboration among the limited numbers of women multispecialty association for women in medicine. e who hold leadership positions in academic medicine and the mission of AMWA is to advance women in medicine, larger numbers of women in GME across all ranks. advocate for equity, and ensure excellence in health In the academic and scientific community, including dis- care. Recognizing the crucial role of supporting faculty ciplines outside medicine, changes were happening as sim- members in preparing the next generation of physi- ilar needs were recognized. In 2017, the ACGME revised cians, AMWA launched an initiative in 2017 focused the common program requirements to emphasize the im- on graduate medical education (GME). A key com- portance of psychological, emotional, and physical well- ponent of this initiative is a 2-hour GME symposium being in residency and fellowship training, regardless of during the AMWA Annual Meeting to provide a col- medical specialty.2 In 2018, the National Academies of Sci- laborative forum for GME leaders, clinician-educators, ences, Engineering, and Medicine published a report ex- and trainees. is report represents a collection of amining sexual harassment in our medical institutions (and symposia presentations from the first 3 years: 2018 downstream consequences) and concluded that addressing (Philadelphia, PA), 2019 (New York, NY), and 2020 these challenges would require systemwide changes in both (Virtual Meeting). v the climate and culture of our institutional environments.3 Since that time, there has been a surge in publications focused on the need for gender equity, diversity and inclusion, WOMEN IN GRADUATE MEDICAL EDUCATION and the imperative for physician and trainee well-being. Against the backdrop of a shifting sociopolitical landscape Establishing a Graduate Medical Education Task Force for across the country, 2018 turned out to be a year for change. the American Medical Women’s Association A key component of the AMWA GME initiative is a dedicated 2-hour GME Symposium4 during the AMWA Joan C Lo, MD, MS, FACP Annual Meeting as a forum to exchange ideas, collaborate, Kaiser Permanente Northern California Division of Research, The advance initiatives, take action, and ignite change. is is Permanente Medical Group; Graduate Medical Education, Kaiser one of a few national meeting programs that bring together Permanente Oakland Medical Center, Oakland, CA institutional officials, Deans, Program Directors, emeritus Keywords: gender equity, graduate medical education, women in medicine and core faculty, trainees, and professional medical society Conflict of interest: None. leadership representing a wide range of medical disciplines DOI: https://doi.org/10.7812/TPP/20.030.1 to share innovations, develop areas for support, and address key issues in GME and the training environment for stu- In 2017, the American Medical Women’s Association dents and physicians. With approximately 40 to 50 annual (AMWA) established the Graduate Medical Education symposium attendees thus far, the AMWA GME Task (GME) Task Force in response to the recognized need Force intends to continue to engage more GME faculty and among its membership to support women faculty and the trainees across the country, with diverse representation of training of the next generation of physicians. Although each specialties, geographic locations, and institutional settings. academic institution and specialty society has its own GME A major focus of our 2018 GME Symposium was res- committee or Association of Program Directors, limited idency mentorship, well-being, and humanism in medicine. opportunities exist outside the Accreditation Council for In 2019, we addressed gender equity and workforce pre- Graduate Medical Education (ACGME) and the Associa- paredness. In March 2020 amid the early COVID-19 tion of American Medical Colleges1 for Program Directors, pandemic, we held a Virtual GME Symposium (as part of faculty, and trainees to interact across medical disciplines, the Virtual AMWA Annual Meeting) that was focused on

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burnout and resilience, GME expansion, and faculty devel- made. But much of the data used do not take gender into opment. A priority each year is the engagement of local account because it treats men as the default and women as GME communities in the city where the national AMWA atypical. e book Invisible Women by Caroline Criado Annual Meeting is hosted. e Symposium also provides the Perez2 highlights many areas in which gender inequity has opportunity to share innovations in medical education through greatly affected our world. presentations and posters; these have included games in med- Men and women present with different disease symptoms, ical education, visual arts, wellness initiatives, sex and gender- clinical courses, and responses to therapeutics. As we under- based medicine, and health equity and disparities training. stand and teach the impact of gender/sex on health,3 we can In the accompanying compilation of short reports, we enhance disease prevention and advance health promotion present the AMWA GME Symposia proceedings from the strategies. Take, for example, the use of zolpidem (Ambien). 3 inaugural years.4 Most importantly, we invite the broader When it came to market, the clinical trials had mostly been GME community to partner with us in our journey forward. done with men, and the maximum dose as a sleep aid was 10 mg. Once it was in use, the population was more than Action item: Develop GME partnerships within a national 50% women, many of whom had substantial side effects, re- organization serving women in medicine to enrich the training sulting in the change to a maximum dose of 5 mg in women. experience, support faculty, and promote positive institutional Had the clinical trials included women, this might have change. been identified before the launch of the drug. Examples of this gap exists in many areas of health. Perhaps the best ex- References “ ” 1. Group on Women in Medicine and Science (GWIMS) [Internet]. Washington, DC: ample is in heart disease, in which the typical complaints American Association of Medical Colleges [cited 2020 May 10]. Available from: www.aamc. of chest pain radiating to the jaw and arm are less common org/professional-development/affinity-groups/gwims “ ” 2. Improving physician well-being, restoring meaning in medicine [Internet]. Chicago, IL: in women who atypically present with nausea, fatigue, and Accreditation Council for Graduate Medical Education (ACGME) [cited 2020 May 10]. abdominal complaints. Worse is the testing for cardiac ische- Available from: www.acgme.org/What-We-Do/Initiatives/Physician-Well-Being mia in which the cutoff for a “positive” (abnormal) troponin 3. National Academies of Sciences, Engineering, and Medicine; Johnson PA, Sheila E, Widnall SE, Benya FF, eds. Sexual harassment of women: Climate, culture, and level is not categorized differently for men and women, lead- consequences in academic sciences, engineering, and medicine. Washington, DC: ing to a possible increase in false-negative results in women. National Academies Press; 2018. DOI: https://doi.org/10.17226/24994 4. Supporting graduate medical education [Internet]. Schaumburg, IL: American Medical As in business, creating a diverse and well-informed Women’s Association [cited 2020 Jun 5]. Available from: www.amwa-doc.org/initiatives/GME/ biomedical workforce leads to better science and health. ere are strong data indicating that diversity results in Leveling the Playing Field for Women in Medicine and increased productivity in business and more substantial re- Training search in our institutions. When a group of leaders represents only a few voices, there is a paucity of ideas and Theresa Rohr-Kirchgraber, MD, FACP, FAMWA alternative solutions to problems. Indiana University National Center of Excellence in Women’s Health; Calling out the lack of diversity is one start that many Departments of Clinical Medicine and Pediatrics, Indiana University in the American Medical Women’s Association and other School of Medicine, Indianapolis, IN organizations are promoting. Recognizing when there is a Keywords: diversity, gender equity, graduate medical education, sex and gender lack of diversity helps delineate the need. By pointing out medicine, women in medicine when “manels” (all-male speaking panels) exist at meetings,4 Conflict of interest: None. when magazine covers only depict male physicians and sci- DOI: https://doi.org/10.7812/TPP/20.030.2 entists, when portraits at your institution are all of 1 gender or race, or when salaries are tied to scoring systems that are Wired had this headline on March 28, 2019: “e fail- inherently biased, and highlighting these perhaps unin- ure of NASA’s spacewalk snafu? How predictable it was.”1 tentional but obvious deficiencies will help delineate the From studying the way men and women’s bodies differ on problem and bring it out into the open. ose of us in grad- space and on earth, it was not surprising that when the uate medical education share in this important responsi- National Aeronautics and Space Administration (NASA) bility. We must not feel ill at ease when we tell the leaders canceled its highly promoted first-ever all-women astronaut of our programs that putting up pictures of scantily clad spacewalk, it was because the space suits available were the women physicians as a “joke” is not appropriate. wrong size! e failure to translate science into real-world We must also provide options and solutions to increase solutions is partly due to the lack of policies, data, and diversity. research that take into account sex and gender. Gender inequality exists at home, the workplace, and the doctor’s Action item: Address issues pertaining to gender equity, office, and it affects how resources are allocated and decisions diversity, and inclusion at your institution and integrate

44 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.030 SPECIAL REPORT AMWA GME Symposium

sex- and gender-based medicine into undergraduate and in our newly expanded gender equity policy. In spring graduate medical education curricula. 2018, Dr Susan ompson Hingle, 2017-2018 Chair of ACP’s Board of Regents, convened a Diversity and In- References clusion (D&I) Task Force to begin this important work. 1. Dreyfuss E. The failure of NASA’s spacewalk snafu? How predictable it was. Years of ignoring the specific needs of women astronauts led up to this moment [Internet]. WIRED. Subsequently, the D&I Task Force became the Diversity, 2019 Mar 28 [cited 2020 May 10]. Available from: www.wired.com/story/nasa-spacewalk- Equity and Inclusion subcommittee and reported to ACP’s spacesuit-snafu-predictable/  2. Perez CC. Invisible women: Data bias in a world designed for men. New York, NY: Abrams Governance Committee to ensure maximal impact. is Press; 2019. subcommittee is systematically reviewing, modifying, track- 3. McGregor AJ, Chin EL, Rojek MK, et al. Sex and Gender Health Education Summit: Advancing curricula through a multidisciplinary lens. J Womens Health Larchmt 2019 Dec; ing, and implementing policies and procedures to achieve 28(12):1728-36. DOI: https://doi.org/10.1089/jwh.2018.7301. This summit was an the end points we put forward in our policy paper. One initiative sponsored by the Sex and Gender Health Collaborative of the American Medical ’ fi ’ Women’s Association [cited 2020 May 10]. Available from: www.amwa-doc.org/sghc/ of the subcommittee s rst actions was to update ACP s 4. Collins FS. Time to end the manel tradition [Internet]. The NIH Director. 2019 Jun 12 [cited Diversity Policy and the Vision, Goals, and Values to en- 2020 May 10). Bethesda, MD: National Institutes of Health, US Department of Health and sure these important organizational components emphasize Human Services. Available from: www.nih.gov/about-nih/who-we-are/nih-director/ statements/time-end-manel-tradition JEDI in a way that reflects our renewed commitment to achieving it. e ACP Awards Committee reviewed awards and mastership recipient demographics and language, INSTITUTION AND ENVIRONMENT conducted committee implicit bias training, and reviewed Women in Medicine: Creating a JEDI Health Care Environment all awards to ensure they reflect evolving demographics and values of the ACP. e ACP has launched dynamic and Darilyn V Moyer, MD, FACP, FRCP, FIDSA comprehensive online member resources (available from: American College of Physicians, Philadelphia, PA www.acponline.org/WIM).2 As part of our longitudinal Keywords: diversity and inclusion, gender equity, health care environment, commitment to disseminating science on gender equity, the physicians, women in medicine ACP conducted and published the results of a survey that Conflict of interest: None. found $25,000 lower annual pay for women relative to men 3 DOI: https://doi.org/10.7812/TPP/20.030.3 after adjusting for a number of factors. With humility and diligence, medical professional soci- Inextricably etched in our minds, the word JEDI conjures eties need to embark on foundational work to ensure that up the iconic images from the Star Wars movies. In the con- their core values, governance activities, policies, procedures, text of our health care environments, JEDI means that we and systems lead to a more JEDI environment. Our pa- will need to collectively work toward more Just, Equitable, tients and those on the front lines in health care are relying Diverse, and Inclusive environments. Medical professional on us to lead the way.4 We all benefit from having more societies are particularly poised to lead the journey because JEDI practitioners for whom we can wish, “May the force of their broad representation of diverse groups that include be with you.” medical students, trainees, and practicing physicians. Our increasingly diverse patient population and health care work- Action item: Medical professional societies should work with force present quality and safety imperatives for medical societies their companion GME organization(s) to catalyze, harmonize, to lead the way to a more JEDI health care environment. and synergize initiatives to advance the JEDI imperative for e American College of Physicians (ACP) is the world’s their graduate medical trainees. largest medical specialty society, with 159,000 medical students, physicians-in-training, and practicing physician mem- Acknowledgments bers. In September 2016, the ACP’s Council of Resident/ The author would like to thank Eileen Barrett, Sue Bornstein, Wayne Bylsma, Susan Thompson Hingle, and Robert McLean for their helpful suggestions for this Fellow Members (CRFM) brought a resolution to expand manuscript. the ACP’s policies around achieving equity in compensa-  tion and advancement for women physicians. eresulting References evidence-based, comprehensive policy, published in the 1. Butkus R, Serchen J, Moyer DV, Bornstein SS, Hingle ST; Health and Public Policy Annals of Internal Medicine in 2018,1 posited major equity Committee of the American College of Physicians. Achieving gender equity in physician compensation and career advancement: A position paper of the American College of position domains: physician compensation, family and Physicians. Ann Intern Med 2018 May;168(10):721-3. DOI: https://doi.org/10.7326/ medical leave, leadership development and advancement, M17-3438 2. Women in medicine [Internet]. Philadelphia, PA: American College of Physicians [cited 2020 unconscious bias training, research on gender inequity, and May 10]. Available from: www.acponline.org/advocacy/where-we-stand/women-in-medicine opposition to harassment, discrimination, and retaliation. 3. Read S, Butkus R, Weissman A, Moyer DV. Compensation disparities by gender in internal  medicine. Ann Intern Med 2018 Nov 6;169(9):658-61. DOI: https://doi.org/10.7326/M18-0693 e ACP created a road map to examine, measure, and 4. Fiellin LE, Moyer DV. Assuring gender safety and equity in health care: The time for action track processes and procedures to achieve the stated principles is now. Ann Intern Med 2019 Jul 16;171(2):127-8. DOI: https://doi.org/10.7326/M19-0229

Ensuring Safe and Equitable Environments for Women problem is systemic and enduring. To ensure that we create Training to Become Physicians an inclusive work environment that allows all members of the workforce to thrive and advance, we will need to ex- Samyukta Mullangi, MD, MBA1; Reshma Jagsi, MD, DPhil2 haustively confront each of the obstacles with targeted 1,2 1Department of Medicine (Hematology/Oncology), Memorial Sloan interventions. For example, institutions need to establish Kettering Cancer Center, New York, NY clear policies and reporting structures for reporting harass- 2Department of Radiation Oncology and the Center for Bioethics and ment, to undergird these policies with support for targets Social Sciences in Medicine, University of Michigan, Ann Arbor, MI and whistleblowers, and to ensure visible consequences for Keywords: discrimination, diversity and inclusion, gender equity, graduate medical perpetrators, no matter their rank or influence in the or- education, harassment, women in medicine ganization. A commitment to pay parity across faculty must Conflict of interest: None. be accompanied by transparency and consistent criteria for DOI: https://doi.org/10.7812/TPP/20.030.4 compensation and regular self-audits to ensure adherence. Gender-based inequities within mentorship and sponsor- Despite tremendous progress by women over the past ship structures involve a sad circular logic (like promotes few decades, substantial gender-based disparities persist like) and must be mitigated with well-resourced program- within all facets of academic medicine. An inexhaustive list ming and cultural change. of such includes inequities in academic promotion, under- e onus is not on individual women, especially indi- representation of women as authors and editors of medical vidual women who are still in training. However, with journals, unjustified gender differences in compensation, knowledge comes power, and the cultural transformation and sexual harassment and discrimination.1 that is needed will require the participation of all, includ- Here are some of the facts. Promotion in academic ing those who are still trainees. Ultimately, ensuring that medical schools remains highly skewed; while women make women physicians have a fair chance at actualizing their up 41% of full-time medical faculty members, they consti- full potential is not just important for the health and tute only 18% of medical school Deans, 18% of department longevity of our profession: it is also important for our Chairs, and 25% of full professors in academic medicine.2 patients. Diversifying our work environments is integral Publication in medical journals—an important measure of to ensuring optimal medical, surgical, and public health academic productivity and highly emphasized in the academic outcomes. promotion process, as well as a key form of influence—is slowly becoming more equitable. Nevertheless, research Action item: All trainees, as well as those in graduate medical shows in study after study that women constitute only a education leadership, should advocate to fix the systems that minority of authors, writers of invited editorials, and edi- perpetuate inequity rather than expect female trainees to torial board members. continue adapting to these broken systems. Gender differences in compensation have also been documented. For example, a survey of midcareer male and References ff 1. Beeler WH, Cortina LM, Jagsi R. Diving beneath the surface: Addressing gender inequities female physician researchers revealed a $12,000 di erence among clinical investigators. J Clin Invest 2019 Aug;129(9):3468-71. DOI: https://doi.org/ in mean salary between men and women, even after ad- 10.1172/JCI130901 ff 2. Lautenberger DM, Dandar VM. 2018-2019 The state of women in academic medicine: justment for di erences in specialty, institutional charac- Exploring pathways to equity [Internet]. Association of American Medical Colleges; 2020 teristics, academic productivity, academic rank, work hours, [cited 2020 Jul 9]. Available from: www.aamc.org/data-reports/data/2018-2019-state- 3 women-academic-medicine-exploring-pathways-equity and other factors. Finally, an unconscionably high per- 3. Jagsi R, Griffith KA, Stewart A, Sambuco D, DeCastro R, Ubel PA. Gender differences in centage of female physicians report having experienced the salaries of physician researchers. JAMA 2012 Jun;307(22):2410-7. DOI: https://doi.org/ sexual harassment by colleagues and superiors compared 10.1001/jama.2012.6183 4. Choo EK, Byington CL, Johnson NL, Jagsi R. From #MeToo to #TimesUp in health care: 1 with their male counterparts. Many of these studies have Can a culture of accountability end inequity and harassment? Lancet 2019 Feb; not even considered harassment perpetrated by patients. 393(10171):499-502. DOI: https://doi.org/10.1016/S0140-6736(19)30251-X Recently, the #MeToo and Time’s Up movements have garnered attention on the issue of sexual harassment, which is both welcome and long overdue.4 Yet, as the afore- TRAINEE SUPPORT AND MENTORSHIP mentioned facts reveal, academic medicine remains far from Nurturing Residents—A Rewarding Career the optimal environment for women who seek to craft a long and productive career within its confines. Marshall A Wolf, MD, MACP Addressing the gender-based inequities in academic Department of Medicine, Brigham and Women’s Hospital; Department of medicine requires that we avoid looking for or scapegoat- Medicine, Harvard Medical School, Boston, MA ing specific bad actors, and instead acknowledge that the Keywords: graduate medical education, mentorship, program director, training

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Conflict of interest: None. do so. is provided me with the funds to bankroll my DOI: https://doi.org/10.7812/TPP/20.030.5 trainees’ dreams. Most Program Directors are capable of excelling in so Your responsibilities as a Program Director are to teach many activities that they often have trouble setting limits on your trainees to be good physicians, to inspire them to be their professional obligations. My cardiology experiences good persons, and finally to help their dreams come true. taught me that a little diastole is a good thing. To ensure A good physician is one who can quickly establish rapport some diastole in your lives, when you are asked to participate and trust with patients, can tell who is sick vs really sick, is in an activity that is not absolutely necessary, answer that comfortable asking for help, is comfortable admitting when you need to check your calendar (this indicates you’ve taken they do not know, and once admitting they do not know, is the request seriously), and sometime later let the requestee vigorous in trying to learn. Maimonides’ saying, “teach thy know that you are sorry but “it’s just impossible.” Do not tongue to say I do not know, and thou shall progress,” is still explain why it’s impossible because they will think you are true today. You can help your trainees attain these char- negotiating and might fulfill the request. Protect your time; acteristics through frequent and specific feedback (rather your family, patients, and trainees need it. And you need than occasional evaluations), by admitting yourselves when time to nurture your trainees who someday will make you you do not know, and by praising your trainees when they proud—the ultimate reward for a Program Director. pursue the unknown and share new knowledge. It is invaluable to encourage them to teach, as nothing makes it clearer that you have not really mastered a topic than trying ’ to teach it. Women s Leadership and Gender Bias Curriculum for Your trainees will be better persons if you are explicit in Internal Medicine Residents stating that you expect them to take good care of their peers Maria A Yialamas, MD as well as their patients. What was most special about ’ Brigham and Women’s Hospital’s residency program was Department of Medicine, Brigham and Women s Hospital; Department of that several times each year, one of the residents would come Medicine, Harvard Medical School, Boston, MA to tell me that I had to send another resident home because Keywords: curriculum, gender bias, graduate medical education, leadership, his/her parent was ill, but the resident didn’t want to go mentorship, women in medicine because others would need to cover. e resident would Conflict of interest: None. then volunteer to cover for his/her colleague and say that DOI: https://doi.org/10.7812/TPP/20.030.6 I should insist their colleague go home, often adding that I also needed to pay their airfare. Your choice of Chief e low number of women medicine faculty in leader- Residents is crucial to creating a residency in which resi- ship positions and the gender bias experienced by women dents care about and for their peers; kind and nurturing faculty have been well described, as have faculty programs Chief Residents are far better than ones who are all- that can help address the gender leadership gap. However, knowing but competitive and judgmental. less is known about the experiences of women trainees Residents need to be encouraged to dream, and you need during residency, an extremely formative time of career to be energetic in helping them make their dreams, not your development. e Brigham and Women’s Hospital internal dreams for them, come true. You will occasionally need to medicine residency has created a novel leadership and help them pick a dream with legs: one that will survive the gender bias curriculum for resident trainees. e current development of a new vaccine (a career focused on polio is structure of the residency’s Women in Medicine program less than optimal). Asking trainees what this week’s fantasy includes networking events with faculty, peer networking of what they will be doing in 15 years can help them clarify events, leadership skill building for women, and gender bias their dreams. Often you will need to encourage trainees to training for both men and women. e leadership for the think outside the box, to pursue topics even when there are program includes 1 Chief Resident, 2 senior residents, and no formal training programs. You need to help them choose 1 junior resident. ere are 2 faculty advisors. mentors—faculty willing to mentor rather than those just eprogramfirst began in 2006 with quarterly dinners recruiting an assistant for their research. You also need to for women trainees and faculty at a faculty member’shome. accumulate resources that enable you to support their ac- ese dinners offered an opportunity for residents to share ademic and altruistic efforts. My strategy was to tell new their experiences during training, get advice from peers patients, after they thanked me for seeing them, that I was a and faculty, find new mentors, and network. In 2011, really expensive physician, since I would ask for their sup- because of recurrent themes identified at these dinners, a port of my medical education efforts. Most were glad to series of 3 annual retreats, each specific to each year of

training, were added to the curriculum. emes include Conflict of interest: None. leadership skills, mentoring relationships, communication DOI: https://doi.org/10.7812/TPP/20.030.7 skills, and negotiation strategies. ese retreats are highly interactive with small-group case discussions and reflec- e Accreditation Council for Graduate Medical Edu- tion exercises. cation (ACGME) emphasizes wellness as a cornerstone Over the last few years, as the new generation of trainees of its common program requirements. It tasks each insti- entered our residency and implicit gender bias and tution and program with promoting a learning and working microaggressions have been further described in the liter- environment that demonstrates a commitment to the well- ature, an implicit gender bias curriculum was created.1,2 is being of residents, faculty members, and the health care curriculum, initiated in 2017, is for both men and women team. e ACGME Clinical Learning Environment Re- and includes education about implicit gender bias as well view Program, however, documents that 88.8% of trainees as strategies on how it can be mitigated via an interactive report signs of burnout or depression among their faculty annual noon conference and twice-yearly workshops led by or Program Directors.1 A systematic review showed that expert faculty members. 29% of physicians-in-training had depression or depressive e leadership and gender bias curriculum has been symptoms, and these symptoms increased over time.2 highly rated by residents. It is not unusual to hear spon- In 2014, the Council of Florida Medical School Deans taneously from residents how the curriculum has helped surveyed medical students from 9 schools via an anonymous them navigate challenges during residency. online questionnaire regarding health and risk behaviors, in We have learned important lessons about creating such a an institutional review board-approved anonymous survey.3 curriculum. First and foremost is to listen to your residents. Of the 1137 respondents, 79.8% reported their stress level Residents have played an important role in the development as significant or severe; 70.1% felt they would benefit from and dissemination of this curriculum, which almost cer- psychological resources, although 60.2% admitted that they tainly has ensured its success for so many years. Another never used any; 46.3% recently questioned whether they lesson we learned is to be flexible and willing to change the really wanted to become a doctor; 31.3% reported drinking curriculum to ensure that it remains up to date and relevant more since beginning medical school; and among the 18.6% to current trainees. Last, the program has been successful reporting prescription stimulant use, 64.3% admitted taking because of strong support by Program Directors and the pills not prescribed for them. Chair of Medicine. Florida medical school Deans and graduate medical education (GME) Associate Deans or Designated Institutional Action item: Create leadership curriculum programs for Officials (DIO) were surveyed in 2017 to identify elements women residents and gender bias training for all residents. of their wellness programs. On the GME surveys, positive responses included incorporation of clinical psychologists, Acknowledgments multispecialty learning communities, small-group coach- The author thanks Sonja Solomon, MD; Brigid Dolan, MD; and Rose Kakoza, fi MD, the Women in Medicine program Chief Resident and Resident Chairs, for their ing, hospital-based wellness committees, and de ning ex- leadership, and Joel Katz, MD; Marshall Wolf, MD, MACP; and Joseph Loscalzo, pectations for wellness, self-care, and burnout. Challenges MD, PhD, for their support of the program. faced by GME programs were the stigma of using wellness or psychological support services, access to services without References retribution, lack of funding, resident schedules and time 1. DeFilippis EM. Putting the ‘she’ in doctor. JAMA Intern Med 2018 Mar;178(3):323-4. DOI: ’  https://doi.org/10.1001/jamainternmed.2017.8362 pressure, residents skepticism, and faculty buy-in. eGME 2. Rotenstein LS, Berman RA, Katz JT, Yialamas MA. Making the voices of female trainees leaders reported difficulties in linking value to outcomes and heard. Ann Intern Med 2018 Sep;169(5):339-40. DOI: https://doi.org/10.7326/M18-1118 assessing effectiveness of programs. e Florida State University (FSU) College of Medicine responded to the suicide of a medical student in 2017 by RESILIENCY AND WELLNESS establishing a multidisciplinary wellness committee with Promoting Wellness during Residency Training: Examples peer-selected representatives. e committee developed a from the Field multipronged approach to assessing and monitoring student, faculty, and staff well-being and implementing pro- Joan Younger Meek, MD, MS, FAAP, FABM grams to improve the culture of wellness. Resource Web Division of Graduate Medical Education, Department of Clinical Sciences, pages were developed, specific events were planned, and Florida State University College of Medicine, Orlando, FL wellness was integrated into the medical school curriculum. Keywords: burnout, depression, graduate medical education, medical training, An FSU GME wellness subcommittee chaired by a wellness clinical psychologist was formed with representation from

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all GME programs. Program-level initiatives included 2. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis. JAMA 2015 Dec; meditation and mindfulness training; team-building activ- 314(22):2373-83. DOI: https://doi.org/10.1001/jama.2015.15845 ities; and didactic programs in stress management, building 3. Merlo LJ, Curran JS, Watson R. Gender differences in substance use and psychiatric distress among medical students: A comprehensive statewide evaluation. resilience, and work-life balance. Multicultural social events Subst Abuse 2017 Oct-Dec;38(4):401-6. DOI: https://doi.org/10.1080/08897077.2017. helped to establish comradery in the programs. Residents 1355871 4. National Academy of Medicine. Taking action against clinician burnout: A systems advocated for and achieved healthier nutrition choices in approach to professional well-being: Consensus study report. Washington, DC: National the physician lounges. Most programs regularly included Academies Press; 2019. DOI: https://doi.org/10.17226/25521 wellness activities in structured program didactics. In response to the high rates of depression, burnout, and suicide among physicians, including those in training, the National Academy of Medicine (NAM) established an Stress, Burnout, and Depression in Graduate Medical Action Collaborative on Clinician Well-Being and Resil- Education ience (https://nam.edu/initiatives/clinician-resilience-and-well- Carol A Bernstein, MD being/). e Collaborative, led by the NAM, ACGME, and Association of American Medical Colleges, is committed Departments of Psychiatry and Behavioral Science and Obstetrics and ’ to reversing trends in clinician burnout. Goals include im- Gynecology and Women s Health, Albert Einstein College of Medicine/ fi proving baseline understanding of challenges to clinician Monte ore Health, New York, NY; Department of Education and Organizational Development, Accreditation Council for Graduate Medical well-being; raising the visibility of clinician stress and burn- Education, Chicago, IL out; and elevating evidence-based, multidisciplinary solutions that will improve patient care by caring for the caregiver.4 Keywords: burnout, graduate medical education, residency training, stress e ACGME also maintains well-being resources (www. Conflict of interest: None. acgme.org/What-We-Do/Initiatives/Physician-Well-Being). DOI: https://doi.org/10.7812/TPP/20.030.8 ese are important action steps for the future to promote wellness throughout the continuum of medical education. Over the past 7 years, following the highly publicized Enhancing well-being in GME programs requires a co- suicides of 2 interns in internal medicine in New York City, ordinated approach between the GME sponsoring insti- the graduate medical education community has been gal- tution and clinical training sites. Hospital Chief Executive vanized to action to confront the multiple challenges facing Officers, Chief Academic Officers, Wellness Officers, and trainees and faculty in the current health care environment.1,2 Chief Medical Officers should engage with the GME Although these challenges are not new, the corporatization leadership, including medical school Deans, DIOs, and of American health care, increasing technological chal- Program Directors in creating wellness initiatives. In ad- lenges in patient care delivery, increasing acuity, a focus dition, program faculty, staff, and trainees need to play an on productivity, an unchecked regulatory environment, a active role in developing wellness programs that are ac- poorly designed electronic medical record, and loss of au- cessible to all members of the health care team and meet the tonomy and control have all conspired to heighten the usual needs of the individuals and the institutions. Surveying the angst the new physician encounters when learning his/her needs of the community and monitoring the outcomes of craft. Furthermore, anxiety about competency heightens wellness programs are important to justify the resources the tension. Changes in the medical school curriculum as a devoted by the institution. result of the knowledge explosion have also removed students from being true partners in the patient care experi- Action item: DIOs and Program Directors should collaborate ence because of concerns about patient safety among other with medical school and hospital leadership to include the well- things. ese circumstances are being replicated in the being of the workforce and trainees as part of overall strategic residency environment and may contribute to producing planning, developing wellness initiatives and metrics for residents who are less resilient than those who entered monitoring success. medicine 40 or 50 years ago. e epidemic of burnout among physicians and, indeed, Acknowledgments among all health care workers has been well documented in The author would like to acknowledge the Council of Florida Medical School the literature.3 e particular challenges that face today’s Deans and its GME Working Group in the development and analysis of the surveys fi of medical student and GME wellness in the State of Florida. trainees include nancial stress, prior medical and psychiatric issues, isolation from friends and family, loss of support References systems, inadequate mentorship, and the higher expectation 1. Koh NJ, Wagner R, Newton RC, Casey BR, Sun H, Weiss KB; CLER Program. Detailed findings from the CLER National Report of Findings 2018. J Grad Med Educ 2018 Aug; for and increasing inability to develop appropriate work-life 10(4 Suppl):49-68. DOI: https://doi.org/10.4300/1949-8349.10.4s.49 integration. Moreover, they are faced with overburdened

faculty who also struggle with these issues and who do not References have the “bandwidth” to provide adequate support. Students 1. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis. JAMA 2015 Dec; still enter medicine for most of the reasons that all of us did: 314(22):2373-83. DOI: https://doi.org/10.1001/jama.2015.15845 a powerful desire to treat and even cure patients and relieve 2. Goldman ML, Shah RN, Bernstein CA. Depression and suicide among physician trainees: suffering. Unfortunately, the balance between the stresses Recommendations for a national response. JAMA Psychiatry 2015 May;72(5):411-12. DOI: https://doi.org/10.1001/jamapsychiatry.2014.3050 and the joys of medicine have tipped precariously in the 3. IsHak WW, Lederer S, Mandili C, et al. Burnout during residency training: A literature wrong direction. All these issues present additional chal- review. J Grad Med Educ 2009 Dec;1(2):236-42. DOI: https://doi.org/10.4300/JGME-D-09- 00054.1 lenges for women trainees, especially those of color, who 4. Templeton K, Bernstein CA, Sukhera J, et al. Gender-based differences in burnout: Issues must also confront the long-standing male hierarchy, micro- faced by women physicians. NAM Perspectives. Discussion paper. Washington, DC: aggressions and macroaggressions, and discrimination— National Academy of Medicine; 2019. DOI: https://doi.org/10.31478/201905a both overt and subtle.4 Causes and solutions for these issues are both individual MEDICAL HUMANITIES and systemic, with an emphasis on the latter. ere should be more open discussion between trainees and faculty of the Using Story to Change Medical Culture challenges that each face in the work environment, with Jessica Nutik Zitter, MD, MPH interactions focused on promoting the development of solutions that are specific to their experiences. Such solu- Palliative Medicine, Highland Hospital, Alameda Health System, tions may include increased, destigmatized access to con- Oakland, CA fidential mental health services; opportunities for increased Keywords: graduate medical education, medical humanities, narrative medicine, community engagement to address isolation; mentorship storytelling for career and work-life integration issues; and recogni- Conflict of interest: None. tion of the specific issues that women, including those DOI: https://doi.org/10.7812/TPP/20.030.9 who are gender underrepresented and/or underrepresented minorities, might face. In addition, discussions regarding Dr Rita Charon started the first program in narrative the stresses of career transitions (eg, student to resident, medicine at Columbia Medical School in 2000, begin- resident to faculty) are especially important. Solutions ning the formal use of storytelling in medical education. must also include efforts to find ways to address work- Since then, we have learned that reading, writing, and even place inefficiencies, to build resilience, and to develop drawing stories—our own and others’—benefits doctors as cultures that promote community, engagement, auton- well as their patients. Yet these storytelling opportunities omy, respect, and shared values. All initiatives in these remain few and far between. areas should be supported and encouraged by the health Medical residents and practicing physicians need a story- care system.2 driven curriculum that fits easily into an already packed Resident, fellow, and faculty physician well-being is an schedule. is short exposure could serve as a building block important initiative of the Accreditation Council for Grad- for a more reflective and humanistic health care culture uate Medical Education (www.acgme.org/What-We-Do/ in programs or institutions. e ideal program would be Initiatives/Physician-Well-Being), and resources specific downloadable, easy to facilitate, and provide concurrent to the graduate medical education community are regularly continuing medical education for interested clinical faculty. updated on its Web site, including specific resources related e author developed and presented a pilot version of to the coronavirus disease 2019 (COVID-19) pandemic. such a program in 2018 at the American Medical Women’s On a broader scale, both resources and evidence-based Association 103rd Annual Meeting in Philadelphia, solutions are also being disseminated through the Action Pennsylvania. e program, framed in a slide presentation, Collaborative on Clinician Well-Being and Resilience, an spans 60 minutes and guides participants through 4 “re- initiative of the National Academy of Medicine (https:// flection exercises” focusing on several themes that affect nam.edu/initiatives/clinician-resilience-and-well-being/) medical culture and practice. Each exercise opens with an that includes a network of more than 60 organizations embedded audio or visual clip from 1 of 2 published works: committed to addressing clinician burnout. a physician memoir or a short documentary film. Each clip is followed by a short debrief video by the author of these Action item: We need to identify key factors contributing 2 works, Jessica Zitter, MD, MPH, then by 1 or 2 prompt to stress and burnout, develop approaches to addressing these questions for the group. e program can include 3 or 4 issues both at the individual and systemic levels, and implement themes, depending on allotted time. solutions that increase the well-being and resilience of trainees e program’s key stories were extracted from an Oscar- and faculty. and Emmy-nominated short documentary, Extremis,1 and

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a memoir, Extreme Measures: Finding a Better Path to the Conflict of interest: None. End of Life.2 Both works dive deep into some of the most DOI: https://doi.org/10.7812/TPP/20.030.10 difficult and rarely discussed obstacles that challenge our practice as we care for patients with life-limiting illness.3 Recently there have been increased efforts to integrating Both have resonated deeply with health care audiences since medical education with the humanities, particularly with their publication in 2017 and are now used around the visual art viewing. ese programs are usually based on country in teaching capacities too numerous to list. partnerships between art museums and medical schools. Each exercise explores a challenging aspect of medical ey use the concept of Visual inking Strategies, a ped- culture not commonly discussed in clinical environments. agogic approach using observation of curated art to explore Some examples include avoiding patient emotion, the fear the meaning behind them.1 Prior research has shown that of being wrong, the fear of judgment or conflict with col- art viewing curricula can help to enhance visual skills, leagues, and our collective tendency to make uninformed improve tolerance of ambiguity, and increase empathy in judgments about people and situations. For instance, the medical learners. ese programs are based on group visits “fear of being wrong” themed discussion starts with a story to art museums and sometimes include group discussions of a physician relaying a prognosis to a family, which turns as a means for sharing ideas.2 e museum-based curricula out to be wrong, and explores the physician’s subsequent studied have been based on individual collaborations be- sense of shame and self-doubt. By addressing such scenarios tween medical schools and well-resourced art museums and inviting others to join in, we can all, as a community, headed by curators. However, not all medical learners have work together to change shame into humility, fear into access to these programs because of the resources required courage, and numbness back into the compassion. for their creation and maintenance. Aspects of this program have been already piloted in We describe a simple teaching tool for visual art-based internal medicine, anesthesiology, and pulmonary/critical programs that can be used by medical educators and learners care programs and were met with enthusiastic response from to guide small-group visits to art museums or galleries and both faculty and trainees. A 60-minute downloadable cur- improve public speaking, visual thinking, and wellness riculum is being developed for physician training in a variety among medical learners, regardless of their knowledge of art of medical specialties.3 Educational programming is also curation. being developed using a newly released film, “Caregiver: We developed Art-Heal, a simple educational tool A Love Story,”4 which explores the understudied issue of consisting of 3 parts to be used by small groups of medical family caregiver burden. learners in curated art visual spaces. e goal was to empower medical educators, who are not trained in art or Action item: Introduce storytelling and its humanizing curatorial studies, to lead programs using a set of simple impact in medical training and practice environments with directions that can be implemented with any group of a program that is easy to facilitate and does not require learners in any space and with a variety of visual art. much time. e first part of the Art-Heal tool allows learners to improve their public speaking skills and confidence in am- References fl biguity by having them speak about new works of art using 1. Krauss D, director, producer. Extremis. Los Gatos, CA: Net ix; 2016.  ’ 2. Zitter JN. Extreme measures: Finding a better path to the end of life. New York, NY: a guided verbal script. e second part hones the learners Penguin Random House; 2017. observation abilities by having them find similarities and 3. Zitter JN. Discussion guides for Extremis and Extreme Measures and resources for  healthcare educators [Internet]. [cited 2020 Aug 11]. Available from: https:// unique qualities in visually complicated pieces of art. e jessicazitter.com/healthcare-provider-resources/ and https://jessicazitter.com/healthcare- third part of the curricula focuses on having learners choose educators/ ffi 4. Zitter JN, Gordon K, directors, producers. Caregiver: A love story [Internet]. 2020 [cited pieces of work that can help them explore di cult patient 2020 Jul 10]. Available from: https://caregiveralovestory.com/ experiences during their training to help facilitate discussions about common challenges they face as physicians. e opportunity for reflection also creates space that sup- Art and Critique in Medicine ports resilience and well-being. By simplifying the process of visual learning while keeping it open ended, this visual Somalee Banerjee, MD, MPH1; Yoko Kiyoi, MA2 art observation tool can be implemented in any medical 1Hospital Medicine, Kaiser Permanente Oakland Medical Center, The learning environment to improve equity in the access to Permanente Medical Group, Oakland, CA education innovations. 2Pulitzer Arts Foundation, St Louis, MO Keywords: art and medicine, graduate medical education, medical humanities, Action item: A simple visual art teaching tool can be in- visual art corporated into graduate medical education wellness initiatives

to guide small-group visits to art museums and promote verbal by 80% of respondents. We also included a joint wellness expression, visual thinking, and self-reflection, regardless of art session with residents about writing a condolence letter to curation knowledge. a patient or her family. Talks were scheduled for day and evening times to accommodate a variety of schedule pref- References erences, and fellows were notified well in advance so they 1. Tishman S. Slow looking: The art and practice of learning through observation. New York, NY: Routledge; 2018. could plan accordingly. 2. Naghshineh S, Hafler JP, Miller AR, et al. Formal art observation training improves medical Fellows evaluated each individual session as well as the students’ visual diagnostic skills. J Gen Intern Med 2008 Jul;23(7):991-7. DOI: https://doi. org/10.1007/s11606-008-0667-0 overall program. All 3 sessions received extremely positive reviews, with a mean rating of 5.0 of 5.0. Representative comments included the following: “anks for organizing, ” “ PREPARING TRAINEES FOR PRACTICE this was a great and underaddressed topic. and Struggling ’ with home-life balance and my ambitions to be innovative and Developing a Fellows Academy to Prepare Senior Trainees focus on driving my career to what I imagine/have pictured. for Independent Practice Really helpful.” At the conclusion of the academic year, 100% of respondents felt that the Fellows’ Academy should Rini Banerjee Ratan, MD be continued. Based on this enthusiastic response, we que- Department of Obstetrics and Gynecology, Columbia University Vagelos ried fellows about adding a Fellows’ Retreat for the fol- College of Physicians and Surgeons, New York Presbyterian Hospital, lowing year, and 100% of respondents were in favor. New York, NY Our inaugural retreat was an all-day event, held off- Keywords: career preparation, entering practice, fellowship, graduate medical campus. Nearly all fellows asked for education regarding education personal finances, so we brought in a team of financial plan- Conflict of interest: None. ners for an in-depth informational morning session. e DOI: https://doi.org/10.7812/TPP/20.030.11 afternoon event was a fun team-building event: a scavenger hunt through the Museum of Modern Art in New York, In our university-based Obstetrics and Gynecology NY. e day concluded with a cocktail reception attended Department, we developed a Fellows’ Academy to bring to- by our Chair and fellowship Directors. Coverage of clinical gether fellows across subspecialties to discuss common is- duties was provided by faculty, residents, nurse practitioners, sues as they prepare for independent practice and to enhance and physician assistants. Funding was provided by each a broader sense of community. Although most academic of our clinical divisions using an equitable hybrid model. programs equip fellows with the clinical knowledge and Fellows in our department appreciated the opportunity to surgical expertise necessary to function independently, we come together as a community to partake in junior faculty rarely provide trainees with the nonmedical information1-3 development events relevant to their stage of training. that is equally essential for them to flourish in practice. We set out to develop a Fellows’ Academy to provide our fellows Action item: A departmental Fellows’ Academy provides with an inclusive educational forum, interdivisional men- senior trainees with an inclusive community forum in which to torship, networking opportunities, and wellness activities. discuss common issues as they prepare for independent practice. We met with our fellowship Directors, Chair, educational leadership team, and the fellows themselves. All supported References 1. Shanafelt TD, Raymond M, Horn L, et al. Oncology fellows’ career plans, expectations, and crafting an academy dedicated specifically to the unique well-being: Do fellows know what they are getting into? J Clin Oncol 2014 Sep;32(27): needs of our fellows. We conducted an initial needs as- 2991-7. DOI: https://doi.org/10.1200/JCO.2014.56.2827 2. Ahmad FA, White AJ, Hiller KM, Amini R, Jeffe DB. An assessment of residents’ and sessment survey to determine interest, meeting frequency, fellows’ personal finance literacy: An unmet medical education need. Int J Med Educ 2017 and topics of interest. About half of the fellows completed May;8:192-204. DOI: https://doi.org/10.5116/ijme.5918.ad11 3. Bar-Or YD, Fessler HE, Desai DA, Zakaria S. Implementation of a comprehensive the needs assessment; 70% of respondents felt that a Fel- curriculum in personal finance for medical fellows. Cureus 2018 Jan;10(1):e2013. DOI: lows’ Academy would be beneficial to their training, and https://doi.org/10.7759/cureus.2013 30% were unsure. We surveyed fellows regarding their interest in topics ranging from an overview of the US health system to conflict resolution, team building, contract ne- Physician Reentry to Practice: The Role of Graduate gotiation, malpractice insurance, personal finances, and Medical Education delivering “bad news.” In response to this needs assessment, we planned 3 talks Kimberly Templeton, MD, FAMWA for the first year of our Fellows’ Academy—1 on malpractice Department of Orthopedic Surgery, University of Kansas School of and 1 about preparing for a job interview—both requested Medicine, Kansas City, KS

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Keywords: graduate medical education, physician reentry, women in medicine Led by the American Medical Women’s Association2 Conflict of interest: None. and other organizations, efforts are under way to address DOI: https://doi.org/10.7812/TPP/20.030.12 these hurdles and make the reentry process easier to navigate. Essential information pertaining to local require- Workforce preparedness in medicine requires that resi- ments is available through the Federation of State Medical dents understand the full range of issues that they may Boards.3 In the meantime, it is important for those involved face in practice. is can include such disparate topics as in graduate medical education to ensure that learners un- emerging public health issues, disaster preparedness, diverse derstand the implications of taking time away from practice. practice settings, and navigating the changing business of If leaving practice, physicians need to maintain their con- medicine. However, topics increasingly include more per- tinuing medical education and board certification, if possible, sonal aspects of the physician’s life, such as physical and to facilitate the reentry process. With more women entering mental health, burnout, and integrating responsibilities medicine, taking time away will become more common- outside medicine with work demands. e last can be place. Women physicians should plan as carefully for their challenging, especially for women faced with the need to time away as they do any other aspects of their careers. take time away from medicine, either for childrearing or other family issues for which they have primary responsi- Action item: Educate trainees about the need to plan ahead bility. To prepare for the entirety of their careers, trainees before taking time off during their careers, including the need to need to understand that taking time away from their career research state license requirements and alternative options for is not unusual but must be planned. minimal clinical activity. Trainees should understand that even According to the American Medical Association,1 phy- if they do not anticipate returning to medical practice, circum- sician reentry refers to “a return to clinical practice in the stances can change, and they should keep their career options open. discipline in which one has been trained or certified following an extended period of clinical inactivity not result- References ”  1. Resources for physicians returning to clinical practice [Internet]. Chicago, IL: ing from discipline or impairment. is does not refer to American Medical Association; 2020 Jan 28 [cited 2020 May 10]. Available from: www. retraining for another specialty or practice remediation, and ama-assn.org/practice-management/career-development/resources-physicians-returning-  “ clinical-practice the time away from practice is voluntary. e length of an 2. Templeton K. Physician re-entry to practice [Internet]. Schaumburg, IL: American extended period of clinical inactivity” is defined by state Medical Women’s Association blog; 2018 Jan [cited 2020 Mar 28]. Available from: www. 1 amwa-doc.org/physician-re-entry-to-practice/ regulations and can vary considerably. Physician reentry 3. Federation of State Medical Boards (FSMB) [Internet]. [cited 2020 May 10]. Available from: is gaining more attention because of increasing public www.fsmb.org/ demand for accountability, the physician workforce shortage, and more parents (especially women) in the workforce. e process of physician reentry also enhances the return on EXPANDING GRADUATE MEDICAL EDUCATION investment for the increasing personal and societal cost of training physicians. So You Think You Want to Start a Family Medicine e most commonly cited reasons that physicians leave Residency practice are health, retirement, career change, burnout, and Deborah Edberg, MD; Lauren Anderson, MEd family needs. ere are no gender-based differences in the number of physicians who leave practice for health reasons. Department of Family Medicine, Rush University Medical Center, However, men are more likely to leave practice to pursue Chicago, IL other career options, whereas women are more likely to Keywords: family medicine residency, graduate medical education, primary care leave to raise children or care for other family members. training Since women frequently reenter practice once children start Conflict of interest: None. school, they are typically younger than men when attempt- DOI: https://doi.org/10.7812/TPP/20.030.13 ing to return to practice. Physicians with a period of clinical inactivity longer than Health outcomes and costs in the US are strongly linked allowed by their state may be required to undergo assess- to the availability of and access to primary care physicians ment of clinical competency and may need a period of (PCPs). Patients with a PCP have better health out- monitored practice before active licensure is granted. comes while spending less overall on health care than those Finding monitored settings or more intensive educational without a PCP. To ensure that all individuals in the US experience mandated by state medical boards can be dif- have access to a PCP, it is estimated that we will need an ficult. In addition, the entire process can be long and ex- additional 1700 primary care residency slots to fill the gap of pensive, requiring time away from home for evaluation. 33,000 PCPs by 2035.1 ese projections underscore the

need for more primary care training programs, particularly hospital that supports inpatient admissions. If so, ensure in regions of greater need. However, starting a new family mission alignment as well as equal participation in lead- medicine residency can be daunting. Based on our expe- ership oversight. rience in establishing clinical training programs in under- Curriculum: Once the agreement is signed, curriculum served urban communities, we highlight the key steps on the development may begin. Although Accreditation Council road to a successful program, which include partnership, for Graduate Medical Education requirements must be ful- mission alignment, and drafting an agreement that repre- filled, it is recommended that during curriculum develop- sents a leadership collaboration among all partners. ment, the faculty leverage areas of flexibility to reflect the Partnership: Community health centers (CHCs) are more needs of the community. Review health disparities, chronic cost effective and have produced better outcomes for med- illnesses, addiction, and other high-stake issues that impact ically complex patients with social risk factors than other the specific patient population; develop curriculum to inform models.2 Residents who train in CHCs are 3 times more and improve health care delivery specific to their needs, and likely to remain in a CHC after graduation.3 Support from involve partners and other stakeholders in development. an academic institution can enhance the educational re- Recruitment: During recruitment, screen for applicants sources of this model and bring community and academia that show a vested interest and highlight the specifics of together for an optimal partnership. community education. Develop ongoing and rapid evalu- Alignment: Choosing a viable partnership can be chal- ation of the curriculum to improve and advance innovation. lenging. e first step is mission alignment. Community health centers have a natural commitment to underserved Action items: Identify champions and mission alignment individuals but not education. Academic institutions are among all potential partners. Invest time in writing a comfortable with education but may not have a focus on thoughtful mission statement and program aims that reflect the underserved populations. Potential partners should nego- priorities of all partners. Begin! tiate priorities, which may include at-risk patient subgroups, leadership structure, space for innovation, and financial References 1. Petterson SM, Liaw WR, Tran C, Bazemore AW. Estimating the residency expansion resources. Identify champions in each organization who required to avoid projected primary care physician shortages by 2035. Ann Fam Med 2015 share the core mission and values. Identify value added; for Mar;13(2):107-14. DOI: https://doi.org/10.1370/afm.1760 fi 2. Ku L, Rosenbaum S, Shin P. Using primary care to bend the cost curve: The potential example, CHCs nd that recruitment of attending physi- impact of health center expansion in Senate reforms. Geiger Gibson/RCHN Community cians is easier when the centers also have a residency. e Health Foundation Research Collaborative policy research brief no. 16. Washington DC: George Washington University, School of Public Health and Health Services, Department CHCs can access academic resources to enhance patient of Health Policy; 2009 [cited 2020 May 10]. Available from: https://hsrc.himmelfarb. care. An underserved community-based residency can sup- gwu.edu/cgi/viewcontent.cgi?referer=&httpsredir=1&article=1023&context= fi sphhs_policy_ggrchn port a not-for-pro t status for an academic institution and 3. Morris CG, Johnson B, Kim S, Chen F. Training family physicians in community health offer clinical training slots for medical students. centers: A health workforce solution. Fam Med 2008 Apr;40(4):271-6. Agreement: Develop vision, mission, and aims statements that include strategic priorities from both organizations. e statement should reference serving the underserved Graduate Medical Education Expansion to Rural Community  community as well as prioritizing education. is document Hospitals: Residency Training Beyond the Academic Health will be a critical tool through negotiations about finances and structure of the residency curriculum alongside patient care. Center Community health centers are often candidates for gov- Stephen John Cico, MD, MEd ernmental as well as private funding. Many funding streams Departments of Graduate Medical Education, Emergency Medicine, and are eligible to only CHCs or only academic institutions; this Pediatrics, Indiana University School of Medicine, Indianapolis, IN unique partnership can leverage both. e agreement should include financial support for at least 5 years, employment of Keywords: expansion, graduate medical education, primary care, rural medicine residents and faculty, malpractice, chain of command, and Conflict of interest: None. dispute resolution. It may also include hospital admissions, DOI: https://doi.org/10.7812/TPP/20.030.14 community benefit, faculty development, information technology resources, and other negotiated items. In 2016, the Indiana University School of Medicine Decision Making: Residency and CHC leadership should (IUSM) and rural community hospitals began to address a overlap at the highest level so decisions are in mutual major need for additional Graduate Medical Education agreement. We recommend a leadership committee that (GME) positions in Indiana. According to the 2019 Asso- meets regularly to review successes and challenges. It is ciation of American Medical Colleges (AAMC) Physician possible that a third partner will exist, such as a community Workforce Data Report,1 Indiana ranks in the lower

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quartile for primary care physicians and GME trainees. enabled the IUSM GME Office to reduce barriers for ese needs are greater in the rural areas of the state, yet establishing residency programs in GME-na¨ıve rural com- only 14% of GME trainees in Indiana are trained outside munity hospitals. Training individuals at community res- the metropolitan Indianapolis region. e IUSM trains idency sites under the GME Office at a statewide medical more than 80% of GME residents and fellows in Indiana, school offers credibility, name recognition, and additional but none trained in rural communities.1,2 academic resources. We provide a formal system for over- By attracting residents with an interest in primary care sight of these programs at both GME and departmental and training them in rural communities, we hope to increase levels. ese programs have the same high-quality educa- recruitment and retention of physicians to underserved tional experiences and standards as the programs at the rural communities. Data from the AAMC show that 54% academic medical center. By training residents interested in of active physicians in Indiana trained in Indiana GME community medicine in a community hospital, we hope to programs, and if a physician did both undergraduate med- help decrease the rural physician deficit currently experi- ical education and GME training in Indiana, 77.5% stayed enced in Indiana and better serve the citizens of our state. in the state to practice.1 Yet each year, Indiana was losing more than 130 residency physicians to other states,3 despite Action item: Academic medical centers can create successful the estimate that Indiana will need an additional 817 partnerships with GME-na¨ıve, rural hospitals to create aca- primary care physicians by 2030.2 demically affiliated primary care residency programs. ese resi- To help meet the physician needs of the state, the IUSM dency programs may help meet the health care needs of underserved developed a structured pathway for rural residency ex- communities while delivering high-quality medical training to pansion and accreditation. Our stepwise process included residents of ACGME-accredited training programs. developing relationships with faculty and C-suite adminis- trations of interested GME-na¨ıve hospitals, guiding fund- Acknowledgments ’ The author thanks the Indiana University School of Medicine GME Expansion ing opportunities, creating strong relationships with IUSM s Team members: Michelle Howenstine, MD; Linda Bratcher; and Emilie Eleveque. clinical departments, and finally, successfully integrating ffi these newly accredited programs with the IUSM O ce of References GME. With a focus on primary care and psychiatry and 1. 2019 State Physician Workface Data Report [Internet]. Washington, DC: Association of American Medical Colleges; 2019 Nov [cited 2020 May 10]. Available from: https://store. with assistance from state-funded GME feasibility and ex- aamc.org/downloadable/download/sample/sample_id/305/ pansion grants, the IUSM GME Office undertook GME 2. Umbach T; for Indiana Graduate Medical Education Board. Cultivating the physicians of the future through targeted funding initiatives: A roadmap to measurably expand graduate expansion at a statewide level. medical education in Indiana [Internet]. Indiana Graduate Medical Education Board [cited To facilitate the process, 2 new resource and oversight 2020 May 10]. Available from: www.in.gov/che/files/TrippUmbach_IndianaGME-Report_ positions were created in the IUSM GME Office: an FINAL.pdf 3. Indiana Graduate Medical Residency Program: Meeting state need for more quality primary Assistant Dean for GME statewide expansion and an ex- care physicians [Internet]. Indiana Commission for Higher Education; 2019 Jan 23 [cited pansion coordinator. Using the experience of the GME 2020 Jul 6]. Available from: www.in.gov/che/files/Indiana%20GME%20Expansion% 20Plan_2019_UPDATED.pdf Office and accreditation resources from the Accreditation Council for Graduate Medical Education (ACGME), a list of tasks was created, along with a reasonable timeline for FACULTY DEVELOPMENT AND ADVANCEMENT completion of each task required for establishment and successful accreditation of an ACGME residency. Totaling Training Future Faculty with the Clinician-Educator Training 64 items in 9 content areas and spanning the 2 years before Pathway the start of educating residents, our timeline helped hospital Christen K Dilly, MD, MEHP partners and academic departments understand and plan for the needs of new programs. Importantly, the plan clearly Division of Gastroenterology, Hepatology and Nutrition, Indiana University delineates responsibilities among hospital partners, the School of Medicine, Indianapolis, IN sponsoring academic department, and the GME Office. Keywords: clinician-educator, faculty development, graduate medical education, Four programs have been accredited by the ACGME: identity formation 1 psychiatry, 1 internal medicine, and 2 family medicine Conflict of interest: None. residencies. To facilitate program development, 1 region of DOI: https://doi.org/10.7812/TPP/20.030.15 the state developed a hospital consortium with an Assistant Designated Institutional Official reporting to the IUSM To be successful as clinician-educators, early-career fac- Designated Institutional Official, to assist with local over- ulty members have several important needs.1 ese include sight, fundraising, and direct communication with the hos- an understanding of the criteria for promotion and tenure, pital administration. Creating this comprehensive process pathways for career development, expert faculty mentors

and role models, and a culture that supports educators. e is helps them feel part of a community of practice, which Indiana University School of Medicine (IUSM) Clinician is a crucial component of a strong professional identity. Educator Training Pathway is a 2-year program designed to e Program Director’s salary is supported through the GME Office and the Department of Medicine. Admin- · prepare residents and fellows for careers as clinician- istrative support is provided through the GME Office. educators Participants report high levels of satisfaction with the pro- · support participants’ professional identity formation as gram and a strong sense of community. Our participants’ educators curricula and education scholarship projects benefit the · train participants in teaching strategies, education lead- IUSM GME and undergraduate medical education pro- ership, and education research grams. For example, one fellow developed an echocardi- · assist participants with developing education scholarship ology curriculum for internal medicine residents. As the · integrate participants into a community of educators that program matures, we look forward to engaging participants can support their work and development. from a variety of GME programs, engaging our participants to help meet teaching needs of the medical school, and After an initial pilot program,2 the IUSM Department of increasing the scholarly productivity of our participants. Medicine launched and enrolled the first cohort of residents and fellows in 2018. In 2019, the program expanded Action item: Institutions should consider whether they are to accept residents and fellows from all IUSM graduate adequately preparing trainees to take on the role of clinician- medical education (GME) training programs. Our current educators and whether a GME-wide program might enhance cohort includes 15 residents and 6 fellows from 12 GME recruitment and retention of talented trainees. programs. Participants attend monthly, 90-minute skill- building workshops presented by IUSM faculty. ese work- References 1. Kumar K, Roberts C, Thistlethwaite J. Entering and navigating academic medicine: shops address diverse topics such as simulation, mentoring, Academic clinician-educators’ experiences. Med Educ 2011 May;45(5):497-503. DOI: teaching communication skills, the importance of diversity https://doi.org/10.1111/j.1365-2923.2010.03887.x 2. Dilly CK, Carlos WG, Hoffmann-Longtin K, Buckley J, Burgner A. Bridging the gap for future in education, and how to be promoted based on education clinician-educators. Clin Teach 2018 Dec;15(6):488-93. DOI: https://doi.org/10.1111/tct. work. During the first year, participants complete asyn- 12737 3. Bakken LL, Byars-Winston A, Wang MF. Viewing clinical research career development chronous curriculum development modules. In parallel through the lens of social cognitive career theory. Adv Health Sci Educ Theory Pract 2006 with the modules, they develop a curriculum of their own. Feb;11(1):91-110. DOI: https://doi.org/10.1007/s10459-005-3138-y During the second year of the program, they can either 4. Monrouxe LV. Identities, self and medical education. In: Walsh K, ed. Oxford textbook of medical education. Oxford, UK: Oxford University Press; 2013 Oct. DOI: https://doi.org/10. implement and evaluate this curriculum or complete an- 1093/med/9780199652679.003.0010 other education scholarship project. ey also have their teaching peer reviewed and review a peer’s teaching. Benefits to participants include a certificate, credibility when applying for clinician-educator jobs, membership in a Advancing an Academic Career in the Graduate Medical community of educators, and a better understanding of the Education Environment role of the clinician-educator and criteria for promotion, Anne Walling, MB, ChB which will help trainees be successful earlier in their careers. We have been studying the professional identity forma- Family and Community Medicine, University of Kansas School of tion of our participants. rough interviews every 6 months, Medicine-Wichita, Wichita, KS we have learned that the core elements of Socio-Cognitive Keywords: academic career, faculty advancement, graduate medical education, Career eory (self-efficacy, outcomes expectations, and women in medicine personal goals)3 and the possible identities theory4 fit nicely Conflict of interest: None. with our participants’ identity development. We have used DOI: https://doi.org/10.7812/TPP/20.030.16 our findings to enhance the program in several important ways, to support participants’ professional identity Building a successful career in academic medicine re- formation. ese program elements include encouraging quires interacting with institutional systems for academic longitudinal teaching experiences, improving scaffolding promotion and award of tenure (APT). Besides obvious ad- education scholarship projects, featuring role models who vantages for an individual, a successful promotion poten- describe their career pathways, and encouraging reflection tially enhances the residency program, specialty department, on teaching experiences and feedback received. During and institution, including in accreditation review.1 Never- our skills workshops, we are intentional about introducing theless, many clinical faculty members distrust the APT our participants into the community of faculty educators. system, and regard it as tedious, poorly related to their

56 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.030 SPECIAL REPORT AMWA GME Symposium

everyday activities, and biased toward classical research.2 · seek and use faculty development in one’s institution, Faced with escalating demands from clinical and educa- specialty organizations, or other organizations tional responsibilities, an increasing number of clinicians are · become involved in national organizations. delaying application for academic promotion—or declining to consider it altogether. For multiple, complex and often Strategies and resources are available to build appropriate synergistic reasons, women have slower rates of promotion credentials and proactively prepare for APT in the GME than do their male colleagues.3 In every clinical specialty environment.1 Ideally, preparation for academic promotion fewer women achieve professorial rank than do men; over- begins early; recruitment may be the best time to secure the all in 2019, 11.6% of all female full-time clinical faculty optimal academic track and position description. Faculty members were full professors, compared with 25.8% of their with a “promotion mindset” use daily activities and regular male colleagues.4 reviews to contribute to career growth. Regular docu- An understanding of basic concepts and practices in mentation of achievements in the institutional format builds APT provides insights on why the system can be so diffi- the evidence and helps monitor progress toward promotion. cult for female clinicians to navigate. For faculty based e promotion dossier must robustly convey achievements in graduate medical education (GME), the APT system is to reviewers, many of whom are research focused and/or particularly challenging because of the many differences have nonclinical backgrounds. Faculty based in GME pro- between GME programs and classic academic departments, grams may need to take additional steps to ensure that the plus a general identification of GME programs with the required documents (often formatted for research careers) health system (or hospital) rather than the medical school. convey the full extent and importance of their achievements. To build a successful academic career in the GME envi- Nevertheless, a GME-based faculty member can present ronment, a faculty member must take her career of clinician- a complete, valid, and persuasive dossier that enables re- educator or clinician-investigator seriously. e following viewers from diverse backgrounds to appreciate the quan- are recommended: tity, quality, and impact of the applicant’s achievements and her value to the institution—and above all, provides the · be on the APT track that best matches the position evidence and motivation for reviewers to enthusiastically description and daily responsibilities recommend academic promotion. · learn about the formal (and informal) APT process, criteria, expectations, and timelines Action item: Find out everything you can about the pro- · optimize energy and time; be resilient and persistent motion system at your institution. Schedule a serious discussion · identify and prioritize high-yield activities with your departmental or division Chair about your academic · ask (judiciously) to be involved; negotiate effectively; say track and practical strategies to fulfill all the expectations for “no” positively when necessary your next promotion. · excel in daily activities (and document the evidence to prove it!) fi References · nd scholarship in everyday activities: use everything at 1. Walling A. Academic promotion for clinicians: A practical guide to academic promotion and least twice (eg, parlay grand rounds talks and lectures into tenure in medical schools. Cham, Switzerland: Springer Nature; 2018. 2. Bunton SA, Corrice AM. Perceptions of the promotion process: An analysis of US medical review articles, clinical cases into case reports, and per- school faculty [Internet]. Analysis Brief 2011;11(5):1-2. Washington, DC: Association of sonal experiences into reflective essays; participate in American Medical Colleges [cited 2020 May 10]. Available from: https://core.ac.uk/ download/pdf/37765741.pdf discussions through letters to the editor) 3. Carr PL, Raj A, Kaplan SE, Terrin N, Breeze JL, Freund KM. Gender differences in document everything in the institutional format using academic medicine: Retention, rank, and leadership comparisons from the National · Faculty Survey. Acad Med 2018 Nov;93(11):1694-9. DOI: https://doi.org/10.1097/ACM. quantity, quality, and impact measures 0000000000002146 · ensure regular robust documented reviews of progress 4. Association of American Medical Colleges. Table 13. U.S. medical school faculty by secure APT advisors inside and outside one’s own di- sex, rank, and department, 2019 [Internet]. Association of American Medical Colleges · [cited 2020 Aug 13]. Available from: www.aamc.org/data-reports/faculty-institutions/report/ vision, department, or specialty faculty-roster-us-medical-school-faculty

Lisa Sanders, MD1; Belen Gallarza-Wilson, MD2 Perm J 2020;24:20.007 E-pub: 09/08/2020 https://doi.org/10.7812/TPP/20.007

Physician burnout is the current buzzword and signifies I became a women in medicine champion for my hospital how physicians are losing their way in this profession. and started championing for gender equity, diversity, and Countless hours of studying in medical school and training inclusion in this community. I have helped to plan our re- in residency are just the beginning of our careers. After gional Women in Medicine symposium, was recently chosen proving our worth time and time again, we graduate into the as part of the Emerging Leader cohort for our hospital, and real world of medicine and are confronted with real-world became assistant chief of the Emergency Department. issues. Overbooked schedules and electronic medical record- Belen Gallarza-Wilson, MD: I am a family medicine keeping deplete what little time there is during the work- physician by training and have worked as a per diem in both day to participate in educational meetings or a casual lunch family medicine and urgent care for the past 19 years. With with colleagues. Providers are increasingly faced with lon- a background in the humanities, I enjoy tempering the ger hours on the job to accommodate a growing patient rigors of medicine with the arts, finding joy in the narratives population and a shortage of physicians. Large amounts of my patients’ histories and life stories. is is not always of debt are accrued during medical school and training, easy to do, however, when multiple responsibilities compete and the possibility of cutting back hours to alleviate this for my time and attention as a working mother and wife. pressure can be challenging. e resilience of other pro- e magic of medicine often gets overlooked and is at times viders in medicine such as nurses, nurse practitioners, phy- replaced by irritability and fatigue. Fortunately, I have been sician assistants, dentists, and pharmacists is similarly being on several trips to Jamaica with Dr Lewin and Integrative tested. ese frontline providers in patient care can develop Clinics International, and I find that this type of medical “compassion fatigue,”1 and this is likely to lead to emotional mission travel provides me with a much-needed pause: a exhaustion and physical burnout. sanctioned time when I can step away from the demands of It often feels like we are always playing a game of catch- a fast-paced clinic yet still remain professionally relevant, up, and our purpose and meaning in medicine become lost. and a quiet place where I can repair intellectually. is may be especially true for women in medicine. We What if we could gather a group of female providers describe how we found a solution for burnout. abroad to inspire and renew the positive intentions of our Lisa Sanders, MD: As an emergency medicine doctor, this career in medicine? It has been shown that participating in impasse happened in the first decade of my professional short-term medical missions can have positive and mean- career, during which I had other personal milestones: ingful effects on such aspects of the workplace as “emotional marriage, the death of a parent, and overcoming infertility exhaustion and lack of personal accomplishment.”2 to have a child at age 40. e stagnant environment of being Last fall, we were chosen to be co-leaders for another a worker bee made me lose my inspiration and love of group to Jamaica. However, this would be different from the medicine. At a travel medicine conference in 2014, I heard a other trips: this would be a group composed of all women. colleague, Bruno Lewin, MD, speak about a charity he co- Our group included 7 physicians (including 1 resident), 4 founded, Integrative Clinics International, which performs nurses, 1 dentist, 1 acupuncturist, and 1 logistician to be 2 medical missions a year in Falmouth, Jamaica. I joined one exact. We were excited and nervous but saw the oppor- of the trips, and it changed my life. My love for medicine tunities afforded to us by this unique compilation of people. was rediscovered and renewed. By reflecting on my career Our trip was completed in the middle of October 2019, during this trip, it inspired me to look forward and focus on and the experience was exhilarating. Similar to previous the issues I wanted to tackle back home. trips with Integrative Clinics International, we were a group of like-minded individuals united by a common desire to serve the impoverished communities of Jamaica. We carried out the same clinics in the communities of Falmouth and Author Affiliations 1 Emergency Medicine Department, Kaiser Permanente Los Angeles, Los Angeles, CA Nine Mile and added on extra health fairs in Kingston and 2 Kaiser Permanente Baldwin Park – Family Medicine – Regular Clinic, Baldwin Park, CA Trelawny. Every day, our team collaborated to run the clinics and health fairs in a timely and efficient manner. In Corresponding Author addition to seeing patients, we counted and packed up Lisa Sanders, MD ([email protected]) medicines to provide to the community. e experience and Keywords: burnout, medical mission trip, women in medicine 58 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.007 NARRATIVE MEDICINE Collaborations, Connections, and Conversations: A Journey to Meaning in Medicine

goals of the medical mission remained the same. We de- CONNECTIONS scribe the ways in which our experiences were unique. As a group of professional women, our connections were palpable and authentic. On the first night, not only did we COLLABORATIONS introduce ourselves and find common ground, but we also ere was always a daily debriefing in Jamaica to discuss bonded over a book exchange of prominent Jamaican lit- the unique perspectives of medical care that each provider erature. During the week, we continually complimented brought to the day’s work. Our physicians (family practice, each other and supported every single person in our group internal medicine, emergency medicine, and OB/GYN) dis- in a number of ways. ere were no insecurities and our cussed the types of patients we saw with the group, from the confidence was high. In this setting, not one woman di- patient with the common cold to the possible dengue fever. minished another, and microaggressions were absent. ere e resident physician worked independently yet had 6 was recognition and respect between every participating strong female physicians by her side to teach and mentor member of the group. her. e nurses triaged more than 500 patients in the span of 4 days and worked tirelessly to make sure every patient CONVERSATIONS was seen and taken care of. Members of the group assisted No topic was off-limits. We shared stories of how we our dentist as she provided much-needed dental care and grew up and how we are raising our children. We discussed tooth extractions. Our acupuncturist was embraced as a prac- personal health concerns, how we practice self-care, and titioner of alternative medicine, and she taught us different how our various political and religious backgrounds shape ways to treat a patient. our worldview. We talked about our current positions in the

The Permanente Journal·https://doi.org/10.7812/TPP/20.007 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2020 The Permanente Press. All rights reserved. 59 NARRATIVE MEDICINE Collaborations, Connections, and Conversations: A Journey to Meaning in Medicine

workplace and where we see ourselves professionally in the Although a medical mission may not always be feasible future. By having these intimate conversations, we bonded for a provider to join, the lessons learned on this women’s as a group and learned that we are not alone in our struggles. trip will ensure a greater sense of unity and success in the More importantly, we each gained an instant community workplace. We may not be able to stem the tide of the from which to draw support, both during the mission week burdens associated with our profession, but it is our duty to and beyond. combat burnout in our own community with compassion We represented a communion of successful women, each and creativity. powerful in her own way. We came together through a One of our nurses, Mariamia Gil Huie, RN, said it best shared love of medicine and health promotion; some of us before we left for home: “I went to Jamaica to help others needed to recharge, rediscover, and reconnect. Mentoring but realized that I was the one being helped.” v our resident was invaluable because senior and peer mentoring has been shown to increase productivity and work How to Cite this Article satisfaction.3 We also left Jamaica with the emotional and Sanders L, Gallarza-Wilson B. Collaborations, connections, and conversations: A nurturing connections that women, in particular, are able to journey to meaning in medicine. Perm J 2020;24:20.007. DOI: https://doi.org/ 10.7812/TPP/20.007 make. We strongly believe that having these types of opportunities available for women in medicine can contribute to more successful organizations and a better sense of well- References being in the medical community. If we promote each other 1. Coetzee SK, Klopper HC. Compassion fatigue within nursing practice: A concept analysis. Nurs Health Sci 2010 Jun;12(2):235-43. DOI: https://doi.org/10.1111/j.1442- instead of battling the barriers to job advancement alone, we 2018.2010.00526.x will allow women to rise to leadership positions. If we 2. Campbell C, Campbell D, Krier D, Kuehlthau R, Hilmes T, Stromberger M. Reduction in burnout may be a beneﬁt for short-term medical mission volunteers. support and listen to each other when another struggles Ment Health Religion Cult 2009 Nov;12(7):627-37. DOI: https://doi.org/10.1080/ with work-life balance, we can prevent burnout and despair. 13674670903124541 3. Levinson W, Kaufman K, Clark B, Tolle SW. Mentors and role models for women in If we collaborate and honor the work of our female col- academic medicine. West J Med 1991 Apr;154(4):423-6. https://www.ncbi.nlm.nih.gov/ leagues, we empower and prosper together. pmc/articles/PMC1002790/