“I just wish that, for once, the feedback a patient gives me at the end of a visit would be about the clinical care I delivered, and not inappropriate comments regarding my appearance.”
Explore This IssueJanuary 2020
I know too well that wistful wish, and the long sigh that often accompanies it. These inappropriate comments can strip a physician of her confidence and sense of belonging. They seek to belittle her expertise and to objectify her. This is the most common form of overt bias I see. It is by no means an isolated example, however. Anything that sets someone apart can be grounds for discrimination. Recent studies show that discrimination most commonly comes from patients and their families; however, other medical professionals are also frequent offenders.1
This issue is not isolated to one singular aspect (race, ethnicity, religion, gender, sexuality) of identity. Equity is not just a “women’s issue” or a “minority issue.” We are all impacted, whether or not we recognize or acknowledge this fact. It’s borne out in our everyday interactions: the students we fail to connect with, the colleagues we fail to adequately support, the patients we fail to reach.
Meanwhile, the data are clear about the pervasive lack of equity in medicine. Promoting diversity is recognized as an essential component of improving access to care, providing culturally and linguistically competent care, and eliminating health disparities.2 For example, across all specialties, physicians from historically underrepresented groups in medicine are more likely to serve in disadvantaged areas.2 Yet admission of these very students significantly lags behind their application rates. Minority physicians are also the most likely to experience harassment and abuse by both patients and peers. While 62 million Americans live in rural areas, students from rural areas comprise a disproportionately low percentage of medical school enrollments.2 The same goes for students with annual family incomes of less than $20,000.3 Women, who now comprise more than 50% of medical students, remain underrepresented at all levels of leadership in all specialties. In academic surgery, women are 18% less likely to become full professors than their male counterparts.4
We can begin by making the House of Medicine safer. It can be as simple as standing next to a colleague while telling another that his inappropriate comments are not welcome, as someone once did for me. —Jennifer A. Villwock, MD
In 2016, Dr. Kathy Stepien published the letter “A Mother in the House” to the mothers of daughters pursuing surgery.5 It seeks to reassure these women that their daughters are training in a new era, despite survey data showing that most surgical trainees experience mistreatment. The most common form of mistreatment in the survey was sex discrimination (32%), with women exposed to mistreatment at twice the rate (71%) experienced by men (36%). Patients and family members were the most common perpetrators of both sexual and racial discrimination; attending physicians were the most frequent sources of verbal and physical abuse (52%) and sexual harassment (27%).1,6 Dr. Stepien promises these mothers that the current generation of daughters “…will never be told that sexual harassment is just a part of the curriculum. No one will ever tell her she is just a pretty face and won’t amount to anything…She will be valued and respected rather than humiliated on a daily basis. Unlike those before her, she will not wonder if it would be better to die than to face another day, hour, or minute of training. Rest assured. There are Mothers in the House now… And we are looking out for your little girl.”6 It is the role of all of us—not just the mothers, but also the fathers, sisters, brothers, cousins, uncles, and aunts—to hold the entire Household of Medicine accountable to these expectations for women and all under-represented groups.
I am not suggesting that conditions have not improved significantly from prior eras. However, as Dr. Caprice Greenberg noted in her 2017 Association for Academic Surgery Presidential Address, “[i]t is precisely because we have made these great strides that we can start to focus on the more difficult, more deeply embedded, and more nuanced problems.”7 For example, pay is a pivotal issue, because while money has no inherent worth, it is a proxy for value. Thirty-nine percent of the gender pay gap in surgery cannot be controlled by any conceivable factors such as faculty rank, age, years since residency, productivity, specialty, NIH funding, clinical trials participation, or number of publications.8
Even in seemingly “fair” situations, bias may be embedded. Consider a multispecialty group in which salary is simply wRVUs billed. If all the male physicians in the group earn more money than their female colleagues, it must be because they are more “productive.” A 2015 study, however, demonstrates that the value of analogous urologic and gynecologic procedures favors those performed on men 72% of the time. For example, there is a 141% difference in wRVUs in favor of the male procedure—for excision of a penile lesion versus excision of a vaginal lesion.9,10 If more women are gynecologists and more men are urologists, a dramatic salary gap will exist despite “fair” contracts, because our current system literally values the health and lives of women less than those of men.
How do we move forward together when it comes to these difficult issues? We can begin by making the House of Medicine safer. It can be as simple as standing next to a colleague while telling another that his inappropriate comments are not welcome, as someone once did for me. It can be discussing with a patient why suggestively commenting on a resident’s physical appearance will not be tolerated in your clinic, as I did for my resident. While I believe that the majority of those called to medicine are good people, we all have to be willing to confront viscerally uncomfortable aspects of ourselves and our culture. This is the only way to lay the groundwork for the equitable future we deserve and desperately need.