Although women now comprise almost half of all medical students in the United States and more women occupy leadership positions in academic medicine now than ever before in U.S. history, they still face challenges in the healthcare sector. Most notably, these include gender bias and sexual harassment (Acad Med. 2018;93:163–165.)
As a medical student interviewing with a program chairman for an otolaryngology position, Inna Husain, MD, assistant professor and section head of laryngology in the department of Otorhinolaryngology and director of the Voice, Airway, and Swallowing Disorders Program at Rush University Medical Center in Chicago, had an experience that still bothers her today. “When reviewing a letter of recommendation, the chairman commented on how one of the male writers held me in such high regard,” Dr. Husain recalled. “He then jokingly asked what I had done to get such a raving review—did I have a relationship with the author?”
Dr. Husain was shocked at the implication. “I was taken aback by the question and wasn’t sure how to respond; I laughed nervously and smiled to make it seem like it wasn’t a big deal,” she said. “To do so much hard work and to have someone imply that my achievements might be due to something non-academic was very upsetting. It made me feel like I wasn’t worthy of the position. I don’t think something like this would have happened if I was a man.”
The #MeToo Movement
As more and more Hollywood actresses share their stories about sexual harassment and gender bias, women in other industries—including the medical field and even those as specialized as otolaryngology—are opening up about similar experiences. The scenarios run the gamut.
Sujana S. Chandrasekhar, MD, past president of American Academy of Otolaryngology-Head and Neck Surgery and director of New York Otology, recalled being asked by men interviewing her for residency positions if she was dating, engaged, or married. “It was really ridiculous, but of course I didn’t respond by saying that he wasn’t supposed to ask me such questions, because he was in a position of power,” she said. “I didn’t feel comfortable saying that.”
Dr. Chandrasekhar also believes that men view men and women with younger children differently. “A man with children is viewed as someone with solid character who will stick around for the long run, while a woman [with children] is viewed as someone on the ‘mommy track’ who will either stop working or reduce her hours to part-time,” she said. “I remember telling a chairman I was pregnant, and his response was, ‘You’re going to ruin another summer for me.’”
Melissa A. Pynnonen, MD, MSc, medical director of West Ann Arbor Health Center at Parkland Plaza and professor of otolaryngology and director of Health Services Research at the University of Michigan in Ann Arbor, has experienced frustration as a result of gender bias, particularly with regard to the lack of opportunities women have in comparison with men. “I started noticing this after finishing my training,” she said. “As a faculty member, opportunities weren’t evenly dispersed. Most healthcare providers in the otolaryngology field are men, and they typically reach out to other men with opportunities, such as writing a book chapter.”
Dr. Pynnonen believes she has to work much harder than men to obtain opportunities. “It seems like men my age have had many more richer and interesting experiences because they were given to them—which I resent,” she said. She admits, however, that as the primary caregiver to her children, she has had to decline some opportunities such as traveling to meetings to be a presenter. She also believes she has missed out on social events. “One of our male faculty members used to have fun social outings, but he would only invite male residents,” she said.
To do so much hard work and to have someone imply that my achievements might be due to something non-academic was very upsetting. It made me feel like I wasn’t worthy of the position. —Inna Husain, MD
Where Bias Occurs
In his studies of gender bias in otolaryngology, Jean Anderson Eloy, MD, professor and vice chairman of the department of otolaryngology–head and neck surgery at Rutgers New Jersey Medical School in Newark and chairman and chief of service of the department of otolaryngology and facial plastic surgery at Saint Barnabas Medical Center–RWJBarnabas Health in Livingston, N.J., has found a variety of ways in which gender disparity is occurring, and multiple reasons for it.
In an article Drs. Eloy and Chandrasekhar co-authored with others on gender disparities in scholarly productivity within academic otolaryngology departments, the authors found that while men have higher overall research productivity in academic otolaryngology, women demonstrate a different productivity curve. Women produce less research output earlier in their careers than men do, but at senior levels, they equal or exceed men’s research productivity (Otolaryngol Head Neck Surg. 2013;148:215–222).
Dr. Eloy believes this is because it is challenging for women to take a leave of absence from medical school, residency, or fellowship training to have a child, so many choose to have children early in their career.
The researchers also found that before a woman takes maternity leave, she tends to generate a spike in productivity in clinical work or research. Then, when she returns to work, she tends to work especially hard to make up for the time she was away. “She may feel that she needs to prove herself,” Dr. Eloy said.
The article also provides several reasons for disparities in women’s participation in surgical specialties, such as fewer senior female role models, lack of mentoring (formal or informal) by either men or women to young women considering surgical subspecialization, and concerns about work/life balance. “A lack of female leadership starting at the residency level can lead to women having to work harder to obtain mentorship comparable to their male counterparts,” said Lauren B. Harris, an employment and labor attorney at Greensfelder, Hemker & Gale, P.C., in St. Louis.
While women are still underrepresented in otolaryngology and other surgical specialties, they are even further underrepresented in positions of leadership. One analysis noted that four of 103 academic otolaryngology departments had female chairs in 2011 (Otolaryngol Head Neck Surg. 2012;147:40–43). Of 1,054 academic otolaryngologists examined, women comprised 24% of assistant professors, 20% of associate professors, and 12% of professors.
In a separate study, Drs. Eloy and Chandrasekhar also found gender disparity in financial relationships between industry and academic otolaryngologists (JAMA Otolaryngol Head Neck Surg. 2017;143:796–802). For instance, among 1,514 academic otolaryngologists, 1,202 (79.4%) were men and 312 (20.6%) were women. In 2014, industry contributed a total of $4.9 million to academic otolaryngologists. Of that money, $4.3 million (88.5%) went to men, in a population in which 79.4% were male.
Drs. Eloy and Chandrasekhar also found gender differences in NIH grant funding in otolaryngology. Individual mean NIH awards to men ($362,946 ± $21,247 standard error of mean) were higher than those granted to women ($287,188 ± $38,029). Furthermore, of all NIH grants awarded, men had a higher percentage of the more prestigious R-series grants (76.2%) than did women (63.4%) (Otolaryngol Head Neck Surg. 2013;149:77–83). “Researchers need to have significant money to fund projects in order to be academically productive,” Dr. Eloy said. “Men have a significant advantage compared to women in that regard.”
Pay disparities also exist between men and women. Not only are female physicians not considered for leadership roles as frequently as males, but females are also not paid at the same level or proportionally to males, said Katie L. Fechte, an employment and labor attorney at Greensfelder, Hemker & Gale, P.C., in St. Louis.
Other Causes of Gender Disparity
Dr. Eloy also thinks that, due to our past culture, many people still have implicit bias against women excelling in the workplace. “It’s hard to break old habits,” he said.
Another reason for gender disparity can be linked to women’s family responsibilities. “For the majority of couples, the woman takes on the bulk of the family work,” Dr. Eloy said. “I think that still happens a lot because, biologically, the woman is more involved; men don’t birth a child. Gender disparities can decrease as men start sharing more of the family responsibilities, including household chores and child care. This will enable women [to have] more freedom to pursue career opportunities.”
As a faculty member, opportunities weren’t evenly dispersed. Most healthcare providers in the otolaryngology field are men, and they typically reach out to other men with opportunities. —Melissa A Pynnonen, MD
Examining Sexual Harassment
Among the many forms of sexual harassment are lewd innuendos, touching, groping, assault, and rape. “Most examples are generalized or ‘innocent’ sexist remarks and behavior made by male patients (i.e., ‘I should really come to the hospital more often’),” Harris said. The most common examples of sexual harassment by co-workers emerge between male physicians and female nursing staff in the form of “locker room talk.”
In looking at reasons why sexual harassment continues to be problematic in the workplace, Barbara Fivush, MD, associate dean for women in science and medicine and professor of pediatrics at Johns Hopkins University School of Medicine in Baltimore, and her colleagues reported that medical students, residents, fellows and other post docs, and junior faculty are all in vulnerable positions. (Acad Med. 2018;93:163–165). They are dependent on recommendation letters and evaluations to advance to the next stage of training and to access new opportunities in their careers. Additionally, those in more junior positions often depend on those among the higher ranks to include them in projects, introduce them to colleagues in professional networks, share authorship on relevant scholarship, and provide information on other beneficial, career-advancing opportunities.
Institutions may also not always reprimand offenders, often due to financial concerns. Many accused of harassment are senior faculty who contribute substantially to the bottom lines of their institutions through patient care revenues and/or grant support, the authors wrote.
The American Association of Medical Colleges Graduation Questionnaire reported that 3.8% of 13,897 students said they had experienced unwanted sexual advances; 12.9% had been subjected to offensive sexist remarks or names, and 0.2% experienced requests for sexual favors in exchange for grades or other awards. The questionnaire also reported that 27% of all students who had not reported serious behaviors named fear of reprisal as a reason for staying quiet. “Until victims can be assured that there won’t be any retribution for reporting harassment, I think a lot of cases will go unreported,” Dr. Fivush said.
Stopping Sexual Discrimination
To stop discrimination, Dr. Fivush and her co-authors recommend these first steps, which are based on their research and conversations with thought leaders:
- Institutions must develop mechanisms that encourage victims of harassment and discrimination to come forward without fear of retaliation.
- Sexual harassment training must be mandatory for everyone at all institutions.
- Sexual harassment cannot be tolerated.
- The academic medicine community must get to a place where no one engages in sexually charged conversations (“locker room talk”).
- Professional societies should break the silence and address harassment during leadership councils and at annual meetings.
- Additional research should be done to characterize the nature of sexual harassment behavior, the outcomes of investigations, and the success of interventions with harassers to inform practice moving forward.
Fechte recommends encouraging employers and medical facilities to vocalize their prohibition and intolerance for sex or gender harassment, discrimination, and bias. “It is not enough to have a policy in a handbook and an anonymous complaint hotline,” she said. “Employers should be conducting trainings or holding conferences to discuss what harassment and bias look like, how it should be reported, how it will be investigated, and what consequences harassers will be subject to if they are found to have engaged in the illegal conduct.”
Karen Appold is a freelance medical writer based in Pennsylvania.