KEY POINTS
Gender inequity persists in medicine and medical academia in Canada, particularly
in leadership.
Greater gender equity has been shown to be better for health policy-making and patient
care.
Evidence-informed, multipronged approaches that promote gender equity in medicine
are required at all levels of medical organizations and for all stages of medical
career progression.
The medical profession has an equity problem, particularly in leadership. Several
Canadian studies have highlighted the extent of gender inequity in leadership in medicine,
and the extent to which opportunities in academic medicine are inequitable by gender.
Gender (as defined in Box 1), in combination with race, religion, sexual orientation
and cultural origin, elicits discrimination, including in medicine. In the medical
profession, inequities in compensation and career advancement, and discriminatory
treatment by peers and patients, has been associated with the intersection of race
and gender. Historically, however, research in this area has rarely considered intersectionality.
Box 1:
The multidimensionality of gender
According to the World Health Organization, gender is a multifaceted concept that
captures “the roles, behaviours, activities, attributes and opportunities that any
society considers appropriate for girls and boys, and women and men.”1 Gender is not
binary; it is a multidimensional phenomenon. Gender inequity is largely underpinned
by socially constructed gender norms, roles and relations. However, most of the medical
literature describes gender as being binary (women and men) and as such, most of the
research focuses on differences between women and men rather than considering intersectionality.
Gender roles are shaped early in childhood and influence all aspects of human development
and perceptions of the world, (e.g., traditional expectations for women to be caring
homemakers and men to work outside the home). Traditional gender roles explain why
women do more unpaid care than men at home and at work, which affects their work productivity.
Gender norms are common, shared ideas of how people should speak, dress, groom and
behave in social, workplace and private settings (e.g., assertiveness being seen as
a masculine leadership trait and women being expected to behave submissively, which
may lead to discrimination or differential opportunities based on gender).
Gender relations refer to dynamics in relationships between genders that are determined
by several factors (e.g., religion, culture or society), which can lead to inequities
in power and access or control of resources. These inequities can result in, for instance,
men having fewer consequences for uncivil behaviour or for engaging in workplace harassment
than other genders.
Gender equity and racial diversity in medicine can promote creative solutions to complex
health problems and improve the delivery of high-quality care. We discuss the problem
of gender inequity in medicine in Canada, its root causes, the problems inequity raises
for the profession and multipronged approaches to promoting equity at all levels of
medical organizations, based on best available evidence, as outlined in Box 2.
Box 2:
Evidence used in this article
We searched PubMed and MEDLINE for English-language articles published any time as
of August 2020, using the words “solutions,” “gender inequity” and “medicine.” We
selected randomized control trials, systematic reviews, meta-analyses and observational
studies. We also searched for grey literature using Google and Google Scholar, bibliographies
and reference lists of included articles, the Gender in Global Research group project
folder established by Elsevier and various Canadian and international websites, including
the Association of American Medical Colleges, the Association of Faculties of Medicine
of Canada, the Society for Canadian Women in Science and Technology, the American
Medical Women’s Association and the Canadian Institutes of Health Research, Institute
of Gender and Health.
What is the scale of gender inequity in medical leadership in Canada?
Although women have outnumbered men in Canadian medical schools for a quarter of a
century, women are not equally represented in leadership positions2 and are less likely
to reach higher ranks than men, even after controlling for age, experience, productivity
and specialty.3 In their 2018 report, the Canadian Medical Association (CMA) acknowledged
that gender inequity among medical leaders is an important problem.4 Only 8 of the
152 past presidents of the CMA were women. A woman first became dean of a Canadian
medical school in 1999, 170 years after the first medical school was established,5
and only 8 women have been deans since then. Yu and colleagues analyzed data from
the Association of American Medical Colleges on the faculty of United States medical
schools from 1997 to 2008, and showed that when gender intersects with race and ethnicity,
the gender leadership gap is even wider. For example, among internal medicine chairs,
12 were Asian men, 10 were Black (9 men, 1 woman), 7 were Hispanic (5 men, 2 women),
and 137 were White (116 men, 21 women). It is also worth noting that, among faculty,
only 11%, 9%, 11% and 24% of Asian, Black, Hispanic and White women, respectively,
were full professors compared with 21%, 18%, 19% and 36% of Asian, Black, Hispanic
and White men, respectively.6
Several studies have documented the extent of gender inequity in academic medicine,
where success is judged by productivity in grants, presentations, publications and
mentored trainees. Gender gaps are apparent in national health research funding competitions
at both the scientist level7 and project level.8 If more men in science are getting
funding than women after controlling for factors such as age and experience, this
further exacerbates disparity and negatively affects a woman’s career trajectory.
For example, the more grants a person holds, the more trainees they attract and the
more successful and productive they are, ultimately leading to career promotion and
tenure advancement. Clinical practice guidelines are used extensively to inform practice
and are often widely cited, yet female clinicians are underrepresented on guideline
panels and are less likely to be senior authors than men.9 Grand rounds are opportunities
to model leaders and diversity in medicine; however, a 2018 retrospective study of
presenters at medical grand rounds at 5 major academic hospitals in Canada showed
that women are underrepresented.10 Women are more likely to work in lower paid and
typically undervalued areas of medicine,11,12 obtain reference letters for medical
school faculty positions that are less supportive than their male counterparts,13
and experience a decreased likelihood of being addressed by their professional title,14,15
than men. In both academia and in practice, women are paid less than their male counterparts
even after adjusting for several factors, such as age, experience and workload;11,12
indeed, estimates suggest that women are paid an average of 30% to 40% less than men
through fee-for-service models of payment for family doctors and specialists, respectively.
What contributes to this gender inequity?
The problem of gender inequity in medical leadership is not the result of too few
candidates who are not men with the appropriate experience and training to fulfill
leadership roles, nor can it be explained by merely suggesting that different genders
do not have the same aspirations as men.16 Gender inequity is largely underpinned
by socially constructed gender norms, roles and relations, as defined in Box 1. For
example, gender roles explain why female clinicians with children spend 100.2 minutes
more per day on household activities and child care than their male counterparts.17
This makes it more challenging for female clinicians with children to get ahead. Gender
norms explain why more men are given leadership opportunities and have stronger letters
of reference than other genders. Furthermore, gender relations explain why men have
fewer consequences for uncivil behaviour or for harassment in the workplace compared
with other genders. A recent observational study of operating room culture evaluated
the prevalence and predictors of exposure to disruptive behaviour in the operating
room.18 Disruptive behaviour was described as a range of unacceptable workplace behaviours,
including incivility, bullying and harassment. A further definition provided is “interpersonal
behaviour (i.e., directed toward others or occurring in the presence of others) that
results in a perceived threat to victims and/or witnesses and violates a reasonable
person’s standard of respectful behaviour.”18 The study found that clinicians who
are women report more exposure to disruptive behaviour and are substantially less
confident or empowered to take action to address incivility in their hospital and
university settings.18 Gender and sexual harassment may be associated with environments
that exhibit gender inequity in pay, opportunity and promotion.19,20 Disruptive behaviour
and overt harassment likely endure within our medical institutions because the offenders
are often considered invaluable to the organization for their stature, leadership,
productivity or reputation,19,20 and are largely not held unaccountable for their
actions, which further amplifies gender inequities.
Why do we need gender equity in medicine?
Ensuring gender equity in medicine is an issue of justice and rights. Having more
physicians who are women and more women in health policy leadership also appears to
enhance the provision of high-quality patient care. Large, well-conducted observational
studies have shown that patients of female clinicians experience better quality of
care for diabetes,21 and significantly lower rates of mortality,22–24 hospital readmissions22
and emergency department visits25 than those treated by male clinicians.22 One study
considered that reasons for this may include that women spend more time with their
patients, are more patient-centred in their approach and provide more evidence-based
care.22 Two recent opinion pieces discuss research showing that female representation
on corporate boards, such as hospital boards, results in more socially thoughtful
decisions and less corruption.26,27 Without gender equity, we risk extinguishing creative
solutions to complex health problems26 and, most importantly, limiting patient access
to the best care.20
How can we achieve gender equity in the medical profession?
Although providing people with training in diversity and unconscious bias, as well
as clarifying unprofessional behaviour, may seem like attractive solutions to gender
inequity,28 such interventions represent a small step toward raising awareness of
problems. Moreover, the impact of these interventions is short-lived, and they can
be harmful when the blame for inequity is focused inappropriately and no systemic
measures are put in place.
There is no quick fix for gender inequity. Multipronged interventions composed of
a combination of structural and individual interventions (as summarized in Box 3)
are needed to foster lasting and meaningful change.29–38 According to Hui and colleagues,39
implicit gender bias is pervasive across the continuum of medical training and practice.
Therefore, solutions must begin with recognition of the systemic nature of the problem.
Solutions should also be holistic and supported by professional organizations, including
at the national (e.g., the CMA, the Association of Faculties of Medicine of Canada,
the Royal College of Physicians and Surgeons of Canada and the College of Family Physicians
of Canada), provincial (e.g., provincial and territorial medical associations) and
local (e.g., hospital, clinic, practice and university leadership level) levels.
Box 3:
Solutions to gender inequity in academic medicine
*
Quantification of gender inequities in funding, publications, promotion and compensation
Communicating gender statistics
Annual reporting on the impact of gender equity efforts (completed and made publicly
available to ensure accountability)
Behavioural or systemic change
Recognition of the systemic nature of gender inequity and the need for systemic solutions
from organizations
Role modelling equity principles by the leaders of professional institutions (academic
and health care)
Enshrining core principles of equity, diversity, inclusion, mutual respect, collegiality
and professionalism in all organizational policies
Communication of clear objectives to address inequities, describing how it will be
achieved with well-defined plans
Open and transparent procedures and policies to protect whistleblowers
Appropriate and evidence-based remediation for the perpetrator if an underlying cause
(e.g., burnout or mental health issues) is identified
Gender-inclusive language in recruitment, hiring, and grants and funding assessments
Use of reverse quotas
Search committees reflecting the diversity of the profession or the broader population,
and committee awareness of gender bias in reference letters
Gender bias training and champions of gender equity
Seminar training, with a curriculum based on Systems of Oppression theories, using
a formally trained search advocate
Proportional approach for research grants
Career flexibility
Integrated career–life planning, coaching to create a customized plan to meet both
career and life goals, and a time-banking system
Flexible policies, including family-friendly, parental and career flexibility policies
Nongendered parental leave schemes
Shortened workdays
Policies prohibiting assigning work or sending emails in the evenings and on the weekend
Increased visibility, recognition and representation
Career development planning
Leadership program
Ensure availability of role models to foster identity compatibility and belonging
Social media campaign
Creating opportunities for development, mentorship and sponsorship
Career advising plan
Curriculum vitae review program
Peer mentoring program
Sponsorship program
Financial support
Financial support for childbearing and caregiver responsibilities
Lottery for research grants
*
Solutions that combine several of these components are recommended.
Quantifying gender inequities
Obtaining and publicly reporting gender and other intersectional data can increase
awareness of inequities, as shown by a 2015 case study of gender equity among medical
conference speakers,40 which showed that measurement highlighted the problem and,
when combined with public accountability, provided incentive for change and to monitor
impact. The work of both measuring and reporting and driving change to support gender
equity must be recognized and adequately compensated.
Championing behavioural and systemic change
Drivers of behavioural and systemic change need to be championed from the top down.41
This was evident in a case study of an intervention that evaluated the effect of a
top–down structural change within science, technology, engineering, mathematics and
medicine faculties at Oregon State University. The intervention was an in-depth seminar
designed to foster reflection on systems of oppression and power within university
leadership. Findings led to the implementation of action plans and policies that shifted
the faculties toward greater equity and justice on objective measures. Furthermore,
when senior faculty exhibit behaviours in support of equity, it can lead to a more
inclusive and supportive climate in academia. Thus, leaders of professional societies,
as well as academic and health care organizations, should model the principles of
equity. However, although role models in leadership are necessary, they are not sufficient
to achieve equity. The core principles of equity, diversity, inclusion, mutual respect,
collegiality and professionalism must be enshrined in all policies, programs and procedures,
from undergraduate to postgraduate education, through to clinical practice and professional
leadership. Organizations, through their boards and administrative leadership, must
communicate clear objectives to address inequities and describe how these objectives
are going to be achieved. Organizations must also be held accountable. Furthermore,
allies and whistleblowers of all genders who report unprofessional behaviour must
be supported and protected by open and transparent procedures that enable them to
speak up,18 and perpetrators of unprofessional behaviour must be remediated according
to best practice and evidence relevant to the circumstances.
Selection and hiring
Advancing an organizational culture of equity in medicine should ideally begin with
enrolment in medical school and continue through all stages of professional advancement.
Because implicit gender bias is common and, by definition, largely unrecognized,42,43
gender bias training is necessary for people involved in candidate selection, although
without clear measures to effect behaviour change such training may be insufficient.
Open and transparent procedures and policies support more equitable hiring of academic
and clinician candidates,11 and open search procedures (including job postings) should
embed equity requirements. For example, all eligible candidates must be encouraged
to apply and active strategies to increase the diversity of applicants should be undertaken.
Job postings should use neutral language that does not implicitly favour one gender;
online tools devoted to the use of gender inclusive language are available.44 Although
specific processes to reduce implicit gender bias such as blinding can result in an
increased proportion of applicants who are diverse,45 nongendered language has not
been effective in reducing gender bias in the grant application process.46
In addition to receiving bias training, search committees should reflect the diversity
of the population to raise the likelihood that diverse applicants will be treated
equitably during the selection process. Having a search advocate who has received
training sit on recruitment committees can also show commitment toward equity and
inclusion, and can assist search committees in their efforts to avoid unconscious
and unintentional biases. All committees should require training on equity, diversity
and inclusivity to ensure the best candidate gets selected, independent of bias.41,43,47
Committee members should also be aware of gender bias in reference letters (e.g.,
a focus on relationships versus achievements for female candidates48). Nontraditional
capability metrics, such as the impact of the candidate’s work rather than number
of publications, should be the focus of the interview, including new expertise in
gender equity. Given that the outputs of female candidates may have been affected
by time taken to have a family or unpaid labour at home, it is important to consider
diverse measures when considering candidates’ productivity and impact. Considering
only number of publications, presentations and grants obtained will bias selection
toward male candidates. Prioritizing other criteria such as ratings of the candidate
by students, patients and peers, can allow for more equitable ranking. The use of
reverse quotas49 (e.g., only 50% of the leadership can be men) should be encouraged
to promote meritocracy and help neutralize male privilege.50
Supporting women’s careers
Existing support for women to advance their careers is minimal and inadequate. Attracting
and retaining talented candidates in academic medicine will require that institutions
have policies to ensure career flexibility through a supportive environment that challenges
“the ideal worker norm.”51,52 Initiatives that promote team success with benefits
that mitigate work–life and work–work conflicts can include integrated career–life
planning, coaching to create a customized plan to meet both career and life goals
and time-banking systems.53 Time-banking interventions measure unacknowledged work
such as teaching, service and clinical activities, and acknowledges them with practical
rewards in the form of support services that are meant to benefit career and personal
goals by alleviating time pressure and by promoting career success.54 Parental leave
and family-friendly policies include income-replacement plans that provide more resources
to the family.55–57 Not specific to physicians, evidence suggests that up to 6 months
of paid parental leave can increase the participation of women in the labour force
and reduce wage inequalities.58 In addition, making parental leave available to both
men and women is critical to ensuring equal economic opportunities. Two studies that
analyzed California’s paid family leave found that it increased the usual work hours
of employed mothers of children aged 1–3 years by 10%–17%. The studies also showed
an association of the policy with higher probabilities of work and employment for
mothers 9–12 months after childbirth.59,60 In addition, maternal earnings from 1 to
5 years after childbirth increase when paid maternity leave of moderate length is
available.61,62 Financial support earmarked for faculty with caregiver responsibilities
can result in staff retention and a greater likelihood of promotion.63
Minority groups lack role models and mentors who are women in academic medicine. To
increase the visibility of diverse women in all areas of academic medicine, career
advising plans can enhance confidence around professional self-advocacy, achieving
a promotion to the next academic rank and expanding training or job opportunities.64
Peer mentoring can contribute to increasing recognition and representation.65–69 Mentors
and role models who are women in academic medicine have an important influence on
career guidance, career choice, research productivity and personal development.70,71
Because of the shortage of women leaders in academic medicine, there might not always
be women available to be mentors. Mentorship alone might also not be enough to support
career advancement. Sponsorship, which is the intentional effort by a current leader
to advocate for a woman to help her advance her career may be more effective.72 Sponsorship
directly targets career advancement and is anchored in the sponsor’s established network
and substantial influence on decision-making processes or structures to provide critical
professional opportunities for junior faculty. In the present context of a dearth
of women leaders who wield that power in academic medicine, men must be evaluated
based on how effectively they provide sponsorships for women.73
Organizational approaches, with proposed action plans and publicly reported, measurable
effects in promoting good practice in the wider community, are required (Box 4).77,78
Box 4:
The Athena Scientific Women’s Academic Network Charter: an example of a multipronged
solution to gender inequity in academia
The Athena Scientific Women’s Academic Network (SWAN) charter encourages and commits
universities in the United Kingdom to advance the careers of women in science, technology,
engineering, mathematics and medicine.74 As an award-based program, Athena SWAN promotes
the progression of women to senior roles by removing obstacles to advancement, ensuring
equal pay and mainstreaming support, through action at all levels of the institution.
Peer-review panels assess applications, make suggestions on awards and provide applicants
with constructive feedback. Categories of interventions include the following: self-assessment
and monitoring; key career transition points; permanent and long-term contracts, including
job security for academic-related and research staff; career development; promotion
of flexible working, including management of career breaks; improvements in organization
and culture with respect to gender equity; and a combination of complex, context-specific
action planning and system-level organization.
Athena SWAN is widely used throughout the UK as a tool to address gender challenges
in institutions for higher education. Women in the highest award category are more
likely to be satisfied with performance and development reviews, to be familiar with
criteria and processes for promotion, to have been encouraged to apply for promotion,
to believe that there are flexible working practices, to be more optimistic about
career prospects and to have a mentoring scheme available to them.74 Some evidence
linked the charter to higher levels of engagement by women.74 White, middle-class
women are the main beneficiaries of Athena SWAN. Athena SWAN and similar initiatives
need to incorporate intersectionality and the effects of the overlap of race and other
social identities (including gender) for women in science, technology, engineering,
mathematics and medicine. Other countries have implemented similar programs, contextualized
to their own setting, such as Science in Australia Gender Equity (SAGE) in Australia75
and the Dimensions Charter in Canada.76
Conclusion
Gender equity in medicine will occur when the culture shifts across the entire system.79
If gender equity is truly valued, robust research into the drivers of, and potential
solutions to, gender inequity will be necessary for effective change. Some of the
authors are currently working with colleagues from 7 countries to evaluate the efficacy
of different types of gender equity interventions, supported by funding from the Canadian
Institutes of Health Research.80 However, many evidence-based solutions can be adopted
now, and there is no excuse for not working to change the climate and environment
of the medical profession so that it is welcoming of diversity. The medical profession
should be professional, be collegial, show mutual respect, and facilitate the full
potential and contribution of all genders, races, ethnicities, religions and nationalities
for the benefit of patient care. Equity will only be realized when everyone — regardless
of gender and other differences — experiences equity in pay, promotions and other
opportunities. There is no better time than now to implement policies to advocate
for and support equity in medicine.