Gender Inequality in Medicine: Too Much Evidence to Ignore

Rebecca M. Allen, MD, MPH;

We have long known-based on research from social psychology, political science, and business-that men and women are perceived and treated unequally in our work environments. The difference this year is that we are talking about it much more than usual. Nothing brings gender quite to the forefront of one’s thoughts like the intersection of-in my case-being pregnant most of last year, applying for a job, and following the news coverage of the election. In the wake of our first-ever major party female candidate for US President, there has been a remarkable amount of news coverage on sexism.

Author bio:

Dr. Allen is a graduate of the Harvard Longwood Psychiatry Residency Training Program. She is currently in her second year of the Harvard Medical School affiliated Fellowship in Behavioral Neurology/Neuropsychiatry at Brigham and Women’s Hospital in Boston, Massachusetts. She reports no conflicts of interest concerning the subject matter of this article.

The 2016 election highlighted the difference in standards for male and female leaders. During the election, many journalists discussed how voters viewed Hillary Clinton and how her opponents treated her. Her opponents carefully questioned her health, “stamina,” presidential “look,” and lack of broad shoulders as coded comments about her gender.¹ She was scrutinized for every aspect of her appearance, especially her clothes, bringing to mind the brilliant demonstration of sexism by a male television reporter in Australia who wore the same suit every day for a year-and nobody noticed.² Hillary Clinton was perceived by some as cold or aloof. As she herself said, “I had to learn as a young woman to control my emotions. And that’s a hard path to walk. Because you need to protect yourself, you need to keep steady, but at the same time you don’t want to seem ‘walled off.’”³ Post-election coverage has largely focused on how the current President treats women-given the lack of female cabinet members, this comes as no surprise.

Gender inequality at work is well supported by data. Women tend to be interrupted much more often than men⁴ and, despite the perception that women talk excessively, men actually do about 75% of the talking in mixed gender groups.⁵ A Yale series of studies on “volubility” (total amount of time spent talking) cheerily concludes that “though men primed with power talk more, women show no effect of power on volubility” and “powerful women are in fact correct in assuming that they will incur backlash as a result of talking more than others-an effect that is observed among both male and female perceivers.”⁶ In other words, women who speak up suffer consequences.

Women also get judged more harshly for ethical violations. A recent study that analyzed American Bar Association data found that female attorneys were more than twice as likely to be disbarred as males, despite having identical ethical infractions.⁷ In a follow-up experiment, volunteers were asked to recommend a jail sentence for a hospital administrator who unethically filed a false Medicare claim. If the administrator was named Jack, the jail sentence was 80 days, but if the name was Jane, the sentence was 130 days.⁷

In academic science, perceptions of scientific achievement and potential are also affected by gender. A 2012 study asked a broad, nationwide sample of biology, chemistry, and physics professors to evaluate the identical application materials of either a male or a female undergraduate science student who had ostensibly applied for a science laboratory manager position. Both male and female faculty judged a female student to be less competent and less worthy of being hired than an identical male student-and also offered her a smaller starting salary and less career mentoring.⁸

Compared with men, women in academic medicine perceive lower gender equity, are less likely to believe their institutions are making changes to address diversity goals, are less likely to consider their workplace family-friendly, and report less congruence between their own values and those of their institutions.⁹ The 2013-2014 American Association of Medical Colleges’ report on the state of women in academic medicine found that while 46% of all residents are female, this number drops rapidly up the academic hierarchy: only 38% of faculty, 21% of full professors, and 16% of deans are female. The report concluded that “the proportion of full-time full professors who are women has increased since 2003–04, but the percentage of new tenures who are women remains unchanged since 2008–09. Although the percentages have slowly increased over the past 10 years, women continue to hold a smaller proportion of key leadership positions (department chair, dean) than do men.”¹⁰

In psychiatry, as in every field of medicine, there is gender disparity in salary and promotion. A 2016 study that looked at academic physician salaries showed that even after accounting for physician age, experience, faculty rank, specialty, scientific authorship, National Institutes of Health funding, clinical trial participation, and Medicare reimbursements, female physicians still earn less than males in every field with the exception of radiology.¹¹ In psychiatry, after adjusting for all of these factors, men earn an average of $211,709, while women earn $14,799 less per year, or $196,909.

Although the numbers of women and men who enter psychiatry have been equal since 1999, a recent demographic study showed only 12 of 118 psychiatry departments have female chairs.¹² Male chairs are much more likely to be in charge of large departments and are more likely to be married. Women psychiatry chairs report barriers to career development such as little or no mentorship, gender discrimination, and family obligations.

In reflecting on these data, a woman who receives a job offer may wonder if the proposed salary is lower than would be offered to a man-but there is no way to know for sure. She then may have a difficult time negotiating her salary without being seen in a negative light. A 2013 series of studies on salary negotiation and backlash concluded:

Assertive, self-advocating female negotiators suffer backlash consistent with negative masculine characterizations. They are seen as dominant and arrogant, and people do not want to interact on a peer level with them. Non-assertive, other-advocating female negotiators suffer a different backlash consistent with negative feminine characterizations. They are seen as weak and gullible, and people do not want to be led by them.¹³

As a female physician, I fortunately have difficulty thinking of examples of overt sexism. I do not have war stories like those told by Dr. Frances K. Conley, the first female tenured professor of neurosurgery in the US, in her book Walking Out on the Boys.¹⁴

But one incident does come to mind. When I was a 4th-year medical student, the neurosurgery residency program had just been shaken up by matching not 1, but 2 female neurosurgery interns, filling both available slots after several years of no women matching. I did not hear physicians say anything negative about this change, but staff in the operating rooms, both male and female, were shockingly non-subtle in declaring their fear of facing 6 years of working with female doctors. “Neurosurgery is not a good field for women,” one surgical technician declared, while another told me that women in neurosurgery are unhappy and mean. They anticipated future conflict and possibly verbal abuse. The basis for this concern? They saw the single woman who had completed the program as exemplifying all women in neurosurgery.

Anecdotally and experientially as a medical student rotating on different services, I found that overt sexism varies among the specialties in medicine. A recent Washington Post article on sexism in medicine by an Emory medicine resident cited examples of Mad Men–style misogyny from a surgical service.¹⁵

But subtle gender differences are still noticeable in psychiatry, despite the much higher percentage of women in our field than in most other specialties.¹⁶ The leadership in my department is largely male. Most meetings I attend are dominated by male voices, even if the absolute number of women and men in the room is fairly balanced. Women speak less, and their comments are noticeably shorter, prefaced by more uncertainty, and more often interrupted than male contributions. Other examples of subtle sexism include patients and staff mistaking me for a nurse or non-physician, patients defaulting to calling me by my first name, and both male and female nurses treating me somewhat differently than male residents when on call.

In a medical world where we are exposed to subtle gender discrimination that, although measurable, is hard to see on a day-to-day basis, maybe it is not so surprising that younger women physicians are rather complacent. My female medical school classmates and co-residents were hesitant to describe themselves as “feminist” and rarely complained about sexism. Many of my female classmates in medical school and residency followed the cultural norm of marrying men a few years older and potentially higher earning or farther along in their careers (and most women also changed their names). This tends to perpetuate a system in which women take on more of the childcare responsibility than men by choosing less demanding specialties or working fewer hours.

The choice to prioritize childcare is one that every person, male or female, should be able to make. However, our current culture leads to women doing this much more often than men. Indeed, although many male and female medical school faculty members in the US work part-time, men more often work part-time to accommodate their work at another practice site or in another professional position, while women work part-time to provide care for dependent children.¹⁷

Because women are more likely than men to make career changes after having children, patients and colleagues may, consciously or not, perceive a pregnant physician differently. There is no equivalent experience for male physicians. Pregnancy puts one’s private family life on display, and dodging patient questions about family can be just as awkward as answering them. Many patients asked me not when, but if I planned to return to work after having a baby-a question they likely would not ask men who go on paternity leave.

As a third-year resident pregnant with my first child, I was very concerned about how my colleagues and superiors would view me and how much my mentors would want to invest in my career. I had no intention of altering my career goals after having a baby, but I felt (correctly or not) that I had to work hard after returning from leave to show that I was the same committed physician as before I became a mother. Now, having my second child at the same time as applying for a job, I have similar concerns. I had to disclose that I was pregnant to avoid scheduling the interviews during a time when I could not travel, and I also feared that if I were visibly pregnant during a job interview, it would be an unwelcome distraction.

While it is important to recognize how gender greatly affects our lives in the personal, professional, and political spheres, and to work to eliminate subtle sexism in our culture, it is also important not to become demoralized in the process. Despite recent events-both personal and political-I recognize the substantial progress women have made and hope we keep up the momentum. In our field, we have strong women role models, including many recent American Psychiatric Association presidents, and I have had the pleasure of working with female psychiatrists who have successfully pursued ambitious work goals while also raising children.

But we still have a long way to go: expectations for women leaders are both high and narrow, while male leaders do well with a variety of personality types and styles. A rise in the number of strong women in power would help foster broader and more positive public perceptions. For our cultural expectation of women to change, we have to start by putting women in leadership positions.

Editor’s note: This piece was adapted from Dr. Allen’s article “Enjoy Being a Girl?” which appeared in the November/December 2016 issue of the Massachusetts Psychiatric Society Bulletin and is published here with permission.

References:

4. Hancock AB, Rubin BA. Influence of communication partner’s gender on language. J Lang Soc Psychol. 2015;34:146-164.

6. Brescoll VL. Who takes the floor and why: gender, power, and volubility in organizations. Am Sci Q. 2011;56:622-641.

8. Moss-Racusin CA, Dovidio JF, Brescoll VL, et al. Science faculty’s subtle gender biases favor male students. Proc Natl Acad Sci U S A. 2012;109:16474-16479.

9. Pololi LH, Civian JT, Brennan RT, et al. Experiencing the culture of academic medicine: gender matters, a national study. J Gen Intern Med. 2013;28:201-207.

11. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176:1294-1304.

12. Doyle M, Pederson A, Meltzer-Brody S. Demographic and personal characteristics of male and female chairs in academic psychiatry. Acad Psychiatry. 2016;40:402-409.

13. Amanatullah E, Tinsley C. Punishing female negotiators for asserting too much . . . or not enough: exploring why advocacy moderates backlash against assertive female negotiators. Organ Behav Hum Decis Process. 2013;120:110-122.

14. Conley FK. Walking Out on the Boys. New York: Farrar, Straus and Giroux; 1998.

17. Pollart SM, Dandar V, Brubaker L, et al. Characteristics, satisfaction, and engagement of part-time faculty at U.S. medical schools. Acad Med. 2015;90:355-364. â