Women in ID push against glass ceiling

Often, as an attending physician, Jasmine Riviere Marcelin, MD, is the only woman on her team. She graduated medical school at the top of her class, finished her ID fellowship in June 2017 and has already landed a position as associate medical director of her institution’s antimicrobial stewardship program. Despite her accomplishments, when managing patients, Marcelin said the power balance inevitably shifts to her male trainees.

“I am an African-American woman. I am short, and I look young. All of these things are working against me,” Marcelin, assistant professor of infectious diseases at the University of Nebraska Medical Center, told Infectious Disease News. “My male trainees are often taller and have deeper voices than me. I find that a lot of times, patients look to them for answers, which is pretty interesting because I always introduce myself as the one in charge.”

Study findings published in 2017 in JAMA Internal Medicine showed that patients cared for by women physicians experience better outcomes than those treated by men. Yet other women in ID shared similar stories with Infectious Disease News about times when they were overlooked, seemingly because of their gender.

“I will walk into a patient’s room with my white coat on and the patient will say to me, ‘I haven’t seen my doctor today,’” said Beth Thielen, MD, PhD, adult and pediatric ID fellow in the departments of medicine and pediatrics at the University of Minnesota.

Source: Sara Bares

Gender biases affect women physicians at work on a daily basis, extending well beyond patients, according to those in the field. Women said they feel as though their opinions are not always valued as much as those of their male colleagues, including men with similar levels of training and experience. Marcelin said there are situations in which she must raise her voice to be heard.

“I know sometimes that happens because I am a woman,” she said. “I can’t make myself bigger. I can’t make myself look less young. I can’t make myself not black. But I know if I assert myself and speak up, then people will listen to me.”

Research has shown that implicit and unconscious gender biases can lead to disparities in compensation, promotion and other career advancement opportunities for women. Infectious Disease News spoke with women in ID to find out how often they encounter these biases, the impact they have had on their careers and what is being done to break down ossified attitudes about gender in medical science.

Rising numbers

The number of women entering the medical field has changed drastically over the past several decades. According to the Association of American Medical Colleges (AAMC), the percentage of medical school graduates who were women rose from less than 7% in 1966 to more than 46% in 2016. That corresponds with trends in Infectious Diseases Society of America membership, said Wendy S. Armstrong, MD, professor of medicine at the Emory University School of Medicine and a past chair of the HIV Medicine Association. Although women account for only about 10% of IDSA members aged older than 65 years, they represent approximately 40% of members aged 45 to 55 years and 50% of members aged 45 years and younger.

“You do not see as much equal representation in some other subspecialties, so to see it in ID is wonderful,” Armstrong said.

In 2015, 39.7% of active ID physicians were women — slightly higher than the national average across all medical specialties of 34%, according to AAMC. The number of women in leadership positions across all medical specialties in the United States remains low. AAMC data show the percentage of women who were medical school deans increased from 0% in 1966 to 17% in 2017. Over the course of a decade, from 2004 to 2014, the percentage of women who were division heads increased from 10% to 16%, department chairs increased from 10% to 15% and full professors increased from 14% to 22%. Monica Gandhi, MD, MPH, professor of medicine at the University of California, San Francisco, said the estimates for ID may be similar.

“Those statistics are not very encouraging because they have not changed as much as you would have thought over the last 10 years for women in higher academic ranks at universities,” Gandhi said in an interview.

Data indicate that minorities in ID continue to be significantly underrepresented. According to the Accreditation Council for Graduate Medical Education, 52% of adult ID trainees and 72% of pediatric ID trainees in 2016 were women. Among them, only 7% of adult ID trainees and 8.6% of pediatric ID trainees were black, and 12% and 10.5%, respectively, were Hispanic.

“This is true in every medical field,” Gandhi said. “It may be a little bit better in ID because this field tends to attract people who are interested in social justice. People who suffer from inequities are sometimes more compelled to go into fields where inequities are addressed, which ID does.”

Gender inequities

Because women are underrepresented in leadership positions, the few women who are eligible to serve on committees are frequently asked to take on multiple assignments, according to Armstrong. Taking on so many organizational and, often, administrative roles adds to the burden of work.

“There is an over-commitment of time because of an increasingly recognized need to have female or minority representation,” Armstrong said. “I think that women feel a commitment to do these citizenship activities for their academic division or group, whereas men are able to focus on activities that are more likely to potentially advance their academic careers.”

“Cultural taxation,” in which women and underrepresented minorities feel obligated to continuously participate in uncompensated institutional services, can be “at the expense of their own clinical and research productivity,” Judith A. Aberg, MD, chief of the division of infectious diseases at the Icahn School of Medicine at Mount Sinai and past chair of the HIVMA, and colleagues wrote last year in The Journal of Infectious Diseases. Gandhi said because women are often expected to represent their entire gender during these citizenship activities, they feel a constant pressure to go above and beyond their duties.

“I think women [researchers] work really hard and probably have slightly different expectations than men,” she said. “They feel they have to be extra professional, extra responsible and extra good at their job because they are trying to overcome these gender biases.”

Other women agreed that they need to prove themselves by performing additional responsibilities before getting promoted, including scheduling, participating in medical education, designing curriculum, giving lectures and working in remediation with struggling learners.

“No one ever verbalized to me that because I am a woman, I need to do more than others. But sometimes, you just feel like that is the case,” Marcelin said. “It seemed like men were being handed research ideas and opportunities. When I asked for them, they just were not there. I had to create my own.”

Results of a survey distributed to more than 3,000 life sciences faculty members at 50 universities showed that women professors worked more hours per week and performed more administrative and professional activities than men. Despite working more hours, women researchers earned on average $13,226 less per year than their male counterparts. Recent survey data from the IDSA revealed that women members earn less than their male colleagues, regardless of their career path. The average difference in annual pay among researchers, clinicians and those working in public health ranges from $20,000 to $50,000.

The additional administrative work that women frequently undertake does not always increase their chances for career advancement, according to Thielen.

“We receive the message that NIH grant funding and publications are more valued in the traditional academic environment,” she said. “While participating in these other activities is important, it may not garner women the same academic promotion abilities as male colleagues, potentially.”

A research letter published in JAMA showed that junior biomedical researchers who are women are less likely than men to receive NIH grant funding. According to the data, 42% of men vs. 10% of women who requested funding were awarded at least $1 million. Women also received significantly less financial support from their institutions for research equipment and supplies. Men, on average, reported receiving $889,000, whereas women said they received approximately $350,000. The authors said the difference could not be explained by education level, years of experience or institutional characteristics.

“Women who apply for NIH grants get higher praise, but lower scores on their NIH grants than men with the same level of training,” Jason P. Burnham, MD, an instructor of medicine at the Washington University School of Medicine in St. Louis, told Infectious Disease News.

In addition to gender disparities at work, Burnham said women are disproportionately affected by responsibilities at home.

“Society expects them to take on the primary caregiver/housemaker role,” he said. “In effect, women end up working two full-time jobs — one at work and one at home. Never being off the clock certainly makes doing either job more challenging.”

Although experts said there has been a shift in responsibilities among men and women, with men taking on more roles that were traditionally viewed as those belonging to women, Carlos del Rio, MD, an ID specialist, past chair of HIVMA andprofessor of medicine at Emory School of Medicine, said there is still an imbalance.

“In my own experience, I try to be as helpful in the household and with parenting as I can,” he told Infectious Disease News. “I try to split the work up with my wife, but at the end of the day, the kids want their mom.”

Women themselves can create barriers to success by focusing on the challenges of raising a family and having a career, Aberg said in an interview. The key to overcoming this, she noted, is confidence. Aberg herself began her career as a single parent of young children. With her ex-husband in another country and no direct family support where she was living, there were times during medical school when she brought her children to class with her.

“They sat in the back while I took notes,” Aberg said. “My children were very much aware of what my career goals were, so we had to adjust how we functioned as a family. The point is, if you have the confidence and the drive to do what it takes to accomplish your goals, you find a way to make it work. There’s no reason why a woman can’t have a career in any type of medical field that she desires.”

Discrimination and harassment

More than one-third of physicians who are mothers in the U.S. report experiencing maternal discrimination, defined as negative attitudes toward pregnancy, maternity leave and breastfeeding, according to data published in JAMA Internal Medicine.

“Women do often end up taking more time off and have to bear more of the responsibilities for family care,” Jeanne Marrazzo, MD, director in the division of infectious diseases, University of Alabama at Birmingham School of Medicine, told Infectious Disease News. “Even if your boss is supportive, you still have a sense that you are missing time from work that you try to make up for while the baby is napping.”

A separate survey published in JAMA explored another area in which women are disproportionately affected: sexual harassment. Of more than 1,000 respondents, 66% of women physician-scientists said they experience gender bias vs. 10% of men, and 30% percent said they have been sexually harassed at work vs. 4% of men.

Of the 150 women who reported sexual harassment, nearly all (92%) indicated they experienced sexist remarks or behavior; 41.3% indicated they were subjected to unwanted sexual advances; 9.3% reported coercive advances; 6% reported subtle bribery to engage in sexual behavior; and 1.3% indicated they received threats to engage in sexual behavior.

“I find it really fascinating that people don’t talk about this,” Gandhi said. “If we can bring this to consciousness, that in and of itself can make a change.”

‘Manels’

Earlier this year, Julie M. Overbaugh, PhD, member of the human biology and public health sciences division and Endowed Chair for Graduate Education at the Fred Hutchinson Cancer Research Center in Seattle, published a commentary in the Journal of Virology that examined the number of women who were last and corresponding authors of research papers in high-impact journals. Over a 3-year period from July 2014 to December 2017, only one of 34 HIV papers in Science had a woman as the “most coveted last and senior author position,” according to Overbaugh. A sample of HIV research papers published in Nature and Cell showed that 8.3% and 11.4%, respectively, had women corresponding or co-corresponding authors.

“These statistics prompted me to ask the obvious question: If we are at a point where women in the HIV field have leadership roles and make substantial contributions to HIV science, then why can’t women break through in some important benchmarks of scientific excellence, such as publishing in high-profile journals?” Overbaugh wrote.

She reviewed potential explanations for why fewer women than men are senior authors. Women, she said, may tend to be more cautious in their conclusions, which could make their study seem less novel to a publisher. In addition, women may not be as effective as men in advocating for themselves, particularly when trying to reverse a negative decision by an editor.

“One way to address this is to provide women with the tools to advocate better for themselves,” Overbaugh wrote. “Indeed, journals could do this through workshops at meetings and include all interested parties, especially junior investigators, both men and women. In that way, the end result of a submission would rest on whether the science is robust and novel, as it should.”

Additionally, women are overlooked when it comes to awards. From 1977 to 2010, only five out of 49 recipients of the IDSA’s Society Citation Award were women. This trend is beginning to shift, with six out of 15 award recipients from 2011 to 2017 being women.

“I think one challenge is that most award winners are older because many of these are achievement awards that represent a time when more men were in medicine,” said Armstrong, a recent recipient of the Society Citation Award. “However, award winners at national societies are still predominately male.”

More women are involved in major scientific conferences, but gender remains an issue in this area. According to Armstrong, the IDSA has made an effort to ensure women are invited to speak at IDWeek. She reported a significant increase in the proportion of women speakers over the last 3 years, which is now approximately 50%. At this year’s Conference on Retroviruses and Opportunistic Infections, conference chair Judith S. Currier, MD, professor of medicine and chief of the division of infectious diseases at the University of California, Los Angeles, announced that the first authors on 537 of the 990 accepted abstracts were women. It was the first time that more women presented at the conference than men.

“Why do you think that is? Look who is at the table making decisions,” Marrazzo said, referring to Currier. “The business really gets done in the planning process. That’s where we need to be.”

Still, men frequently dominate the stage at smaller meetings. Marrazzo said the constant lack of diversity in expert panels comprised of only men — what she calls “manels” — is “discouraging.” She and others have openly voiced opposition to them. In fact, del Rio said he will not participate in a panel without equal gender representation because “it is in the best interest of our profession” to ensure that discussions involve a diverse group of physicians.

“This goes beyond gender,” Marrazzo said. “This is about diversity and recognizing that people who don’t look like you bring something very different to the table that is incredibly valuable.”

‘Women are pulling. Men need to push’

Major efforts to reduce disparities among women in the health care workforce began nearly 3 decades ago, according to Aberg and colleagues. In 1990, the NIH created the Office of Research on Women’s Health to promote research on gender roles in health as well as to recruit and retain more women in biomedical careers. Within this office, NIH established the Women of Color Research Network, which specifically facilitates research careers for minority women. In 1991, the Council of Ethical and Judicial Affairs for the AMA released data on gender inequities in clinical decision-making to raise awareness of cultural and social biases. Since then, loan repayment programs and fellowships were established to increase the presence of women and underrepresented minorities in medical school.

More recently, the American College of Physicians published a paper in April with recommendations to improve compensation and opportunities for advancement in organizations that employ physicians. Its recommendations include investment in leadership development and to implement policies that promote equitable compensation, as well as parental and family leave.

According to Currier, there are more opportunities for women in ID now than ever before, and she expects that the number of women in leadership roles will continue to increase. In ID, progress has been largely driven by women, but the role of men moving forward will be crucial, according to del Rio.

“Women are pulling. Men need to push,” he said. “It has to be a joint effort. We need to be persistent and make sure that we are bringing this up on a daily basis. If not, we are failing as a profession.”

The IDSA Foundation recently launched a campaign called “Women of ID,” a compilation of stories about the struggles and successes of women in the field. This year, the campaign honored four women, including Aberg.

“What these women have done to impact humanity can’t be measured, but the barriers they have gone through have really helped women today,” IDSA Foundation chief development officer Simintha Esson told Infectious Disease News. “It’s good to take a moment and reflect on the hardships these women went through. And they excelled. If they failed, it would have taken us steps back. But because they excelled, it put us steps ahead.”

Aberg said much more can still be done to close the gap in gender disparities, which she suspects is probably going to take another generation or two. In September 2016, the IDSA established the Gender Disparity Task Force, which presented recommendations addressing gender disparities in ID to the organization’s board of directors at IDWeek 2017.

“We called upon IDSA to develop a strategic plan to improve the diversity of our workforce and eliminate disparities,” Aberg said. “I was pleased to see that on July 3, the IDSA Board of Directors announced the approval to establish the Diversity, Inclusion and Equity Task Force.”

The first step to eliminating gender biases may be acknowledging they exist. Having strong female role models and making a conscious effort to bring diversity into the workplace are also key, experts said.

“ID is an area that has always been in tune to disparities and inequities,” Armstrong said. “It is part of the patients we care for and the diseases we embrace. Therefore, I think as ID recognizes there have been gender inequities, we are taking really active steps to address that. This is a really exciting specialty to be in as a woman and one that I’m really confident is willing to address any challenges that exist.” – by Stephanie Viguers

• References:
• AAMC. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2015-2016. https://www.aamc.org/members/gwims/statistics/. Accessed June 15, 2018.  
• Aberg JA, et al. J Infect Dis. 2017;doi:10.1093/infdis/jix332.
• Adesoye T, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2017.1394.
• Butkus R, et al. Ann Intern Med. 2018;doi: 10.7326/M17-3438.
• DesRoches CM, et al. Acad Med. 2010;doi:10.1097/ACM.0b013e3181d2b095.
• IDSA. 2017 Compensation Survey. http://www.idsociety.org/uploadedFiles/IDSA/Manage_Your_Practice/Compensation/2017%20IDSA%20Comp%20Survey_REPORT_Final.pdf. Accessed June 15, 2018.
• IDSA. Society Citation Award Winners. http://www.idsociety.org/Society_Citation_Awards/. Accessed June 15, 2018.  
• Jagsi R, et al. JAMA. 2016;doi:10.1001/jama.2016.2188.
• Medscape. Medscape Physician Compensation Report 2018. https://www.medscape.com/slideshow/2018-compensation-overview-6009667#1. Accessed June 15, 2018.
• Overbaugh J. J Virol. 2018; doi:10.1128/JVI.02127-17.
Sege R, et al. JAMA. 2015;doi:10.1001/jama.2015.8517.
• Tsugawa Y, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2016.7875.

• For more information:
• Judith A. Aberg, MD, can be reached at judith.aberg@mssm.edu.
• Wendy S. Armstrong, MD, can be reached at wsarmst@emory.edu.
• Jason P. Burnham, MD, can be reached at burnham@wustl.edu.
• Judith S. Currier, MD, can be reached at JSCurrier@mednet.ucla.edu.
• Carlos del Rio, MD, can be reached at cdelrio@emory.edu.
• Simintha Esson, can be reached at sesson@idsociety.org.
• Monica Gandhi, MD, MPH, can be reached at Monica.Gandhi@ucsf.edu.
• Jasmine Riviere Marcelin, MD, can be reached at jasmine.marcelin@unmc.edu.
• Jeanne Marrazzo, MD, can be reached at jmm2@uab.edu.
• Beth Thielen, MD, PhD, can be reached at thie0149@umn.edu.

Disclosures: Aberg, Armstrong, Burnham, Currier, del Rio, Esson, Gandhi, Marcelin, Marrazzo and Thielen report no relevant financial discosures.