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It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.
“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”
That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.1
Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”2
In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.
“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.
Fueling the conversation
When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.” 
“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”
Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.
“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”
A 2015 study in the Journal of Hospital Medicine found that just 16% of university hospital medicine divisions were led by women, and women made up just 28% of those physicians leading general internal medicine divisions. Meanwhile, female hospitalists gave just 26% of presentations at national meetings, were first authors on only 33% of publications, and were senior authors on only 21% of manuscripts.3
In addition, Dr. Farnan and Dr. Arora wrote in their review, another recent survey of female physicians – primarily internists – found that 36% reported discrimination based on pregnancy, maternity leave, or breastfeeding. This was – at least in part, Dr. Farnan said – because “physician-mothers were not present at the table when discussions were held about scheduling.”
And while hospitalists have relatively flexible schedules, they can be unforgiving when it comes to traditional child care arrangements, Dr. Arora said.
But, there is hope, particularly within the Society of Hospital Medicine, Dr. Arora and Dr. Farnan wrote. The organization has seen an increase in female leadership – including its president-elect Nasim Afsar, MD, MBA, SFHM – and a board of directors that is split evenly between men and women. Mentorship of junior women is also on the rise, which allows opportunities for senior female physicians to teach younger women how to better negotiate and advocate for themselves.
“I think it has to come from both sides. Leadership does need to recognize that women may be less aggressive in their negotiating skills,” said Dr. Farnan. “But I think there also needs to be some recognition by women that it is okay to ask for more money.”
But it isn’t all about money, she said. “It can be negotiating for anything important in career development, career opportunities, research opportunities.” This also extends to schedule flexibility, training and more.
Leadership in hospitalist groups can help, Dr. Arora and Dr. Farnan wrote in their Annals article, by providing schedule flexibility, support for training, and structured on-boarding for new faculty. Citing efforts in other specialties such as cardiology and general surgery, female hospitalists may benefit from negotiation skills training, structured mentorship, and education around personal and professional development.
However, both physicians recognize the challenges of implicit bias and stereotype threat that may confront many women. For example, women who exert more stereotypically “male” traits such as assertiveness and confidence may face a “harsh likability penalty because they are going against gender norms,” said Dr. Arora.
Being taken seriously
Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.4
“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”
In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.
“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.
“If patients don’t trust the care they are given, it can impact outcomes,” she added. “There is a lot to being a hospitalist that is diagnostic, such as finding the correct diagnosis and implementing the appropriate treatment. However, beyond that, a huge part of this role is to be a knowledgeable caregiver, someone who guides a patient through the experience of being ill in a complex medical system. This requires immense trust.”
Dr. Reiff-Pasarew also believes better mentoring and feedback opportunities would benefit female physicians and trainees. “I often see that equally knowledgeable female trainees and medical students are much more self-deprecating when presenting research,” she said. “They give disclaimers that they don’t know enough, while their male peers are more confident.”
She is quick, however, not to blame women, largely because the same social pressures that Dr. Arora and Dr. Farnan acknowledged may have molded their behaviors. “I meet with residents to talk explicitly about situations where they are treated inappropriately by patients or other staff,” Dr. Reiff-Pasarew said. “We discuss how they might react in those situations in the future and how they can process these challenges.”
Modern American culture equips men and women with “different essential skill sets,” Dr. Reiff-Pasarew noted, but she suggested men and women can learn from one another. “We should be teaching men to be more empathetic listeners, a skill that is generally taught to girls. Similarly, we need to teach women confidence, a skill predominantly taught to boys.”
Just as important, male clinicians should believe in and trust the experiences that women report having, Dr. Reiff-Pasarew said. “It’s very difficult to understand the subtleties of how people are treated differently in patient interactions if you’ve never been in that situation.”
Equal compensation for equal work
Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.
“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”
Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”
Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.5
“Here is evidence that women may be doing a modestly better job than men in terms of outcomes,” Dr. Jena said. “If we are in the business of underpaying and underrewarding females, we are disincentivizing female physicians from entering the field, and in certain specialties female physicians see better patient outcomes.”
Dr. Arora and Dr. Farnan are optimistic that as more studies like those by Dr. Jena and colleagues are published – utilizing large data sets never before available, which account for many of the factors that have been used to justify pay and leadership disparities in the past – times will change for the better.
“There comes a time when everyone realizes a group has been wronged and it’s time to right it. I think now is the time for women. It’s tragic it’s come so late but I’m glad it’s here,” Dr. Arora said. “A lot of work is being done on the ground and in institutions to promote women leaders, to include women in search committees, and improve pay. These are always difficult discussions but now we can have transparency in salaries and we can we discuss them.”
However, Dr. Arora is also concerned about blowback, particularly as issues of sexual harassment of women in the workplace finally emerge from the shadows. “The blowback may be that more people tiptoe around women and are more cautious around them,” she said. “This could end up hurting women in the workplace. Something so deeply cemented like this doesn’t die easily and I think it requires culture change. I do think we’re on that journey and starting to see things change.”
But the real measure of that, said Dr. Farnan, is when these conversations are no longer taking place.
“We will know we’ve achieved what we want to achieve when we don’t have to discuss this anymore,” she said. “We will know we’ve achieved parity when we stop talking about it.”
References
1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.
2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.
4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.
5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.
It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.
“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”
That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.1
Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”2
In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.
“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.
Fueling the conversation
When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”
“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”
Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.
“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”
A 2015 study in the Journal of Hospital Medicine found that just 16% of university hospital medicine divisions were led by women, and women made up just 28% of those physicians leading general internal medicine divisions. Meanwhile, female hospitalists gave just 26% of presentations at national meetings, were first authors on only 33% of publications, and were senior authors on only 21% of manuscripts.3
In addition, Dr. Farnan and Dr. Arora wrote in their review, another recent survey of female physicians – primarily internists – found that 36% reported discrimination based on pregnancy, maternity leave, or breastfeeding. This was – at least in part, Dr. Farnan said – because “physician-mothers were not present at the table when discussions were held about scheduling.”
And while hospitalists have relatively flexible schedules, they can be unforgiving when it comes to traditional child care arrangements, Dr. Arora said.
But, there is hope, particularly within the Society of Hospital Medicine, Dr. Arora and Dr. Farnan wrote. The organization has seen an increase in female leadership – including its president-elect Nasim Afsar, MD, MBA, SFHM – and a board of directors that is split evenly between men and women. Mentorship of junior women is also on the rise, which allows opportunities for senior female physicians to teach younger women how to better negotiate and advocate for themselves.
“I think it has to come from both sides. Leadership does need to recognize that women may be less aggressive in their negotiating skills,” said Dr. Farnan. “But I think there also needs to be some recognition by women that it is okay to ask for more money.”
But it isn’t all about money, she said. “It can be negotiating for anything important in career development, career opportunities, research opportunities.” This also extends to schedule flexibility, training and more.
Leadership in hospitalist groups can help, Dr. Arora and Dr. Farnan wrote in their Annals article, by providing schedule flexibility, support for training, and structured on-boarding for new faculty. Citing efforts in other specialties such as cardiology and general surgery, female hospitalists may benefit from negotiation skills training, structured mentorship, and education around personal and professional development.
However, both physicians recognize the challenges of implicit bias and stereotype threat that may confront many women. For example, women who exert more stereotypically “male” traits such as assertiveness and confidence may face a “harsh likability penalty because they are going against gender norms,” said Dr. Arora.
Being taken seriously
Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.4
“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”
In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.
“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.
“If patients don’t trust the care they are given, it can impact outcomes,” she added. “There is a lot to being a hospitalist that is diagnostic, such as finding the correct diagnosis and implementing the appropriate treatment. However, beyond that, a huge part of this role is to be a knowledgeable caregiver, someone who guides a patient through the experience of being ill in a complex medical system. This requires immense trust.”
Dr. Reiff-Pasarew also believes better mentoring and feedback opportunities would benefit female physicians and trainees. “I often see that equally knowledgeable female trainees and medical students are much more self-deprecating when presenting research,” she said. “They give disclaimers that they don’t know enough, while their male peers are more confident.”
She is quick, however, not to blame women, largely because the same social pressures that Dr. Arora and Dr. Farnan acknowledged may have molded their behaviors. “I meet with residents to talk explicitly about situations where they are treated inappropriately by patients or other staff,” Dr. Reiff-Pasarew said. “We discuss how they might react in those situations in the future and how they can process these challenges.”
Modern American culture equips men and women with “different essential skill sets,” Dr. Reiff-Pasarew noted, but she suggested men and women can learn from one another. “We should be teaching men to be more empathetic listeners, a skill that is generally taught to girls. Similarly, we need to teach women confidence, a skill predominantly taught to boys.”
Just as important, male clinicians should believe in and trust the experiences that women report having, Dr. Reiff-Pasarew said. “It’s very difficult to understand the subtleties of how people are treated differently in patient interactions if you’ve never been in that situation.”
Equal compensation for equal work
Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.
“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”
Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”
Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.5
“Here is evidence that women may be doing a modestly better job than men in terms of outcomes,” Dr. Jena said. “If we are in the business of underpaying and underrewarding females, we are disincentivizing female physicians from entering the field, and in certain specialties female physicians see better patient outcomes.”
Dr. Arora and Dr. Farnan are optimistic that as more studies like those by Dr. Jena and colleagues are published – utilizing large data sets never before available, which account for many of the factors that have been used to justify pay and leadership disparities in the past – times will change for the better.
“There comes a time when everyone realizes a group has been wronged and it’s time to right it. I think now is the time for women. It’s tragic it’s come so late but I’m glad it’s here,” Dr. Arora said. “A lot of work is being done on the ground and in institutions to promote women leaders, to include women in search committees, and improve pay. These are always difficult discussions but now we can have transparency in salaries and we can we discuss them.”
However, Dr. Arora is also concerned about blowback, particularly as issues of sexual harassment of women in the workplace finally emerge from the shadows. “The blowback may be that more people tiptoe around women and are more cautious around them,” she said. “This could end up hurting women in the workplace. Something so deeply cemented like this doesn’t die easily and I think it requires culture change. I do think we’re on that journey and starting to see things change.”
But the real measure of that, said Dr. Farnan, is when these conversations are no longer taking place.
“We will know we’ve achieved what we want to achieve when we don’t have to discuss this anymore,” she said. “We will know we’ve achieved parity when we stop talking about it.”
References
1. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016;176(9):1294-1304. doi: 10.1001/jamainternmed.2016.3284.
2. Farnan JM and Arora VM. Gender equality in hospital medicine – are we there yet? Ann Intern Med. 2017;167(6):HO2-HO3. doi: 10.7326/M17-2119.
3. Burden M, Frank MG, Keniston A, et al. Gender disparities in leadership and scholarly productivity of academic hospitalists. J Hosp Med 2015;8;481-5. doi: 10.1002/jhm.2340.
4. Reiff-Pasarew F. I’m a young, female doctor. Calling me ‘sweetie’ won’t help me save your life. Washington Post. Published June 29, 2017. Accessed Dec. 4, 2017.
5. Tsugawa Y, Jena AB, Figueroa JF, et al. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-13. doi: 10.1001/jamainternmed.2016.7875.
It wasn’t something she planned to have happen but about 2 years ago, Vineet Arora, MD, MAPP, MHM, became what she calls an “accidental advocate” for gender parity in medicine.
“I was asked to review a paper around gender pay,” the University of Chicago Medical Center hospitalist said. “It was stunning to me just how different salaries were – between male and female physicians – even when the authors were attempting to control for various factors.”
That paper was published in the Journal of the American Medical Association (JAMA) in September 2016 by researchers at Harvard Medical School and Massachusetts General Hospital (MGH). It found that even after adjustment for age, experience, specialty, faculty rank, research productivity, and clinical revenue, female physicians at 24 public medical schools in 12 states earned nearly $20,000 less per year than their male colleagues.1
Dr. Arora wrote an editorial to accompany that 2016 paper in JAMA, and in September 2017, she and her colleague at the University of Chicago, Jeanne Farnan, MD, MHPE, coauthored another piece in Annals of Internal Medicine titled, “Inpatient Notes: Gender Equality in Hospital Medicine – Are We There Yet?”2
In the 2017 paper, Dr. Arora and Dr. Farnan assessed recent studies documenting inequity in regard to compensation, discrimination around child-rearing, and gender disparities in medical leadership. They also discussed strategies that might improve the future outlook for female physicians.
“As I approach mid-career, I see these issues affecting my career and my colleagues’ careers and I decided we need to be doing more work in this space,” said Dr. Arora.
Fueling the conversation
When asked whether he thinks his research inspired the current conversation around gender inequity in medicine, Anupam Bapu Jena, MD, PhD – lead author of the September 2016 gender pay paper – said that while he did not initiate it, his work “has fueled the conversation.”
“This is an issue that has been going on in the scientific literature for at least 25-30 years,” said Dr. Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the department of medicine at MGH. “I am sure women in medicine have been feeling this since women entered medicine.”
Many female hospitalists hoped that, as a relatively new field, hospital medicine would avoid some of the time-worn challenges women in other specialties faced.
“The birth of hospital medicine held the promise that, as a new field, it would be immune to the ‘old boys’ club mentality that plagues established specialties,” Dr. Farnan and Dr. Arora wrote in their September 2017 Annals article. And yet, they continued, “gender disparities developed in the areas of leadership and academic productivity.”
A 2015 study in the Journal of Hospital Medicine found that just 16% of university hospital medicine divisions were led by women, and women made up just 28% of those physicians leading general internal medicine divisions. Meanwhile, female hospitalists gave just 26% of presentations at national meetings, were first authors on only 33% of publications, and were senior authors on only 21% of manuscripts.3
In addition, Dr. Farnan and Dr. Arora wrote in their review, another recent survey of female physicians – primarily internists – found that 36% reported discrimination based on pregnancy, maternity leave, or breastfeeding. This was – at least in part, Dr. Farnan said – because “physician-mothers were not present at the table when discussions were held about scheduling.”
And while hospitalists have relatively flexible schedules, they can be unforgiving when it comes to traditional child care arrangements, Dr. Arora said.
But, there is hope, particularly within the Society of Hospital Medicine, Dr. Arora and Dr. Farnan wrote. The organization has seen an increase in female leadership – including its president-elect Nasim Afsar, MD, MBA, SFHM – and a board of directors that is split evenly between men and women. Mentorship of junior women is also on the rise, which allows opportunities for senior female physicians to teach younger women how to better negotiate and advocate for themselves.
“I think it has to come from both sides. Leadership does need to recognize that women may be less aggressive in their negotiating skills,” said Dr. Farnan. “But I think there also needs to be some recognition by women that it is okay to ask for more money.”
But it isn’t all about money, she said. “It can be negotiating for anything important in career development, career opportunities, research opportunities.” This also extends to schedule flexibility, training and more.
Leadership in hospitalist groups can help, Dr. Arora and Dr. Farnan wrote in their Annals article, by providing schedule flexibility, support for training, and structured on-boarding for new faculty. Citing efforts in other specialties such as cardiology and general surgery, female hospitalists may benefit from negotiation skills training, structured mentorship, and education around personal and professional development.
However, both physicians recognize the challenges of implicit bias and stereotype threat that may confront many women. For example, women who exert more stereotypically “male” traits such as assertiveness and confidence may face a “harsh likability penalty because they are going against gender norms,” said Dr. Arora.
Being taken seriously
Expectations around gender norms may also affect relationships female doctors have with their patients. In a June 2017 Washington Post editorial, Faye Reiff-Pasarew, MD, describes being objectified as “cute” and “adorable” and not being taken seriously by her patients.4
“I’d had a number of interactions with patients that upset me,” said Dr. Reiff-Pasarew, assistant professor of hospital medicine, director of the humanism in medicine program, and unit medical director at Icahn School of Medicine at Mount Sinai in New York City. “Later, I reflected upon them and realized that bias was a systemic problem. There needs to be a conversation amongst the broader medical community about the effect that these biases have on our patients and our practice.”
In her editorial, Dr. Reiff-Pasarew explained that when a female physician is written off as too young or is not recognized as a physician, it can delay necessary care. She also touches on the challenge of earning the trust of hospitalized patients.
“There’s a lot of evidence that the success of medical therapy is influenced by the context in which it is given, beyond mere adherence to a regimen or medication,” Dr. Reiff-Pasarew said, noting that it is a result of “the very powerful placebo effect.
“If patients don’t trust the care they are given, it can impact outcomes,” she added. “There is a lot to being a hospitalist that is diagnostic, such as finding the correct diagnosis and implementing the appropriate treatment. However, beyond that, a huge part of this role is to be a knowledgeable caregiver, someone who guides a patient through the experience of being ill in a complex medical system. This requires immense trust.”
Dr. Reiff-Pasarew also believes better mentoring and feedback opportunities would benefit female physicians and trainees. “I often see that equally knowledgeable female trainees and medical students are much more self-deprecating when presenting research,” she said. “They give disclaimers that they don’t know enough, while their male peers are more confident.”
She is quick, however, not to blame women, largely because the same social pressures that Dr. Arora and Dr. Farnan acknowledged may have molded their behaviors. “I meet with residents to talk explicitly about situations where they are treated inappropriately by patients or other staff,” Dr. Reiff-Pasarew said. “We discuss how they might react in those situations in the future and how they can process these challenges.”
Modern American culture equips men and women with “different essential skill sets,” Dr. Reiff-Pasarew noted, but she suggested men and women can learn from one another. “We should be teaching men to be more empathetic listeners, a skill that is generally taught to girls. Similarly, we need to teach women confidence, a skill predominantly taught to boys.”
Just as important, male clinicians should believe in and trust the experiences that women report having, Dr. Reiff-Pasarew said. “It’s very difficult to understand the subtleties of how people are treated differently in patient interactions if you’ve never been in that situation.”
Equal compensation for equal work
Ultimately, it is in the best interest of all physicians, their employers, and their patients to ensure female physicians are satisfied and fulfilled in their professions, said Dr. Jena, and that includes recognizing and rewarding their value.
“What I am trying to argue in my work is for equal pay – equal compensation for equal work,” Dr. Jena said. “Man or woman, it’s a good idea.”
Dr. Jena, who is also a faculty research fellow at the National Bureau of Economic Research, said that when the contributions of a group of people are systematically undervalued, “you run the risk of having those individuals invest less in their career.” In health care, he said, “if fewer women want to go into academic medicine because they know they are underpaid, what impact does it have on new ideas when you eliminate highly successful, intelligent people from a field?”
Dr. Jena and his colleagues authored a February 2017 study in JAMA Internal Medicine that showed hospitalized Medicare patients treated by female internists have lower 30-day mortality and readmissions rates compared with those treated by male internists, including hospitalists. This included millions of hospitalizations and accounted for myriad confounders.5
“Here is evidence that women may be doing a modestly better job than men in terms of outcomes,” Dr. Jena said. “If we are in the business of underpaying and underrewarding females, we are disincentivizing female physicians from entering the field, and in certain specialties female physicians see better patient outcomes.”
Dr. Arora and Dr. Farnan are optimistic that as more studies like those by Dr. Jena and colleagues are published – utilizing large data sets never before available, which account for many of the factors that have been used to justify pay and leadership disparities in the past – times will change for the better.
“There comes a time when everyone realizes a group has been wronged and it’s time to right it. I think now is the time for women. It’s tragic it’s come so late but I’m glad it’s here,” Dr. Arora said. “A lot of work is being done on the ground and in institutions to promote women leaders, to include women in search committees, and improve pay. These are always difficult discussions but now we can have transparency in salaries and we can we discuss them.”
However, Dr. Arora is also concerned about blowback, particularly as issues of sexual harassment of women in the workplace finally emerge from the shadows. “The blowback may be that more people tiptoe around women and are more cautious around them,” she said. “This could end up hurting women in the workplace. Something so deeply cemented like this doesn’t die easily and I think it requires culture change. I do think we’re on that journey and starting to see things change.”
But the real measure of that, said Dr. Farnan, is when these conversations are no longer taking place.
“We will know we’ve achieved what we want to achieve when we don’t have to discuss this anymore,” she said. “We will know we’ve achieved parity when we stop talking about it.”
References
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