Ethical leaders: use science to advance gender equity in medicine

Here’s a scenario that plays out far too often across the U.S. health care landscape: A hospital wants to hire two physicians, a man and a woman, who have just completed their training in emergency medicine. The jobs are identical: an equal number of shifts and hours in a busy emergency department.

The physicians are offered the same starting salary and relocation package, compensation that is competitive for the geographic location. The woman accepts the offer. The man asks for $20,000 more in annual salary before accepting the offer, and the hospital agrees. That represents a small amount in the overall emergency department budget and, because the hospital has already invested more than $100,000 in the recruitment process, he is hired at the higher salary.

Both doctors prove to be wonderful additions to the staff, often working side by side saving lives.

Five years later, the female doctor discovers that her colleague earns $20,000 a year more than she does, and questions the powers that be about this wage gap. They explain it’s her fault because she didn’t negotiate before accepting the job. She responds that during her medical training she spent her time learning medicine, not negotiation tactics, and she is owed $100,000 in back pay plus interest.

Not so, say the administrators. What the hospital did was legal, and it owes her nothing. She claims the institution is being unfair and behaving in an unethical manner. (Whether the hospital did something illegal may depend on the state, as a new report on pay equity laws explains.)

Early-career physicians, like the two described here, tend to be deeply in debt after medical school and residency. They depend on their first “real” jobs to help pay off student loans. For women, unequal pay often begins early and persists through their careers, regardless of medical specialty. As Dr. Michael S. Sinha, a health policy expert and fellow at Harvard Medical School, wrote, “To suggest that women must negotiate to be paid equally is unquestionably unethical. Equal pay for equal work — this is not negotiable.”

Medicine adheres to a strict code of ethics. Yet a large body of research demonstrates the industry’s ambivalence toward addressing rampant workforce gender bias. Compared to their male colleagues, female physicians face disparities in nearly every marker of achievement including, but not limited to, pay, promotion, recognition awards, grants, publications, and speaking invitations. Subtle slights, or micro-inequities, such as calling women by their first names and men by their professional titles in work settings, often support environments in which larger disparities exist. For example, one study showed that during recorded grand rounds introductions, women who introduced women used the speaker’s professional title nearly 100 percent of the time whereas men who introduced women used the speaker’s professional title only about half the time.

The majority of the health care workforce is composed of women, and they are as equally qualified as their male colleagues. Yet many do not receive equal pay for equal work, or don’t have the same opportunities for career advancement. In U.S. medical schools, women make up 38 percent of faculty members, 21 percent of full professors, and 15 percent of department chairs.

In his presidential address to the American Surgical Association, Dr. Keith Lillemoe said, “The number of outstanding, qualified female candidates is more than adequate to fill every open surgical leadership position in America today. The problem is not the pipeline — it is the process.”

How are U.S. medical schools tackling the gender equity problem? Not well. In a survey of medical schools led by Dr. Phyllis L. Carr from Massachusetts General Hospital and Harvard Medical School, “Participants from nearly 40 percent of the institutions reported no special programs for recruiting, promoting, or retaining women, largely describing such programming as unnecessary.”

Why isn’t health care leading the way in workforce gender equity? One reason is that leaders — regardless of gender — are not using their power and considerable resources to scientifically analyze and address disparities. They should be using a comprehensive set of metrics, tracking data, and routinely reporting progress (a complete process known as longitudinal analysis).

Each year, for the Harvard Medical School women’s leadership CME course that I direct, I develop a strategic initiative focused on gender workforce equity and inclusion. This year, the Be Ethical Campaign calls on health care leaders in four “gatekeeper” categories — medical schools/hospitals, medical societies, journals, and funding organizations — to address disparities using scientific methodologies and a comprehensive set of metrics.

The campaign’s white paper provides a six-step procedure with specific metrics, explains how to avoid critical thinking errors (especially those that blame women or aim to “fix” them), and offers a rich list of supportive research. It also includes a checklist for assessing one’s own behavior toward addressing gender workforce disparities. The goal is to shift all health care leaders into the ethical category, which includes these five criteria:

• I am knowledgeable about the research on workforce gender equity and can cite specific studies and statistics.
• I avoid committing critical thinking errors and blaming women in medicine for the disparities they face.
• An audit of what I control in my organization would demonstrate that women are represented equitably, and they are paid and promoted equitably at every level.
• I have used my influence and resources to address workforce gender equity issues and can demonstrate my successes through anecdotes as well as a systematic, data-driven, and transparent approach to promoting equity.
• Because I regularly collect the data I need, I have already developed goals, policies, and procedures to successfully address any existing or developing disparities, and will continue to do so.

The publication of research on gender disparities in academic medicine has not achieved equitable treatment of women. So education and advocacy are sorely needed.

One of the easiest problems to solve is parity on journal editorial boards. Editors-in-chief whose boards do not demonstrate parity should recognize that reports on gender representation on medical journal editorial boards provide undeniable proof that they are on the wrong side of history.

Leaders must also recognize how their relationships with other organizations are promoting and sustaining gender discrimination. Medical institutions, societies, journals, and funding entities should refuse to associate with businesses or organizations that have a documented track record of gender discrimination. Leaders must recognize the many ways the organizations they lead have contributed to the systemic oppression of women in medicine and do everything in their power to change that dynamic now.

With increasing shortages of clinicians and rising burnout rates, leaders need to step up and do what is long overdue: use science to solve equity issues for women in medicine. It is time for all health care leaders to be ethical.

Julie K. Silver, M.D., is an associate professor and associate chair for the Department of Physical Medicine and Rehabilitation at Harvard Medical School, and directs “Career Advancement and Leadership Skills for Women in Healthcare,” a Harvard Medical School women’s leadership CME course.