Career disruptions among women in medicine may 'reverberate far beyond COVID-19'
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The COVID-19 pandemic disrupted progress toward gender equity in medicine that may resonate for years to come, according to experts.
One area of widening gender inequity is research publications. A new study showed that women submitted fewer research manuscripts to Annals of Family Medicine during the pandemic than men, despite an overall increase in volume of submissions.
“During COVID-19, when many had to shift from in-person to remote work, women were taking on a lot at home; I wasn’t surprised that they were submitting at a lower rate than their male counterparts,” Katherine M. Wright, MPH, PhD, the director of research and a research assistant professor in the department of family and community medicine in the Feinberg School of Medicine at Northwestern University, told Healio.
Wright and colleagues evaluated manuscript submissions from Jan. 1, 2015, to July 15, 2020. They reported a 122% increase in submissions among men and a 101% increase among women. In the early months of the pandemic, 58.5% of manuscripts were authored by men while 41.5% were authored by women, highlighting a troubling gap in submission rates, the authors wrote.
The findings represent just one of many gender disparities that have worsened amid COVID-19. Other research indicates that the pandemic has increased burnout, worsened working conditions and diminished career opportunities for women in medicine, despite the high-quality care they provide to patients.
Healio spoke with several women in medicine to assess the toll that the pandemic has taken on them and their female colleagues.
Preexisting burdens exacerbated by COVID-19
Data show that home and family responsibilities have largely fallen on women during the pandemic. Women in medicine have had to balance grueling work conditions during SARS-CoV-2 surges on top of a “second shift” at home with virtual schooling and childcare during lockdowns, according to research published in JAMA Network Open.
In a prospective cohort study, Srijan Sen, MD, PhD, the director of the Frances and Kenneth Eisenberg and Family Depression Center at the University of Michigan, and colleagues examined gender differences in work-family factors among 215 physician parents during the pandemic. The survey results showed that 24.6% (95% CI, 19-30.2) of physicians who were mothers were responsible for childcare or schooling and 31.4% (95% CI, 25.4-37.4) were responsible for household tasks compared with 0.8% (95% CI, 0.01-2.1) and 7.2% (95% CI, 3.5-10.9) of physicians who were fathers.
“The pandemic is having a huge impact on women in clinical practice. Whether it’s childcare or eldercare, women who have families have experienced an increase in domestic responsibilities,” Shikha Jain, MD, FACP, an assistant professor of medicine in the division of hematology and oncology at the University of Illinois Cancer Center, host of Healio’s Oncology Overdrive podcast and a consulting medical editor for Healio's Women in Oncology, said in an interview.
This increase in domestic responsibilities was also demonstrated through data presented at a summit held by the nonprofit Women in Medicine, founded by Jain, which showed that women experienced greater work-family and family-work conflicts than men amid COVID-19.
“I have watched some female colleagues have to step back from academic positions because it’s become more difficult to find childcare and have some of the supports you might need,” Santina Wheat, MD, PhD, the vice chair of diversity, equity and inclusion in the department of family and community medicine in the Feinberg School of Medicine at Northwestern University, told Healio.
These increasing demands have led to greater rates of burnout and stress. In a study published in the Journal of General Internal Medicine, Ellis C. Dillon, PhD, an assistant scientist at the Palo Alto Medicinal Foundation Research Institute, and colleagues surveyed 3,176 clinicians in the U.S. from June 2020 to August 2020. Overall, 39% of women reported burnout vs. 22.7% of men (P < .01), 51.1% of women reported decreased feelings of overall well-being vs. 42.5% of men (P < .01), and 51.1% reported greater job stress vs. 41.3% of men (P < .0001).
Dillon and colleagues also found that more women were worried about losing their jobs (27.2% vs. 18.3%; P < .0001) and often desired support for mental health (15.6% vs. 9.9%, P < .01) and flexible schedules (29.4% vs. 21.6%; P < .0001) compared with men.
The challenges that women in the U.S. face in balancing work and home responsibilities stems in part from preconceived expectations built into society that childcare is the woman’s responsibility, according to Rita K. Kuwahara, MD, MIH, a primary care internal medicine physician and health policy fellow at Georgetown University and a Healio Primary Care Peer Perspective Board member.
While there have been several efforts to promote shared parental responsibility, often, this traditional expectation then “subsequently translates into women not having as much time in their professional spaces, or it might mean that they have to adjust their schedules to work longer hours,” she told Healio.
According to Kimberly J. Templeton, MD, FAAOS, FAOA, FAMWA, a professor of orthopedic surgery at the University of Kansas Medical Center, women are particularly affected by burnout because they can also demonstrate traits of imposter syndrome.
“Imposter syndrome is not an innate characteristic but is learned from external sources, Templeton told Healio. “There can be times during which we, as women, are constantly doubting ourselves. We may think that we're imposters and somebody eventually is going to figure out that we're not as good as they thought we were. One of the ways that women cope with that is by working harder to prove that we belong. If you’re going to cope by working harder, eventually you are going to get fatigued and may become burned out. Working harder does not resolve feelings of imposterism.”
Harassment in the workplace
Another driver of burnout is sexual harassment, said Templeton, who is also past president of the American Medical Women’s Association.
In a survey of 8,218 medical school faculty members, one in three women and one in eight men experienced at least one incident of sexual harassment. The survey, conducted between February 2019 and May 2020, also showed that rates of sexual harassment were more than twice as high for women than men (34.8% vs. 13.3%). The highest rates were among senior women, 40% of whom experienced harassment in the past year compared with 32% of junior women. Data also showed that nearly 36% of minority women experienced harassment.
In a separate survey study targeting 330 dermatologists and trainees (79 men), 83% reported experiencing sexual harassment and 31% reported experiencing a sexual assault from a patient. Among the women, 94% reported experiencing sexual harassment.
Another survey of 52 physicians (90% women) who were sexually harassed in a clinical practice setting showed that many (40%) did not think that reporting the harassment would be impactful, 21% felt ashamed or embarrassed and 17% felt they did not have the time to report it.
“Only about 15% of women who are victims of sexual harassment ever report it,” Templeton said. “Women usually don’t report harassment because the process is not always clear. Women are also concerned that the report won’t be kept anonymous and could have a negative impact on their careers or believe that nothing will happen as a result of a report. We need to make sexual harassment reporting much more visible. It needs to be easier, and there need to be clear ramifications after an investigation confirms that sexual harassment occurred.”
In addition to sexual harassment, women also combat conscious and unconscious biases and microaggressions, which are much more common than harassment and can have a significant impact on well-being, Templeton added.
Jain shared her own experiences of harassment and gender discrimination, including a situation where a male colleague proceeded to make up and spread false statements about her to their colleagues.
“No one actually ever asked me about any of the things they heard,” she said. “He said these things so they must be true and that was the end of the discussion.”
In another instance, Jain said she was denied the chance to represent a new initiative, even though she coordinated and implemented it.
“The reason they gave me was that they didn’t want just another pretty face out there,” Jain said.
Harassment and discrimination in the workplace are big reasons why many women are leaving medicine altogether, she added.
“When women are subjected to biases, it demonstrates to them that they don’t belong in medicine,” Templeton said.
She added that harassment, biases and microaggressions “impact women’s perceptions of their careers and their roles in medicine.”
“Harassment, biases and the attitudes that drive them need to be addressed from a departmental, institutional and societal perspective,” Templeton said.
Disparities in career advancement
In clinical and academic medicine, there has been some progress toward equal opportunities in career advancement.
“There are more women in leadership roles,” Templeton said. “However, it’s been very, very slow progress, especially with upper-level leadership positions such as department chair or dean.”
Representation among department chairs varies by specialty, according to Templeton.
“If you look at something like orthopedic surgery, in which about 6% of surgeons are women and they make up a minority of faculty, there are not a lot of women department chairs,” she said. “However, increasing the number of women in medical schools won’t lead to more women in leadership positions without intentional equity efforts and adequate sponsorship.”
While leadership opportunities in academic medicine are slow moving, representation among research panels is persistently disproportionate.
A cross-sectional study published in The Lancet found that Australian, American, Canadian and British panels that developed clinical practice recommendations most often consisted of white men and excluded women from historically underrepresented communities. Of the 1,379 U.S. panel members included in the study, only 35.1% were women. Also, 20.3% were “racialized,” meaning they were from historically underrepresented groups, according to the researchers. Specifically, 7.6% of the panel members were racialized women and 12.5% were racialized men.
“We have always seen very wide gaps in representation when it comes to race and ethnicity,” Kuwahara said. “It is therefore critical that we make every effort to ensure that each level of leadership reflects the full diversity of our nation and that systems are in place to guarantee that this occurs.”
Women are frequently underrepresented during medical conferences as well. This prompted the Women in Medicine organization to launch the first all-women speakers bureau to increase opportunities for female experts in medicine.
“The COVID-19 pandemic has significantly affected the ability of women to advance into leadership roles and attain higher levels of promotion,” Kuwahara said. “As a society, and as a profession, we need to acknowledge the effects the COVID-19 pandemic has had and make concerted efforts to ensure that women always have a place at the table, are in the highest levels of leadership, are specifically recruited to serve as leaders and every gender is equally supported, encouraged and given the flexibility to balance work and family life.”
Taking time off during pregnancy and to start a family has often been cited as a driving factor in unequal promotion opportunities.
Eve Rittenberg, MD, MA, an assistant professor of women’s health and internal medicine at Harvard Medical School, said the most challenging point of her career was during the early part of her training when she was pregnant. The residency expectations were physically demanding, and she worked long hours up until the day she gave birth.
Despite work hour reforms, Rittenberg said that women in medicine continue to face difficult choices.
“There is an attitude in medicine of kind of ignoring personal and physical needs in order to do the work,” she told Healio. “Residency and fellowship programs need to proactively design systems for maternity leave or potential pregnancy complications, rather than leaving it up to the individual trainees to advocate for themselves.”
In a survey of 850 surgeons (692 women) in the U.S. conducted from November 2020 to January 2021, 65% of women reported that they delayed having children due to their surgical training, while only 43.7% of men reported a delay (P < .001). Also, only 16.5% of women reported reducing their work schedules during the pregnancy. Female surgeons were more likely to work more than 60 hours a week during pregnancy compared with a group of pregnant women who were not surgeons (56.6% vs. 10%, P < .001). The findings were published in JAMA Surgery.
“The impact of these gender inequities in health care actually impacts all aspects of health care. It doesn't just impact the women who are directly affected,” Jain said. “When people say we need to focus on other issues before we get to gender inequity, my counterpoint to that is we know that these gender inequities actually result in worse outcomes for patients.”
Pay gap persists
The differences in career advancement opportunities between men and women contribute to — but do not solely explain — the pay gap in medicine. The health care system was designed in a way that perpetuates the pay gap by devaluing the contributions of women and monetizing the contributions of men, according to Jain. It was built by men during a time when the health care system mostly comprised of men.
“We need to reassess the way we evaluate the contributions of our faculty,” Jain said. “There needs to be a way of compensating and providing some return on investment for the invisible work that is often done by women, such as work with committees and organizational services that are often needed but are not compensated, nor do they work towards improving our overall trajectory into leadership.”
In her own experience with battling the pay gap, Jain said that she was previously discouraged from negotiating her salary during a job interview. The men who were interviewing Jain told her that since her husband was a physician, she could work as much as she wanted and it would not matter how much money she made. During another job interview, Jain asked about the possibility of opening more clinic space, which would increase patient volume and potentially her salary. The male interviewers advised against this since they expected that she would have more children, Jain said.
A research article published in Health Affairs found that over a 40-year career, female physicians in the U.S. earned $2,043,881 less than male physicians, on average. The researchers adjusted for factors like hours worked, clinical revenue, practice type and specialty. Overall, female physicians earned 24.6% less than male physicians.
For primary care specifically, the researchers found that in the first year of practice, male physicians earned about $18,245 more than female physicians. By the tenth year of practice, the income difference between men and women increased to $30,245.
Moreover, in a 2021 report comparing the compensation of 60,000 physicians at academic institutions in the U.S., the Association of American Medical Colleges (AAMC) found that female physicians across races and ethnicities were paid between $0.67 and $0.77 on the dollar compared with white men.
“Reports recently have shown that women are compensated significantly less than men for doing the exact same work and working the same amount of time in every medical specialty,” Kuwahara said.
In academic medicine, female physicians have been given a 10% lower starting salary compared with male physicians, according to a recent study in JAMA Network Open. Using data from 2019 to 2020, researchers reported that gender-based disparities in starting salary led to a 9% difference in 10-year earning potential between men and women.
In another analysis based on data from the 2018 to 2019 AAMC Faculty Salary Report, researchers found that men’s salaries still surpassed those of women in 90% of categories of faculty rank in academic internal medicine. Women comprised of less than 50% of full-time faculty across all ranks. Although female representation was nearly the same at the instructor and assistant levels (47% vs. 46%, respectively), their percentage dropped to 24% in higher-ranking positions.
Jain and others have called for transparency of salaries in order to reveal and address existing disparities.
Until transparency is achieved, Jain advised women in medicine to “find allies who can help advocate for them and be armed with as much information as you’re able to access.”
In regard to policy changes, Kuwahara said that ratifying the Equal Rights Amendment would be a “critical step.”
Lack of racial diversity
Women of historically underrepresented groups face an even greater challenge toward achieving equity.
“Whenever we talk about women who have intersectional identities, they have so many more challenges because they have what we call the minority tax; they get double taxed because they are women,” Jain said. “They have challenges where not only are they dealing with sexism or gender inequity, but they are also dealing with structural racism. It is just amazing to me how many challenges women with intersectional identities face, and it is devastating because some of the most brilliant women I know have left health care because of this.”
In oncology, for example, racial and gender disparities have been shown to impact hiring practices and promotions to leadership positions, Healio previously reported. An analysis revealed that just 2.9% of academic oncology leadership positions in the U.S. were held by female underrepresented minorities.
“It is important not to think of women as this monolithic group,” Wright said.
Women with intersectional identities are also repeatedly called on to participate in diversity, equity and inclusion work and act as a representative for a group, panel or lecture. This work is often uncompensated and prevents them from pursuing other work that is equally important, Jain said. These women then get burned out and, in some cases, end up leaving medicine, she added.
“It is a positive thing that this has become a part of the national dialogue and that we’re discussing these topics openly,” Jain said.
Higher quality of care
Despite the challenges that women in medicine face, research has shown that they provide a higher quality of care to patients.
For example, a retrospective cross-sectional Canadian study published in JAMA Health Forum found that patients who were treated by female physicians had a lower in-hospital mortality rate compared with patients treated by male physicians (4.8% vs. 5.2%).
According to Templeton, women are often referred to more challenging and complicated patients because they tend to take more time with patients.
“However, if we're in a system that doesn’t accommodate that into our clinical scheduling or the compensation model — rather than how many patients you’re seeing but the quality of care that you’re providing them — that leads to a disconnect between the goals of the woman physician and that of her workplace, again demonstrating to women that they may not belong,” she said.
Research suggests that women physicians have greater communication with patients through electronic health records. In a retrospective study published in the Journal of General Internal Medicine, Rittenberg and colleagues found that female PCPs spent 20% more time (1.9 hour per month; P = .02) in the EHR in-basket and 22% more time (3.7 hours per month; P = .04) on notes than male PCPs. Female PCPs also received 24% more staff messages (9.6 messages per month; P = .03) and 26% more patient messages (51.5 messages per month; P = .04), according to Rittenberg and colleagues. The greater time spent on EHRs could not be explained by the proportion of female patients in a PCP’s panel.
“I think that the extra time that female primary care doctors spend in the EHR ... has the potential to produce better care,” Rittenberg said. “Being comfortable communicating with your doctor can improve health in many ways.”
However, work done within the HER outside of the office visit is not often compensated with existing pay models, according to Rittenberg.
“An equitable system of compensation and support is needed to make the greater work burden that women face doable,” she said.
Some of the differences in care between men and women may have to do with how women physicians view themselves and how others view them, Templeton said.
“Women are typically raised to be the nurturers, the caretakers, to put everybody else's needs in front of our own. That perspective of our roles informs how we are viewed in society and how we view ourselves, and we bring that to the workplace,” she said.
A study published in JAMA Surgery analyzed adverse postoperative outcomes within 30 days after surgery among 1,320,108 adult patients in Ontario, Canada. The findings showed that female patients treated by male surgeons experienced worse outcomes compared with female patients treated by female surgeons (adjusted OR =1.15; 95% CI, 1.1-1.2). However, male patients treated by female surgeons did not experience worse outcomes compared with male patients treated by male surgeons (aOR, 0.99; 95% CI, 0.95-1.03).
More efforts are needed to “quantify some of that extra work that women physicians are doing for patients in order to provide high-quality care,” Rittenberg said. This includes altering compensation models to factor in work that is done both during the office visit and outside the office visit.
The future of women in medicine
The pandemic has impacted not only the trajectories of countless women’s careers, but it has also led some to consider a career change entirely.
“I think some of the career disruptions could reverberate far beyond COVID-19,” Wright said.
Gender equality is multifactorial, so one solution will not fix everything, Rittenberg noted.
Jain called for structural changes and “buy-in from people from the top down.”
“We cannot keep putting band aids on the dam,” she said. “We need to have a breaking down and a rebuilding of the entire structure.”
Jain expressed concern that the health care industry will not prioritize gender equity and diversity once pandemic-related disruptions have passed. However, she noted that gender equality “is something we realized is important to prioritize in order to have a better society and better health care outcomes.
“I am cautiously optimistic that will happen, but I guess only time will tell,” she said. “We’ve made three steps forward in gender equity prepandemic. Now, we’ve taken 10 steps back because not only are we trying to address inequities that were present prepandemic, but we are also trying to address disparities that have widened during the pandemic.”
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