State of Women in Medicine: History, Challenges, and the Benefits of a Diverse Workforce Madeline M

State of Women in Medicine: History, Challenges, and the Benefits of a Diverse Workforce Madeline M. Joseph, MD, FAAP, FACEP,a Amy M. Ahasic, MD, MPH, FCCP, ATSF,b Jesse Clark, DO, FAAFP,c Kim Templeton, MD, FAAOS, FAOA, FAMWAd

Women in medicine have made progress since Elizabeth Blackwell: the first women to receive abstract her medical degree in the United States in 1849. Yet although women currently represent just over one-half of medical school applicants and matriculates, they continue to face many challenges that hinder them from entering residency, achieving leadership positions that exhibit final decision-making and budgetary power, and, in academic medicine, being promoted. Challenges include gender bias in promotion, salary inequity, professional isolation, bullying, sexual harassment, and lack of recognition, all of which lead to higher rates of attrition and burnout in women physicians. These challenges are even greater for women from groups that have historically been marginalized and excluded, in all aspects of their career and especially in achieving leadership positions. It is important to note that, in several studies, it was indicated that women physicians are more likely to adhere to clinical guidelines, provide preventive care and psychosocial counseling, and spend more time with their patients than their male peers. Additionally, some studies reveal improved clinical outcomes with women physicians. Therefore, it is critical for health care systems to promote workforce diversity in medicine and support women physicians in their career development and success and their wellness from early to late career.

aDivision of Pediatric Emergency Medicine, Department of Emergency Medicine, College of Medicine-Jacksonville, University of Florida, Jacksonville, Florida; bSection of Pulmonary and Critical Care Medicine, Department of Medicine, Norwalk Hospital, Nuvance Health, Norwalk, Connecticut; cCommunity Hospital East, Family Medicine Residency, College of Osteopathic Medicine, Marian University, Indianapolis, Indiana; and dDepartment of Orthopaedic Surgery, University of Kansas, Medical Center, Kansas City, Kansas

All authors conceptualized and designed the manuscript, drafted sections of the manuscript, reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. DOI: https://doi.org/10.1542/peds.2021-051440C Accepted for publication June 22, 2021 Address correspondence to Madeline M. Joseph, MD, FAAP, FACEP, Department of Emergency Medicine, College of Medicine-Jacksonville, University of Florida, 655 W 8th St, Jacksonville, FL 32209. E-mail: [email protected]fl.edu PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2021 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. FUNDING: No external funding. POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS Volume 148, number s2, September 2021:e2021051440C SUPPLEMENT ARTICLE HISTORY OF WOMEN IN MEDICINE 30% of graduates from some medical “priced out” with rising tuitions and 5 2 Women seem to have always been schools. Traditionally male-only increasing opportunity costs. The 7 healers. In Ancient Egypt, Isis was medical schools also started to accept Black medical schools running before universally worshipped as the women, lauded by some as a step the Flexner report were whittled goddess of medicine, and her toward gender equity in medicine, down to only 2, and graduates priestesses were accepted as but this shift also resulted in many commonly struggled to get ’ 2 physician-healers.1 In Ancient women s medical schools closing or internships or hospital privileges. Greece, Hygeia and Panacea, the merging with existing medical 2 daughters of Aesculapius, were schools. As the feminist movement “sainted mortals” and likely burgeoned in the United States in Around the turn of the century, the practiced as independent the 1970s, there was renewed American Medical Association’s physicians.1 In both Ancient Egypt attention to the role of women in priority to reform medical schools, and Ancient Greece, women medicine and particular attention to standardize, and set minimum appeared to be widely accepted as the paternalistic culture of American requirements for medical education physicians and surgeons.1 From the medicine, in which women who ultimately led to the Flexner report Middle Ages to Colonial America, were patients and nurses were being published in 1910. This report women bore the responsibility for routinely denied the right to was an independent critique of US 2 most medical care in the home.1,2 participate in medical decisions. medical schools and medical This included women in their The proportion of women medical education, supported by the traditional domestic roles and students increased substantially Carnegie Foundation for the women as lay practitioners, but they during the 1970s, representing Advancement of Teaching and >25% of US medical students by the were not typically recognized as 2 2 2 authored by Abraham Flexner. end of the decade. professionals. However, this role Although the number of medical started to change in the schools had already started to STATE OF WOMEN IN MEDICINE midnineteenth century with 1 major decline in the years leading up to milestone, the admittance of the Flexner report, this trend was Acknowledging the state of women Elizabeth Blackwell to medical accelerated by requirements for in medicine is key to understanding school at Geneva College in New longer training periods and higher existing systems and structures that York. Her admittance, however, had tuitions resulting from the higher may influence the trajectory of 3 ’ been intended as a practical joke, costs to medical schools to provide women s progress in medicine, in but she persevered and became the adequate medical education.2 both academic and nonacademic first women to receive a medical Although Flexner himself had stated settings. In addition to educational degree in the United States in 1849. that “privileges must be granted to initiatives for women, data She graduated first in her class and women … on the same terms as collection and analysis are needed ’ 1 then worked in children s hospitals men,” the consequences of the to implement systemic and 4 in London and Scotland, later more stringent educational institution-level interventions to opening the New York Infirmary for standards included a morphing of achieve gender equity and inclusion Women and Children in 1857. the profession into one that was in medicine. Because of the more socially uniform, with variability of practice settings in the Inthelate1800s,therewasasurge declining access of women to United States, it remains difficult to in the number of medical schools. medical education.2 As a result, obtain data from nonacademic These included schools in established women accounted for only 6% of US settings; therefore, much of the data colleges and universities like Johns physicians in 1910, which remained presented here are from academic Hopkins, which opened its medical the same for 50 years.5 environments. However, many of the school in 1893, but also included challenges faced by women in many proprietary and commercial The aftermath of the Flexner report medicine are universal and not 2 medical schools. This increased in creating a more socially unique to their practice setting, so access to medical education opened homogeneous profession also created the concepts presented are broadly the door for women to take on the barriers for immigrants, lower and applicable to academic and professional role of physician, and, by working class Americans, Jewish nonacademic environments. the end of the nineteenth century, Americans, and Black Americans, there were 17 medical colleges for who, along with women, were Since 1983, the Association of womenintheUnitedStates.2 In the discriminated against in their efforts American Medical Colleges has 1890s, women made up as many as to access medical education, or were reported data on women’s

Downloaded from www.aappublications.org/news by guest on October 2, 2021 S2 JOSEPH et al representation in all facets of majority only at the instructor level women of color in departmental medicine using a variety of survey (58%).6 Women faculty from an leadership positions. Beyond the data to illustrate women’s underrepresented-in-medicine race or numbers, women faculty in leadership representation as learners, faculty, ethnicity increased only from 12% in positions were more commonly in and leaders in medicine. In 2009% to 13% in 2018, and women offices that are perceived to be September 2020, the Association of at the full professor rank are 74.6% communal and less influential, such as American Medical Colleges white.6 Overall, 49% of medical offices for diversity, equity, and published its 2018–2019 report on schools reported having a formal inclusion; faculty affairs and/or “ the State of Women in Academic position dedicated to women and/or development; and student affairs and/ ” Medicine. This report reveals that gender equity beyond Title IX and/or or admissions. On the other hand, the although women represent just compliance roles, and this position smallest proportions of women > 50% of medical school applicants was allocated an average of only 0.38 leaders were in offices for research and clinical and/or health affairs.6 This and matriculates, they represent full-time equivalents.6 The proportion only 47.9% of medical school highlights that woman leaders are not of women as division and section graduates, and, in fact, women have in roles that exhibit final decision- chiefs has increased from 16% in never represented $50% of medical making and budgetary power. 2003% to 29% in 2018, an increase of school graduates.6 Although racial only 1% per year.6 Women as and ethnic diversity have been slow In a recent Journal of the American department chairs have grown from to increase, women do represent a Medical Association study, men had 13% in 2009% to 18% in 2018, slightly more diverse group of more National Institutes of Health medical school graduates than men similar to the increase in women as (NIH) awards overall and, therefore, 7 do.6 Although only a small attrition deans rising from 12% to 18% across more total funding. Across all NIH 6 from medical school graduation, thesameperiod. Of importance, funding mechanisms, women women represent only 45.6% of among women department chairs, the received 23% of awards in 1998, 7 total US medical residents6 (Fig 1). vast majority were white, and only slowly increasing to 35% by 2020. 8%and5%ofallwomeninthese A major factor in funding disparity The proportion of women in all faculty positions were Black or African by gender is the low number of ranks has increased since 2009, but American or Hispanic, respectively.6 grant applications submitted by women continue to represent a This reveals a significant shortage of women relative to men, a disparity relatively proportional to that of women in faculty positions making up the NIH research grant applicant pool. Disparities in funding are even greater for women who are also underrepresented in medicine.8 On the other hand, when women apply for NIH funding, award amounts were larger for R01s (R01 awards being the NIH gold standard for independent research awards) associated with women program directors and principal investigators. In addition, once women are funded, their funding longevity is similar to that of men.9–10

Lack of support for women participating in research contributes to their slower progress through the academic ranks and into leadership positions. To close the gaps in NIH FIGURE 1 funding gender disparities, it is Full-time women faculty as a percentage of each rank, 2009–2018. In this figure, we exclude critical not only to train women in faculty with missing gender, which accounts for <0.5% of all faculty in each snapshot year. grant writing and the grant review Adapted from AAMC Faculty Roster (December 31, 2018 snapshot). process but also to address

PEDIATRICS Volume 148, number s2,Downloaded September 2021from www.aappublications.org/news by guest on October 2, 2021 S3 challenges faced by women in among medical specialties. Among was revealed in a cross-sectional transitioning to independent residents, women continue to enter study in which researchers research, career development, and fields such as obstetrics and examined nationally representative advancement. It is also important to gynecology, pediatrics, and data of hospitalized Medicare take steps to mitigate gender dermatology at high rates (83%, beneficiaries, comparing mortality stereotypes in the research 71%, and 60%, respectively); and readmission rates of patients community and promote inclusive however, little progress has been cared for by men and women environments, in which all scientists made in terms of increasing their physicians. Results revealed that can achieve their maximal potential representation in surgical specialties patients treated by women to advance science. and other fields, such as radiology, physicians had significantly lower that have traditionally had few mortality rates and readmission There are several factors that may women.5 Mentorship, sponsorship rates compared with those cared for prevent women from pursuing an and salary equity are among some of by male physicians within the same academic career, including a lack of the factors that create biases or hospital.23 In other aspects of adequate mentoring and suitable structural barriers hindering women’s patient care, such as procedures and – role models, work life balance, and representation across all medical postsurgical care, studies have financial concerns, but the impact of fields. revealed that the patients of women such factors is not clearly physicians tend to experience better 10 understood. Because the greatest There are several studies in which outcomes.24,24 In a study of attrition in commitment to research researchers suggest differences in >100 000 patients who underwent seems to occur during residency, it practice patterns and measures of surgical procedures, the authors is imperative that medical schools quality between women and men found that fewer patients treated by and teaching hospitals work in physicians. For example, women female surgeons died, were partnership to improve gender physicians may be more likely to readmitted to the hospital, or 12–14 climate and culture at the interface adhere to clinical guidelines, experienced complications in the 30 between the medical school and providepreventivecaremoreoften, days after a surgery than those teaching hospitals (Table 1).11 including cancer-specific prevention treated by male surgeons. These 15,16 services, and provide more results were concluded after BENEFITS OF A DIVERSE WORKFORCE psychosocial counseling to their patients were matched on the basis IN MEDICINE 17,18 patients than their male peers do. of age, gender, the presence of other In both academic medicine and the In quality metrics, women physicians diseases or medical conditions, private industry, researchers have tend to use more patient-centered hospital, and surgeon age and found that organizational strategies, communication, when compared with number of surgeries they had 19–21 decision-making processes, and male physicians. In other performed.25 outcomes are strengthened by research, it was indicated that women including and engaging diverse physicians are likely to spend more More broadly, there is a growing perspectives, including gender, racial, time with their patients than male awareness that patients from a ethnic, and other elements of physicians are and adopt a more variety of groups that have diversity. As noted above, women partnership-building style with historically been marginalized and have made strides in terms of entry patients.22 excluded are not being adequately into medicine, although the success of served by the current medical those from historically marginalized In addition, the differences noted in profession and that patient needs andexcludedgroupshasbeenmuch practice patterns between men and may be better met by having more limited and challenging. It is women physicians may have physicians who reflect the diversity also critical to note that women important clinical implications for of patient characteristics and representation in medicine is uneven patient outcomes. This importance experiences. For example, the ability to provide linguistically and TABLE 1 Challenges for Women in Medicine culturally competent care may Potential Challenges emanate from a more diverse Often lack final decision-making and budgetary power workforce. Racial and ethnic or Lack of adequate mentors and role models linguistic concordance have been Greater work–life imbalance and higher rates of burnout identified as key to improving Salary inequities communication and trust in mental Professional isolation especially in subspecialities such as surgery health, essential in the development

Downloaded from www.aappublications.org/news by guest on October 2, 2021 S4 JOSEPH et al of a therapeutic alliance for those such as maternity leave and child the status quo, successful middle needing access to care.26 In addition, care. Although much has been and late career women physicians research has revealed that accomplished, there is still much to continue to be at risk for becoming physicians from historically be done in these areas as well as in victims. In a recent study of more marginalized and excluded groups addressing career development for senior women physicians,34 are more likely to provide care to early-career women physicians, researchers found that although those living in underserved gender bias in promotion and episodes of sexual harassment areas.27–29 Similarly, Americans with attainment of leadership positions, declined with physician age, 10% of disabilities are less likely to receive salary inequity, and professional women physicians over the age of routine medical care, including isolation. However, with a few 60 were still at least at least cancer screening, flu vaccines, and notable exceptions, these efforts tend occasionally victims of sexual vision and dental examinations, and nottobedirectedtowardwomen harassment, with a slighter higher have higher rates of unaddressed physicians in middle or late career, percentage noting verbal abuse or risk factors such as obesity, with the presumption that the bullying on the basis of age. Women smoking, and hypertension.29 challenges and biases faced by early- from racial groups that are Increasing physicians and learners career women will no longer remain underrepresented in medicine often with lived experiences of disability significant issues or impediments face additional challenges because into the workforce can help address with increased seniority and this discrimination is compounded health disparities in patients with experience. Unfortunately, that is not by race-based harassment and bias. disabilities. This is due to the ability the case, and the continuation of of physicians with such experiences theseissuesintomiddleandlate Although more prevalent and consistent policies regarding to demonstrate empathy to these career may be relatively invisible to parental leave and child care are patientsandbearolemodeltoother colleagues, institutions, researchers, needed, the challenges facing physicians in the care of patients with and commentators. women are broader than those at disabilities.30 Recruitment, retention, Seniority and accomplishments in the policy-level. It is important to and promotion of women physicians medicine alone do not protect women remember that societal gendered from a variety of groups may help from the myriad forms of gender-based expectations assume that women, better represent the diversity of the bias and discrimination. Formal regardless of age or profession, will US patient population and better recognition of professional continue to be the primary meet their needs. accomplishments,suchasawardsfrom caretakers for their families. Women 31 In many of these studies, researchers medical societies and invitations to physicians in middle age and older present correlations between speak at conferences and grand are often caretakers for rounds,32 are less likely to be conferred grandchildren, elderly parents and/ physician gender and other onwomenthanmen.Inaddition,when or partners, and other family demographics and patient outcomes. speaking at grand rounds, women are members. These family Even where causation was not less likely to be introduced by their responsibilities and issues with demonstrated, it is important to note professional titles.33 One-third of work–home interference for women that, in these studies, researchers did women physicians over the age of 60 are career-long, yet, again, policies document observable trends in noted, in a recent study, that they still and resources are focused almost patient outcomes and might inform experience gender-based exclusively on issues for early- future research on the delivery of discrimination.34 The slower career physicians. medical care. advancement of women’scareersin medicine lasts throughout the career Gender bias, sexual harassment, lack IMPORTANCE OF SUPPORTING WOMEN continuum, as evidenced by the low of recognition, slower career THROUGH THE CAREER CONTINUUM: advancement, salary inequities, and EARLY, MIDDLE AND LATE CAREER number of women tenured professors, department chairs, and deans of medical lack of career-long family leave With increasing numbers of women schoolsaswellasleadershippositionsin policies can lead women to feel a entering medical school, there has hospitals and medical practices. lack of connection and sense of been more focus placed on providing belonging in the workplace. These opportunities for women students Bullying and sexual harassment, in outcomes are major drivers in the and early-career physicians to all their forms, are also not only a development of burnout35 and may succeed. This much-needed support is concern for early-career women lead to women becoming intended to fill gaps in areas of physicians. Because these behaviors disillusioned and potentially leaving mentorship as well as address issues are typically attempts to maintain medicine. The higher rates of

PEDIATRICS Volume 148, number s2,Downloaded September 2021from www.aappublications.org/news by guest on October 2, 2021 S5 TABLE 2 Opportunities to Support Women in Medicine continue to bring in new Medical schools and teaching hospitals partner to improve gender climate and culture. perspectives. We would also Include and engage diverse perspectives across gender, race, ethnicity, and other elements of recommend limits on terms of diversity throughout organizational strategies. leadership within academia, so that Recruit and promote women physicians from a variety of groups to better reflect the diversity of the US patient population and improve patient outcomes. womeninterestedinleadershipare Design supports for women physicians across the career continuum. recognized and allowed to fulfill their Conduct regular environmental assessments. potential. These actions can help Provide consistent and recurring equity trainings, such as implicit bias training. organizations retain and promote Actively promote an inclusive organizational culture. women in their careers by systematically addressing biases, microaggressions, and stereotype burnout noted among women harassment and gender- and age- threats and promoting a more physicians as compared with men based biases, developing career-long inclusive and supportive culture 36,37 might be attributed to differences in family leave policies, and making (Table 2). presentation and reporting. women feel welcome in medicine. However, even if the prevalence is This requires the engagement and SUMMARY similar, risk factors and institution- investment of all physicians, Although women have made great based efforts to address this differ. especially men currently in leadership progress in terms of entering positions. The mental image of the medicine, they continue to face many In parallel with the sharpened focus “ ” pipeline ofwomeninmedicine challenges that can hinder them from on women medical students and must change from one of getting entering residency, achieving early-career physicians, there has women into the pipeline to start this leadership positions that exhibit final been increased attention on the lack career to one in which women decision-making and budgetary of women in senior leadership become successful while advancing power, and, in academic medicine, positions in medicine. However, throughout their rewarding career. being promoted. Women from advancement of women into historically marginalized and leadership roles in medicine cannot To ensure that students of all genders excluded groups experience occur, regardless of investments in have equal opportunities to become additional barriers, including bias and the initial pipeline and early-career the next generation of leaders and discrimination. In addition to development, if women lack support innovators in medicine, health care educational initiatives for women, during the entirety of their careers. organizations, medical schools, and data collection and analysis are By midcareer, the time at which teaching hospitals might consider needed to implement systemic and physicians are typically applying or conducting regular and recurring institution-level interventions to being considered for leadership environmental assessments and achieve gender equity and inclusion positions, women may become equity trainings, such as implicit bias in medicine. Attention to engagement disillusioned and give up aspirations training. However, implicit bias and promotion of women in science to achieve leadership positions or training tends to be a passive activity, and medicine at all stages of the leave the profession entirely. The and having faculty, especially those career continuum is critical to solution to the issues being faced by on search or promotion committees, ongoing progress. women physicians is not to wait to and leadership identify their own havemorewomeninleadership biases through such assessments such positions. Although that will be a as the Implicit Association Test or ABBREVIATION major step forward, it will not occur similar individual testing may help to unless the issues that women face at inform their decisions. In addition, NIH: National Institutes of Health all stages of their careers, especially there should be mandated gender middle and late career are addressed, and race diversity within search and including eliminating sexual hiring and promotion committees, to

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PEDIATRICS Volume 148, number s2,Downloaded September 2021from www.aappublications.org/news by guest on October 2, 2021 S7 State of Women in Medicine: History, Challenges, and the Benefits of a Diverse Workforce Madeline M. Joseph, Amy M. Ahasic, Jesse Clark and Kim Templeton Pediatrics 2021;148; DOI: 10.1542/peds.2021-051440C

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