What’s Holding Women in Medicine Back from Leadership

jun18-19-200140348-001-Reza-Estakhrian — Reza Estakhrian/Getty Images

For over 25 years, women have made up at least 40% of U.S. medical students. This past year, more women than men were enrolled in U.S. medical schools. Yet overall women make up only 34% of physicians in the U.S., and gender parity is still not reflected in medical leadership. Women account for only 18% of hospital CEOs and 16% of all deans and department chairs in the U.S.—positions that typically direct the mission and control the resources at medical centers. Women are also in the minority when it comes to senior authorship (10%) and Editors-In-Chief (7%) at prestigious medical journals.

Reasons for gender disparities in the C-suite of medicine are manifold. For example, women do not achieve promotions or advancement to leadership positions at the same rate as their male peers. Highly qualified women do not attain independent grants, publications, and leadership positions at the same rate, either. Evidence shows that women in academic medicine experience greater challenges finding mentors and sponsors than men, and that this gap likely contributes to career disparities. Women are offered lower pay and less institutional research funding when they join a faculty, and they continue to earn considerably less than men—even among those at the same level and with comparable productivity. Women physicians in community practice also tend to earn less than men, even after accounting for specialization and billing.

These disparities are terribly disappointing, to say the least. Women physicians add a tremendous amount of strength to the field of medicine. Recent studies show that women physicians may provide better clinical care and health care system savings in comparison with their male counterparts, and women may also generally be more collaborative in both research and education pursuits.

What can be done, then, to reach gender parity in medicine? We combed through the research to identify factors contributing to gender disparities in the field and how organizations can start addressing them.

What’s Holding Women Back

Implicit gender and maternal bias. Implicit, or “unconscious,” bias against women in medicine is prevalent, affecting their hiring, promotions, development, and wellbeing. For example, studies have demonstrated that women are less likely to be hired and/or promoted because of their gender. Anecdotally, we’ve heard many stories about how biased assumptions (such as mothers not having enough time to also be leaders) prevent women from being offered leadership positions. Research has also found that workplace discrimination against women physicians is common, as women have reported not only receiving lower pay, but being disrespected by colleagues, being held to a higher standards than male peers, being treated less formally than men (e.g. being introduced by first names rather than professional titles), and not being invited for major talks, such as grand rounds.

A study of 5,782 physicians in 2016 suggested that some of this discrimination is specific to mothers, pointing to another big factor that seems to stop women from progressing: the “Maternal Wall” that women hit after having children. A qualitative analysis (currently under review) of almost 1,000 physician-mothers found that many feel they are in a double bind. One said, “You just can’t win when they call women who work part time ‘lazy’ while also telling you ‘your kids are growing up without a mother’ if you work full time.”

Research on other professions suggests that women of color encounter additional hurdles in becoming leaders. Although few studies have specifically explored this issue in medicine, it’s clear that there is a paucity of women of color in leadership roles in the field.

System-wide policies that disadvantage women. A number of system-wide barriers undoubtedly contribute to women leaving medicine and therefore not attaining leadership roles. For example, in academic medicine, many university policies inadvertently penalize women who are in their child-rearing years. Despite the fact that the head of the American Academy of Pediatrics has publicly endorsed a minimum of six months of paid family leave (a recommendation based on the child’s medical and developmental needs), the mean length of paid leave offered at the top U.S. medical schools is only around 8 weeks. We don’t have data on policies in individual practices and hospitals, but we’d be surprised if they were any more generous.

Family leave policies usually also remain at the discretion of departmental or practice leadership, which may cause supervisors to encourage shorter leave or lead women to take shorter leaves to be perceived as better workers — both of which can ultimately lower physicians’ motivation, increase burnout, and hurt retention. Even at universities, where policies may be better defined, family leave is often restricted to the “primary caregiver” (a proxy for mother), which prevents partners—who may be at the same center—from taking any leave. This can hamper cooperative parenting and make it harder for women to stay in the field. And since almost half of women physicians are married to another physician, this risk of both partners being at the same workplace is quite real.

Medical centers also typically have insufficient policies and programs to support childrearing, lactation, and caretaking, making it difficult for women to juggle work, motherhood, and family. For instance, daycare facilities often have year-long wait periods, and there are typically no policies reducing workload for lactation. Women in medicine also bear the greater burden of domestic responsibilities, with one study finding that women were spending 8.5 hours more per week on parenting and domestic tasks than their male peers, even after adjusting for spousal employment status and numerous other factors. In addition, women are more likely to care for their ill family members than men, leading many women physicians to become triple-duty caregivers, which likely increases attrition.

Another issue is that certain key grants for career development in academic medicine are limited to physicians who finished training within ten years, which limits women’s flexibility to work part-time or take time off to rear children.

Sexual harassment. The #MeToo movement helped make clear just how common overt discrimination and sexual harassment is in our society—including within medicine. The literature on workplace harassment suggests that such experiences are more common in hierarchical and male-dominated fields like medicine. In fact, a recent report found staggering rates of sexual harassment in science, medicine, and engineering, with 40-50% of medical students reporting experiencing sexual harassment by faculty and colleagues. A study of Generation X academic doctors in the U.S. found that 30% of women (compared to 4% of men) had experienced sexual harassment from a superior or colleague in their careers. Along with facing sexual harassment from colleagues, women physicians are also more likely to experience harassment from patients. Sexual harassment may be underreported because of fear of retaliation or stigmatization, and it has been shown to worsen burnout, retention, and productivity.

What Can Be Done?

A look at the research reveals a number of pragmatic, evidence-based solutions that healthcare leaders—from medical school deans to hospital executives—should consider in order to help retain women and advance their careers in medicine.

Institute family-friendly policies. Strong family leave policies can help ensure that physicians are not faced with a binary choice between career and family. We know that paid maternity leave improves maternal and infant health outcomes, and recent evidence indicates that paid family leave policies also help retain women in medicine and academia, with more weeks of paid leave having the greatest benefit. Based on these findings, and other best practices, we recommend offering:

At least 12 weeks of paid childbearing leave. To address the physical effects of pregnancy and parturition among women who deliver a child, these policies must be clear and system-wide, rather than at the discretion of supervisors.
An additional 4-12 weeks of childrearing leave for all new parents, regardless of gender, sexual orientation, or adoption status. Organizations should recognize the additional time required for all new parents to address the intense physical and emotional needs of a new child. These policies must be clear and accessible.
Lactation rooms and protected time for breast milk pumping during the first year. Physicians often return to busy clinical schedules. Lactation rooms would be a big help to mothers, but we also recommend relieving new moms of clinical duties for at least two 30-minute periods every 8-hour stretch of work to pump. Encouraging breastfeeding has been shown to provide a strong return on investment in terms of reduced sick leave, and improved retention, productivity, and loyalty.
On-site childcare services with emergency back-up childcare. Most childcare facilities at academic medical centers have a prolonged wait list of more than one year. Increasing these services on-site will prevent physicians from having to choose between family and work. UCSF (where three of us work) is a good model, with on-site childcare services that cost 10% below market rate and emergency temporary back-up care for faculty with sick children at home so they can still attend to clinical duties.
Paid catastrophic leave. This would be used to care for a family member who has experienced a serious and/or life-threatening illness or injury. Some programs allow employees to donate vacation time to their co-workers so they can care for loved ones when ill – one at the University of California Riverside, for example, has been quite successful.
Career flexibility. Giving physicians greater control of schedules, flex-time, and the option to telecommute may also help retain those who have children. Promotion policies should also be flexible and supportive of faculty building families.

Mitigate bias, discrimination, and sexual harassment. There are many solutions that have been proposed to mitigate bias and harassment, and we’re now seeing some preliminary findings that can speak to their effectiveness. Leaders should consider:

Implicit bias training. Training in implicit bias—particularly to members of search and hiring committees—can help address gender-based prejudice, particularly when it moves beyond recognition of bias and toward strategies to address bias when it arises. Some organizations have seen promising results already. Certain programs, like Bias Interrupters for Managers training, have been very well received by academic institutions because they are dispassionate, evidence-based, and allow people to brainstorm ways to overcome common patterns of bias in the future. This program encourages using a survey to uncover bias in locations like hiring, mentoring, and compensation, so that institutions can develop concrete strategies.
Annual salary reviews/ Some academic medical centers, like Columbia and UCSF, have begun to conduct system-wide reviews of salaries to mitigate implicit biases. Individual departments should implement annual reviews and be held accountable for any gender discrepancies in salaries, as well as in promotions and awards.
Better reporting systems for harassment. People must be able to speak up about harassment without fear of retaliation or stigmatization. Medical schools and other organizations might consider adopting online reporting systems like Callisto, which has been adopted by several universities, and has been shown to increase reporting of assault, reduce time to reporting assault, and create greater student satisfaction.
Legal assistance for family responsibilities discrimination. Family Responsibilities Discrimination (FRD), also called caregiver discrimination, is employment discrimination against workers based on their family caregiving responsibilities. Leaders should make sure their faculty and staff know about services like the UC Hastings College of Law’s Worklife Law Family Responsibilities Discrimination Hotline, which is available to anyone in the U.S. This service provides free legal advice to understand what constitutes this type of discrimination, how to prevent it, and how to handle situations in which discrimination arises.

Improve mentorship, sponsorship, and targeted funding for women. Medical schools function in an apprenticeship model where mentors — senior faculty who provide input and guidance on research, clinical, and career advancement — are critical for reaching career milestones. A vast literature has highlighted the importance of mentorship and sponsorship for helping women to develop skills needed for leadership — yet women in academic medicine report more difficulty finding mentors than male physicians. A recent study also documented that women are less likely to receive sponsorship experiences such as being recommended as a discussant or panelist at a national meeting, write an editorial, serve on an editorial board, or serve on a national committee. A few things may help on this front:

Creating formal mentoring programs for women. Formal networking programs and events can help women identify potential mentors whom they might not otherwise encounter. For example, the Society for General Internal Medicine has a one-on-one mentoring program at its annual meeting, in which junior faculty and trainees are matched with senior leaders from other institutions. The American Association of Medical Colleges (AAMC) has mentoring and leadership development programs for early and mid-career women faculty, and the Executive Leadership in Academic Medicine(ELAM) program helps women create networks and build senior leadership skills. Programs like this can provide important advice women don’t get elsewhere, such as how to negotiate for higher pay and how to access other resources, like lab space or administrative support. And these programs can improve participants’ job-related well-being and self-esteem. These national programs tend to be highly over-subscribed, reflecting the need to offer training more broadly and prompting other institutions, like the University of Michigan (where one of us works), to offer similar programming locally.
Encouraging peer mentoring. Peer mentoring programs typically convene groups of women at a similar career stage to meet periodically. Some are more focused on skill development and others serve as a supportive community and sounding board for members. These groups have been found to lead to enhanced collaboration, increased productivity, and real change in institutional policies, such as better childbearing leave. Informal online social networks, like The Physician Moms Group and Academic Research Moms on Facebook, also help provide peer support and advocacy for women physicians.
Facilitating sponsorship for women. Organizations need to encourage senior leaders to consider more women as targets for their sponsorship efforts. Specific training for how to sponsor women, as well as conducting audits and getting feedback about sponsorship efforts, can be a helpful start.
Developing workshops specifically for women of color. Universities have started to recognize the unique challenges that academic women of color face and are helping to build mentor and sponsor networks to support them. For example, Stanford and WISE Ventures recently partnered to host a 3-day conference called “Women of Color in the Academy Staying Fit: Mind, Body, and Soul,” which provided practical skills, safe spaces for discussion, and opportunities to develop action plans for academic success.
Offering research support when women are caring for children or ill family members. Nearly a dozen universities across the country have developed novel programs to provide financial support for physician scientists during these caregiving periods. One program at Harvard saw a $51M return on a $2.1M investment through research grants subsequently acquired by these women.

If health care leaders want to retain the growing contingent of women in medicine, they need to invest in understanding their challenges and in pragmatic solutions to mitigate them. By now we know that a more diverse workforce in medicine will help us provide better patient care and drive the most innovative research to improve human health for all. Implementing structural policies can help women not only survive, but thrive in the field.