Gender bias is widely recognized across most industries, and the medical field is no exception. A bias implies unequal distribution of advantages for or against one group compared with another. Gender roles in western culture emerge as early as the preschool years and permeate all aspects of life, including our careers. Gender stereotypes assume men and women should behave a certain way and play distinct roles in society. When a person deviates from these traditional roles, conflict can be created in the workplace through implicit bias, something that we all carry. Gender bias and gender-based pay disparity were given a national platform in 1963 when President John F. Kennedy signed the Equal Pay Act. Nevertheless, nearly 60 years later, gender inequality and gaps in salaries and leadership persist in medicine, regardless of specialty (Trans Am Clin Climatol Assoc 2015;126:197-214; Ann Intern Med 2018;168:741-3; asamonitor.pub/2Jf4ZNu). Neurosurgery, cardiology, and reproductive endocrinology are among the many specialties that have spoken out and published valuable papers in this area (Circulation 2017;135:518-20; World Neurosurg 2019;130:516-22.e51; Fertil Steril 2019;111:1194-200).
Women in medicine are paid less and appointed to academic leadership positions less frequently than their male counterparts (JAMA Intern Med 2016;176:1294-304; CMAJ 2018;190:E479-80; Lancet 2019;393:e14; asamonitor.pub/374Qpk2). The Association of American Medical Colleges (AAMC) reported that during the 2019-2020 academic year, 52% of matriculants from all medical schools were female (asamonitor.pub/3m9er3B). Despite the number of women enrolled in medical schools, women remain grossly underrepresented in leadership roles in academic medicine. According to 2018 AAMC data, women account for only 16% of medical school deans, 18% are departmental chairs, and 25% are full professors (asamonitor.pub/374Qpk2). Assuming that roughly 50% of medical school graduates are female, where do they all go?
The gender pay gap was recognized by JAMA in an article by Jena et al. After adjusting for age, years in rank, and subspecialty, there was an annual pay gap of $19,878 between male and female physicians at public medical schools in the United States (JAMA Intern Med 2016;176:1294-304). Moreover, the most recent 2018 AAMC Faculty Salary Survey revealed there is a difference in median compensation between males and females in every rank for every subspecialty and that the salary gap increases with academic rank. The pay differential at the level of chair between men and women can be as high as $100,000 (asamonitor.pub/3m9er3B). Among clinical science fields, women are earning an average of 77 cents for every dollar a man earns (asamonitor.pub/33lEY6C). Over a lifetime, this salary differential can result in salary losses of six figures or greater.
Because of the impact of gender bias on women regarding compensation and leadership roles in medicine, we decided to conduct an institutional survey among our medical trainees (interns, residents, and fellows) to assess awareness of the issue. With institutional review board approval, an anonymous 12-question survey was distributed via email. The survey focused on the medical trainees' experience with gender bias and their perception of whether gender pay and leadership gaps exist. The overall response rate was 18%, with 100 responses. While both women (96%) and men (78%) believed that gender bias exists in the field of medicine, it is not surprising that twice as many women (87%) than men (42%) reported personally experiencing gender bias. Interestingly, women reported experiencing gender bias more often from nurses (69%) and ancillary staff, i.e., office administrators, technicians, etc., (61%), whereas men were more likely to report bias from other physicians (52%) than nursing (40%) and ancillary staff (24%). Women were more likely to report experiencing emotional distress from gender inequality than men (47% vs. 18%). Nearly half of women said they believed that gender bias has affected their training compared to male (30%) respondents. Neither men nor women believed they had been taught to properly recognize and deal with gender bias during their medical training. Lastly, a majority of women (88%) were aware of the gender pay gap and underrepresentation in leadership roles, compared to men (40%).
Based on the data collected from our survey, gender bias was overwhelmingly perceived (87%) among our medical trainees. It is unfortunate that the two survey questions that show the greatest disparity in awareness were those regarding gender pay and leadership gaps, because awareness is the first step to ensure equal opportunities for advancement in the medical field. Initiatives identified by previous research indicate that awareness should start in the medical curriculum (Br J Anaesth 2020;124:e59-62). Education on gender bias is not currently incorporated in our medical education or postgraduate medical training. Our gender bias survey suggests that co-educational programs should be initiated early in training during medical school and residency training programs.
Women's opportunities for advancement in academic medicine are constrained early on by stereotype-based cognitive bias (Trans Am Clin Climatol Assoc 2015;126:197-214). Explicit and implicit bias are known contributors to the leadership gap. For example, multiple studies have shown that the same work performed by men and women is consistently rated lower when the evaluator believes the work had been done by a woman. Furthermore, it is recognized that promotion committees inadvertently require women to have more publications, awards, and so on, than men to advance (Psychol Rev 2002;109:573-98). So, how do institutions support women's careers? A study conducted by the University of Pennsylvania identified four areas: equal access to opportunities and resources for men and women, facilitation of the discussion and elimination of gender biases, a supportive chief/chair, and a department that encourages work-life balance (Acad Med 2012;87:1622-31).
The signing of the Equal Pay Act in 1963 prohibited discrimination on the basis of sex in the payment of wages (asamonitor.pub/2Jf4ZNu). Equal pay for equal work is expected. As our survey shows, many medical trainees do not realize that a gender pay gap exists. The American College of Physicians and many other national medical associations have released statements promoting pay parity as well as suggestions for achieving the end goal. They believe that physician compensation should be equitable based on each stage of their career, and in accordance with their expertise. Transparency and regular assessment of physician compensation is necessary to abolish the gap (Ann Intern Med 2018;168:721-3). Further, programs to empower and educate women, such as faculty development programs, can help women understand their worth and negotiate salaries.
Gender bias remains prevalent in our medical training systems. Female medical trainees perceive gender bias at a much higher rate than males. The profound consequences for physician's careers, particularly female physicians with regard to pay and leadership opportunities, requires continued efforts. Awareness, education, and formal mentoring are needed to close the gaps in medicine. Eliminating gender bias will provide the best outcomes for our physicians, trainees, medical community, and ultimately our patients. Transparency, education, and mentoring can be ways in which to obtain equality for all sexes.