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II. Status Report on Women in Academic Medical Centers
III. Continuing Disadvantages Related to Professional Opportunities
A. Specialty Choice
B. Sexism and Mental Models of Gender
C. Acquiring Mentoring
D. Practice-Related Areas of Career Disadvantage
E. The Intersection of Gender and Ethnicity
IV. Forward-Looking Institutional Approaches
After three decades of increasing numbers of women entering previously male-dominated health professions, few academic health centers have what might be considered a “critical mass” of women full professors, much less women leaders. A brief status report on women in academic medicine introduces a discussion of recent research on why gender differences in the advancement of professionals persist. For instance, no matter how complex the technical requirements of a woman’s occupation, Western culture expects her to be more nurturing and emotionally accessible than a man. At the same time, it places a low value on caretaking roles, in terms of both prestige and financial remuneration. Forward-looking institutional strategies to enhance the development of women health professionals target features of the work culture that may be “simply the norm” but that disadvantages women. The concluding section of this research paper attempts responses to the questions: Is the increasing number of women entering medicine and other health professions mitigating the impact of gender? And how is gender diversity changing the profession?
II. Status Report on Women in Academic Medical Centers
Of all the health profession schools, the most extensive data is available on medical schools (and they are largest in terms of budget and size); therefore, this statistical report centers on women in academic medicine. Most trends and findings cited would apply as well to other health professions that were male-dominated until recently.
In 2001 women constituted 45 percent of U.S. medical students, 39 percent of dental students, and 41 percent of osteopathic students (by comparison, women are 55% of enrollees in four-year colleges/universities). The number of men applying to medical school has been declining faster than the number of women. For instance, between 1995 and 2001, the number of men applying to medical school declined by 33 percent, compared to 17 percent for women. If this rate of change continues, by 2005, half of first-year medical students nationally will be women.
The proportion of full-time medical school women faculty in 2001 was 28 percent (in dental schools, 25%, and in osteopathic schools, 39%). The proportion of medical school instructors who are women has been steadily increasing and is now 46 percent, but only 12 percent of full professors are women.
With regard to the proportion of men and women faculty at each rank, these proportions have remained remarkably stable, especially at the full professor rank (Bickel, 2001). For instance, in 2001, 10.9 percent of all women faculty and 30.9 percent of all men faculty were full professors; in the mid-1980s, these proportions were 9.9 percent and 31.5 percent, respectively.
In 2001, 14 percent of tenured medical school faculty (all ranks) were women. Between 1995 and 2001, the percent of women with tenure actually dropped from 14 percent to 12 percent, about the same proportional decline as the percent of men tenured (32% to 28%) (Bickel, 2001). Data from the Association of American Medical College’s Faculty Roster System also reveal that the average annual rate of women faculty attrition (9.1%) exceeds that of men (7.7%) (Yamagata).
With regard to academic administrative roles, in 2001 women chaired approximately 214 departments (91 basic science and 123 clinical departments [including interim and acting chairs]), which is about 8 percent of all medical school chairs. This total constitutes an average of just 1.7 per medical school, and at least 20 of 125 medical schools have no women chairs (most of these have never had one). The specialties with the largest number of women chairs are microbiology, pathology, anesthesiology, family medicine, obstetrics/gynecology, and pediatrics (Bickel, Clark, and Lawson).
By 2002 the number of women assistant, associate, and senior associate deans at American medical schools totaled approximately 422 (an average of three per school); three schools had no woman in a decanal position. As of July 2002, women held deanships at eight of the 125 U.S. medical schools (two were interim positions). In osteopathic schools, women held three of nineteen deanships and in dental schools, none.
III. Continuing Disadvantages Related to Professional Opportunities
Numerous studies from the late 1990s and early 2000s have elucidated continuing gender differences in professional opportunities and advancement. Although these areas are highly interrelated, the findings are presented below under five headings: specialty choice, sexism and mental models of gender, acquiring mentoring, practice-related areas of career disadvantage, and the intersection of gender and ethnicity.
A. Specialty Choice
The specialty choices of women physicians have changed little despite their large increases in numbers, with comparatively few women entering surgery and most subspecialties. Why are women not distributing more evenly across specialties? The weight of tradition from earlier eras when women physicians were restricted to treating women and children (Bickel, 2000) explains in part why high proportions of women physicians continue to enter obstetrics and gynecology, pediatrics, general internal medicine, and family practice. But the paucity of women entering surgery also points to characteristics of the field, including hours that may preclude having a healthy family or personal life, and a lack of positive role models (Biermann). Women who enter training, however, do not drop out of surgical residencies at a higher rate than men. The American College of Surgeons’ analysis of the 1993 entering cohort found that male and female U.S. and Canadian graduates had the same attrition rate from surgical residencies (Kwakwa and Jonasson). The largest study of women physicians (U.S. medical school graduates between 1950 and 1989) found that women surgeons are less likely (43%) to have children than nonsurgeons (71%) but reported a higher level of satisfaction with their specialty than nonsurgeons (Frank, Brownstein et al., 1998).
Thus, the more prestigious (and better paid) curing specialties continue to be male dominated (Bickel, 1988). One issue of equity related to women physicians’ concentration in what might be termed the caring specialties is that listening and counseling skills are sometimes viewed as qualities inherent in women rather than acknowledged as technical proficiencies that deserve recognition and recompense.
B. Sexism and Mental Models of Gender
Harassment and sexism continue to detract from the education and opportunities of women health professionals. Even medical school department chairs admit to witnessing inappropriate sexual behavior including pressuring women to participate in sexual relationships (Yedidia and Bickel). Almost half of American women physicians believe they have been harassed during their careers, and most cite medical school as the location. In this national study, harassment was associated with depression, suicide attempts, and a desire to switch specialties (Frank, Brogan, and Schiffman). Abused students are more likely to lack confidence in their clinical skills and in their ability to give compassionate care (Kassebaum and Cutler; Schuchert).
As troublesome as overt sexual harassment continues to be, subtler forms of bias pose a much larger challenge to women’s development as professionals. U.S. society associates decisiveness, rationality, and ambition with men, and gentleness, empathy, and nurturance with women (Tong). Such stereotypes, however, deny individuals the opportunity to be appraised positively on the basis of their unique traits. Indeed, men or women who act “against type” tend to be dismissed or marginalized. The “feminine” man who displays more sensitivity or emotion than is culturally normative risks derision; the assertive woman is perceived as “uncaring” and “unfeminine.”
These widely shared schemas about males and females also include expectations about their professional competence (Valian). Medical school department chairs confirm that lack of recognition and respect of women in routine interactions was prevalent (Yedidia and Bickel). Women report feeling “invisible” and frequently having their contributions at meetings ascribed to men (Valian). Both men and women asked to rate works of art, articles, and curricula vitae give lower ratings when they believe they are rating the work of a woman (Valian, 1998). An analysis of peer-review scores for postdoctoral fellowship applications revealed that women applicants had to be 2.5 times more productive than the average man to receive the same competence score (Wenneras and Wold). Students judge women faculty who are not nurturing much more harshly than they do men professors who are not nurturing (Sandler, Silverberg, and Hall).
Thus, without being conscious of their “mental models” of gender, both men and women still tend to devalue women’s work and to allow women a narrower band of assertive behavior (Valian). Under such conditions, women cannot realize their full potential, nor can they care for their patients with maximum effectiveness. “Mental models” persist in part because individuals, especially dominant personalities, tend to ignore information that runs counter to their stereotypes (Fiske). Features common to clinical medicine, such as time pressures, stress, and cognitive complexity, also stimulate stereotyping and “application error” (i.e., inappropriate application of epidemiological data to all group members) (Geiger). Nonetheless, most scientists and physicians appear to believe that they work in a meritocracy and that they are not influenced by stereotypes (Bickel, 1997). Some even conclude that women are advantaged compared to men. Apparently, while individual men do not feel powerful, power is so deeply woven into their lives that it is most invisible to those who are most empowered (Kimmel). Equity demands, however, that health professionals accept responsibility for unlearning whatever stereotypes interfere with their evaluations of patients, students, and colleagues.
C. Acquiring Mentoring
While most studies find that women faculty are as likely as men to have a mentor, women gain less benefit from the mentor relationship. One internal medicine department found that mentors more actively encouraged men than women proteges to participate in professional activities outside the institution and that women were three times more likely than men to report a mentor taking credit for their work—an unethical practice rarely discussed (Fried, Francomano, and MacDonald). Women cardiologists report their mentors to be less helpful with career planning than men do and more commonly noted that their mentor was actually a negative role model (19% of women versus 8% of men) (Limacher, Zaher, and Wolf ).
These challenges in obtaining mentoring are particularly unfortunate because, for a variety of reasons, women have a greater need for mentoring than men do (Bickel, 2000).
Not only does Western culture tend to devalue women’s work, women tend to be more modest than men about their achievements; they are less apt than men to see themselves as qualified for top positions even when their credentials are equivalent or superior (Austin). Moreover, women’s informal networks are less extensive and less likely to include colleagues or higher-ranking people from previous institutions (Hitchcock et al.). Without the “social capital” and essential information that grow out of developmental relationships, women remain isolated. And isolation further reduces their capacity for risk-taking, often translating into a reluctance to pursue professional goals or a protective response such as niche work or perfectionism (the obverse strategy of identifying a hot topic) (Etzkowitz, Kemelgor, and Uzzi). It is significant that women experience isolation at work whereas for male health professionals work tends to be highly social and socializing. This paradox is compounded when similarly isolated women are appointed as tokens to committees and pointed to as role models (i.e., expected to be solutions to a problem). If women seek affiliation through a women’s group, they may be labeled as needy, lesbian, or rabble-rousers.
Many men have difficulty effectively mentoring women because of lack of experience with career-oriented women or because they find it easier to relate to women in social than in professional roles. A contemporary approach to mentoring builds on the recognition that styles and advice that worked for the mentor may not work for a protege (Thomas) and that advice applicable even five years earlier may no longer be helpful. Thus, many chairs and senior faculty could use assistance in techniques of active listening, avoiding assumptions, and providing supportive feedback that also stimulates the protege’s professional growth (Bickel et al, 2002).
D. Practice-Related Areas of Career Disadvantage
A large national study conducted in 2000 found that compared with men, women physicians have more patients with complex psychosocial problems. Women physicians also have substantially less control of their work than men— in term of patient volume, selecting physicians for referrals, and office scheduling. Women physicians also have more patients with complex psychosocial problems, adding to their time and energy requirements, in an era when physicians are being pressured to see more patients in fewer minutes. Time spent with patients is time not spent with students, writing grants, or on their many other responsibilities. Thus, it is not surprising that women were 1.6 times more likely to report burnout than men, with the odds of burnout by women increasing by at least 12 percent for each additional five hours worked per week over forty hours. This study also found a $22,000 gap in income between men and women, after controlling for age, specialty, practice type, time in current practice, uninsured status of patients, region, hours worked, and other variables (McMurray, 2000). A 1998 survey of board-certified internists in Pennsylvania found that women earned 14 percent less per hour than their male counterparts, even after adjustment for demographic, training, practice, and family characteristics (Ness et al.).
Junior faculty have been hardest hit by imperatives in academic medicine to increase clinical loads; these imperatives disproportionately affect women (67% of women are instructors or assistant professors compared to 44% of men). Women faculty have less “protected” time for research and fewer academic resources than men (Carr et al.). In addition to pressures to simultaneously complete fellowship, start a practice and a research program, and take on heavy service and administrative responsibilities, most young faculty members are raising young children. Women physicians are actually more likely to be married (and less likely to be divorced) than women in the general population (Frank et al., 1997). And about 85 percent of women physicians have children, compared to 83 percent of the general population (Potee, Gerber, and Hall, 1999).
While family-leave policies at academic medical centers are now commonplace, they rarely allow for more than three months of leave and require women to use up annual and sick leave. Some schools have introduced less-than-full-time options; in many cases, however, users sacrifice benefits and the flexibility to return to the tenure track (Socolar et al.). Even when flexible policies exist, individuals who take advantage of the flexibility allowed may be labeled “uncommitted.” Thus, the relationship between medicine and parenthood can be characterized as uneasy and not welltolerated, especially in academic careers.
Moreover, family-related decisions can escalate into moral dilemmas. The traditional obligation of physicians to set patients’ needs above their own sometimes confronts physician-parents (and especially couples who are both in practice) with difficult choices between the needs of patients and those of their own children. How are they to decide when a patient must take priority over their children? While such dilemmas are common because of the lack of easily available child care, they are rarely discussed. The profession would benefit from opportunities for practitioners who are also family caretakers to dialogue about the ethics of family responsibilities as related to the ethics of medicine. Even more helpful would be institutional approaches to improving and supporting flexibility for those with family responsibilities, such as on-site day care, emergency or sick child care, and nonpunitive leave policies. All of these features are much more readily available in Canada, Britian, and Australia than in the United States (McMurray et al., 2002).
E. The Intersection of Gender and Ethnicity
In 2001 the 125 U.S. medical schools had a total of 1,199 African-American women faculty (4% of all female faculty); smaller numbers of Native Americans, Mexican Americans, and Puerto Rican women added up to an additional 4 percent of women faculty. A higher proportion of women faculty than men faculty are underrepresented minorities.
Faculty from ethnic minorities are no more likely to attain senior rank than are women (Palepu et al.; Fang et al.; Bright, Duefield, and Stone). Both women and minorities face stigmatization and prejudice and difficulties in obtaining career-advancing mentoring. Thus women ethnic minorities experience “double jeopardy.” A study of African- American women physicians found that the majority cited racial discrimination as a major obstacle during medical school and residency and in practice. In addition they perceived gender discrimination to be a greater obstacle than did non-African-American women physicians (More).
Psychologists have described the just world bias: That is, people want to believe that, in the absence of special treatment, individuals generally get what they deserve and deserve what they get; they adjust their perceptions of performance to match the outcomes they observe (Valian). If women, particularly women of color, are underrepresented in positions of greatest prominence, the most psychologically convenient explanation is that they lack the necessary qualifications or commitment. Thus, women of color must frequently overcome assumptions that they owe their positions to affirmative action rather than professional qualifications. At the same time, minority women encounter severe surplus visibility, that is, their mistakes are more readily noticed and they are less likely to be given a “second chance.”
Compounding all of the above extra challenges, minority female physicians are also at highest risk for institutional service obligations (Menges and Exum), including committee work, student counseling, and patient care (Menges and Exum; Levinson and Weiner). Thus, while increasing the number of ethnic minorities progressing in academic medicine presents different challenges than increasing women, the challenges overlap, for instance, in overcoming unconscious bias related to “what a leader looks like” (Bickel, 1997).
IV. Forward-Looking Institutional Approaches
Most approaches to improve the advancement of women have attempted to “fix” or “equip” women with skills that they are perceived to lack and to add temporal flexibility to policies. While these efforts are necessary, organizational development experts concluded that such narrow approaches can have only limited success (Ely and Meyerson).
The research findings summarized above clearly raise fundamental questions about organizational culture and the ways in which work is organized. What is wrong with U.S. health systems that women have such a hard time succeeding in them? The faculty tenure system offers a striking example; it is a forced march in the early years, allowing a slower pace later on. Most women would prefer the opposite timing, allowing them more flexibility while their children are young. The most clinically productive decade for women physicians begins at age fifty.
Another example of organizational disadvantage is medicine’s overvaluation of heroic individualism, with the largely invisible work of preventing crises and maintaining relationships going unrewarded. Because women tend to be doing the less visible, collaborative, relational work, their contributions remain underrecognized (Etzkowitz, Kemelgor, and Uzzi).
Thus strategies to promote women must target features of the work culture that may be “simply the norm” but that disadvantage women (Ely and Meyerson). For instance, new models of cooperation are needed to recognize and reward contributions of all members of the team. And these models must avoid expectations that women will do the “relationship” work; dialogue between the sexes is required to achieve the facilitating of caring and leading on the part of both women and men.
Much of the process by which disadvantage is created and reinforced occurs at the department level (e.g., recruitment, mentoring, access to resources). Thus, department heads are key, and one avenue to stimulate their cooperation is to emphasis diversity issues in departmental reviews (Etzkowitz, Kemelgor, and Uzzi).
The most comprehensive analysis to date of initiatives to develop women medical school faculty (Morahan et al.) found that exemplary schools focus on improvements not specific to women: heightening department chairs’ focus on faculty development needs, preparing educational materials on promotion and tenure procedures, improving parentalleave policies, allowing temporary stops on the tenure probationary clock and a less than full-time interval without permanent penalty, and conducting exit interviews with departing faculty. These schools regularly evaluate their initiatives by comparing recruitment, retention, and promotion of women and men faculty and by conducting faculty satisfaction and salary equity studies. Surveying faculty about their career development experiences and their perceptions of the environment, comparing the responses of men and women, and presenting the results to faculty and administrators are particularly useful strategies.
Initiatives to develop women and to improve the work culture do not lower standards or disadvantage men. Interventions on behalf of women tend to improve the environment for men as well. When the Department of Medicine at Johns Hopkins University evaluated its interventions to increase the number of women succeeding in the department (Fried et al.), the proportion of women expecting to remain in academic medicine increased by 66 percent and the proportion of men increased by 57 percent.
With regard to ensuring that students and junior faculty obtain the mentoring they need, institutions find themselves challenged by the increasing heterogeneity of new entrants, not only in terms of gender but also with regard to ethnicity, age, values, and previous life experience. In order to competently mentor students unlike themselves, the relatively homogeneous senior faculty would benefit from opportunities to improve listening and feedback skills and to overcome engrained models of gender and race. Another strategy to increase positive emphasis on mentoring is to evaluate faculty on how well they meet this responsibility. For instance, just as promotions committees count first authorships in major journals, some schools are also now counting last authorships with mentees as first authors (Grady-Weliky, Kettyle, and Hundert). Other schools now require that on each faculty member’s annual evaluation, senior faculty list their proteges; trainees and junior faculty are asked to name their mentors and role models. An increasing number of schools and individual departments offer programs that facilitate mentor/protege pairings; another positive strategy is mentor-of-the-year awards (Bickel, 2000).
Medical schools’ approaches to eliminating sex discrimination and harassment have included sporadically distributed informational resources and occasional educational programs; by and large the effectiveness of such efforts has not been evaluated. Medical educators’ increasing emphasis on professionalism in general shows more promise in drawing positive attention to responsible physicians’ attitudes and behaviors (Epstein and Hundert; Wear and Bickel). However, more attention to barriers created by mental models of gender and race would strengthen most professionalism initiatives. Likewise, programs designed to improve patient communication skills should include assistance in overcoming gender stereotypes.
Finally, there are encouraging trends in medical education toward problem-based learning and toward the incorporation of women’s health into the curriculum. Both require interdisciplinary bridges and teamwork, actually furthering a sense of community within academic medical centers. And adding a focus on women’s health also frequently incorporates a more holistic and community orientation into the curriculum (Donoghue, Hoffman, and Magrane).
Gender differences in professional and leadership opportunities persist, yet perceptions of these continuing inequalities are not widespread. The number of women entering the health professions, and even becoming faculty, actually obscures the work that remains—part of which is persuading many that academic medicine still greatly favors the development of men. Actually, many male physicians and medical students are concluding not only that equal opportunity has been won but also that women tend to have an “affirmative action” advantage. Many young women entering medicine, surrounded by women peers and unaware of their predecessors’ struggles, are assuming that women may be freely choosing to reap fewer rewards than men for their work but that they themselves will not have to settle for less (McCorduck and Ramsey). Thus, impetus for change is lacking, as the women who are not realizing their potential tend to be invisible or to disappear.
Is the increasing number of women entering medicine and other health professions mitigating the impact of gender? Recent studies comparing the careers of men and women consistently show that increases in the number of women is not reducing gender disparities in advancement nor the power of mental models of gender. Reducing the power of gender stereotypes in medicine is a moral imperative because healthcare professionals have a duty to ensure that perceptual bias does not interfere either with the best possible patient care or with clinicians’ responsibilities as role models for and teachers of students of both genders. Healthcare professionals’ effectiveness depends in large part on their sensitivities to others, that is, their ability to “hear” and “see” individual patients.
Is gender diversity changing the medical profession? Too many diverse forces (e.g., technological, economic, political) are shaping modern medicine to link any one change to the increasing numbers of women providers, especially given the extent to which men and women share characteristics. But the primary difficulty in answering this question is that too few women have achieved leadership positions to allow comparison with the records of their male predecessors.
That the health professions are not realizing the full value of their investment in women is not only an injustice, it is also evidence of poor stewardship. These careers involve considerable personal and public resources, but the leadership potential of most women continues to be wasted. This is a collective loss—all the more unaffordable given the leadership challenges facing the health professions. It is highly likely that women leaders can make a positive difference: “Women have lived in embedded roles, roles intimately interwoven into the warp and woof of the social context … serving as links between other roles, between generations, between institutions, between the public and private domains.… Consequently women are no newcomers to the complications generated by interdependence and diversity” (Lipman-Blumen, p. 289).
Gender equity will always be an elusive concept and goal; for one thing, women are as different from each other as men are from each other. Nonetheless, leaders owe it to future generations of trainees and patients to create an environment of equal opportunity—where assumptions and judgments about individuals’ competencies and preferences are not colored by their sex, where women’s goals and traits are as valued as men’s, and where nonpunitive options facilitate the combining of professional and family responsibilities. The future of the health professions is inextricably linked to the development of its women professionals.
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