Action without vision is only passing time. Vision without action is merely daydreaming. But vision with action can change the world.
—Nelson Mandela and Joel A. Barker
We have come a long way since Elizabeth Blackwell became the first White woman in the United States to graduate from medical school in 1849 and Rebecca Lee Crumpler became the first African American woman physician in 1864. According to the latest Association of American Medical Colleges (AAMC) data, the enrollment of women in medical school is now relatively equal to that of men.1 The enrollment of women of color, however, still lags significantly behind that of White and Asian American women.1 Women—especially women of color and those with marginalized identities—continue to face the same hurdles they have faced for years (Table 1). These include a high prevalence of harassment; doubts about women’s aspirations and talents; being discouraged from entering certain specialties and/or not feeling accepted if they do; and being excluded from promotions, recognition, and leadership positions. The status quo of gender equity in academic medicine is unacceptable.
Table 1 -
Percentages of All Women and URiM Women as a Percentage of All Women in Various Academic Medicine Roles, 2019–2020a,b
||% All womenc
||URiM women as a % of all womenc
Abbreviations: URiM, underrepresented in medicine; AAMC, Association of American Medical Colleges; COD, Council of Deans.
aSources: AAMC Applicant Matriculant Data File as of April 24, 2020, last updated October 22, 2019; AAMC Student Records System as of April 27, 2020, last updated April 6, 2020; AAMC Faculty Roster, December 31, 2019 snapshot, as of March 31, 2020; AAMC COD records, December 31, 2019 snapshot, as of April 24, 2020.
bURiM is defined as American Indian or Alaska Native; Black or African American; Hispanic, Latino, or of Spanish Origin; and Native Hawaiian or Other Pacific Islander. Includes individuals with those race/ethnicities whether alone or in combination with another race/ethnicity.
cPercentages were rounded.
dRace/ethnicity data on deans can be provided with authorization from the COD team.
Substantial gender inequities persist because of a systems-based problem in academia—a problem that will require a conscious choice and action at the leadership level to solve. We see this in the established and deeply entrenched structural and cultural hindrances, treasured hierarchies, existing power differentials, and prevailing stereotypes and biases that have historically been protected to preserve this unacceptable status quo.
We already have a good understanding of the problem thanks to a wealth of evidence. The 2018 National Academies of Sciences, Engineering, and Medicine report on sexual and gender harassment (SGH)2 was a wake-up call and served as a national catalyst for academic medicine. In this report, academia had the second-highest prevalence of SGH in the learning and workplace environments (especially in male-dominated disciplines, such as engineering and specific science and medicine disciplines).
We also have a good understanding of how to address the problem, demonstrated by the many effective programs and practices that have produced successful outcomes, including information published by the National Science Foundation’s ADVANCE program.3
What we need now is action.
Leaders in academic medicine can once and for all overcome the system’s inherent challenges by boldly taking actions that will make a lasting impact. We recognize that some leaders have been innovators and early adopters, leading the way by making gender equity a priority, but we will only succeed if all leaders make the conscious choice to act.
Leadership has repeatedly been shown to be a major factor in achieving equity, diversity, and inclusion within institutions.4 To make progress, leaders must shift the balance so marginalized groups are not the only ones leading the effort—leadership at the top must pave the way. Some leaders fear backlash from vocal opponents (sometimes from colleagues within their own executive cabinet) and may perceive little incentive to implement changes given the risks. Taking personal risks and “going against the grain” may create discomforts for many leaders, but choosing comfort (a choice many do not have) is a privilege that must be overcome.
Leaders must have the courage to lean into the discomfort and take a stand against vocal opponents of their institutions’ values of diversity, equity, and inclusion. This means choosing a new status quo; adopting a new mindset; and embedding it within the fabric of their institutions’ governance, policies, and procedures for the long term. Too commonly when a committed leader moves on, all their good work to promote equity and diversity unravels. Securing the work helps sustain the change.
Ultimately, changes will only happen when leaders, including men, proactively make gender equity a priority in a systemic, ongoing way. They must actively involve all who have power within their institutions to make decisions and set strategic priorities, as well as those who are seen as influencers. Leaders decide if equity issues are addressed or not and how. Leaders need to be personally vocal, deliberate, and intentional in their support of equity efforts that publicly demonstrate a personal commitment to progress, infusing that message into all speeches and other activities. In the process, leaders must challenge their own thinking about the status quo in 3 key areas.
First, leaders must acknowledge their privilege, thereby broadening the pool of allies5 who can change the system they perpetuate and benefit from. This may require having courageous conversations about the privilege built into the existing system that benefits some and excludes others (e.g., how this privilege manifests and where it is embedded in policies and processes). These conversations might also address how to critically deconstruct privilege to create the solutions needed to level these inequities.
Second, leaders cannot afford to silo their equity efforts. In the status quo, leaders tend to treat marginalized groups separately within institutions, which dilutes all efforts to promote equity. Gender equity initiatives have mostly benefited White women, and some gender equity strategies may not work for women of color.6 We must be intersectional in our approach, acknowledging the challenges all women and individuals with marginalized identities face while respecting each group’s unique needs.
Finally, leaders need to be clear about what progress really means—the lack of agreement on a comprehensive definition is part of why we have made so little. It is time to move beyond simply quantifying the still-important representation of women in various roles to more broadly assessing an institutional climate of inclusion—one that values women as committed, competent leaders and experts in science, technology, engineering, mathematics, and medicine. This climate is especially critical during times of national emergency, when biases may emerge.7
To set the stage across multiple institutions, the leadership team and Board of Directors of the AAMC have taken personal accountability for gender equity, convening a leadership forum in 2018 that brought thought leaders together to address SGH, creating a sense of urgency that led to a strong statement on gender equity8 and a call to action to member institutions. We urge all institutions to join us in this effort through the newly formed Gender Equity Innovation Lab.9
Research tells us that investment matters. Institutionalizing effective practices does require investment in financial and human capital, but whatever the cost, inaction is even more costly. The loss of one faculty member costs the institution 2 to 3 times that faculty member’s salary to replace them.10 Specifically, leaders should invest in the following endeavors to promote equity throughout their institutions.
Dedicated financial and human resources
Institutions that establish a formal office for diversity, equity, and inclusion—backed by leadership support, staffing, and funding—demonstrate that gender equity is an institutional priority. Leaders need to appropriately compensate individuals who are appointed to take responsibility for gender equity and diversity work and should delegate authority and responsibility to them. This mandate should include decision-making authority and undeniable support through a standing budget and permanent staff positions.
Data drive change. Institutions must conduct ongoing rigorous equity audits, monitoring disaggregated data to understand unique needs by department. Surveys that anonymously assess what the overall environment feels like for people of all backgrounds and genders are crucial.
Updated recruitment, promotion, and hiring policies
It is critical to identify biases in human resources processes to avoid common experiences that undermine equity, such as illegal questions during candidate interviews or offering lower starting salary and start-up packages to women and underrepresented candidates.
Transparency and Accountability Matter
Transparency and accountability are critical levers for driving change in equity, diversity, and inclusion.11 Leaders are frequently asked to demonstrate return on investment and continuous improvement. This means holding institutional leadership responsible for performing equity assessments regularly, including assessing current policies and procedures on hiring practices, promotion opportunities, rank, salary, and climate.
This requires being transparent with all findings. It may initially feel difficult to openly share data about salary discrepancies or gender-related harassment, but doing so establishes trust and grants permission to whistleblowers to speak up using established harassment and bias-reporting systems that, in turn, must be taken seriously. Leaders should demonstrate that commitment by publicly acknowledging when incidents occur to the extent possible, taking appropriate personnel actions when necessary, and documenting how all discovered inequities will be addressed.
This practice of continuous equity improvement ensures accountability. To hold people at all levels accountable, leaders should embed gender equity metrics within performance evaluations and create formal rewards and incentives for efforts related to diversity. This can include recognizing effective mentorship and sponsorship, intentional outreach to and recruitment of women and other underrepresented groups, demonstrated equity-based search committee processes, and demonstrated trends in equitable hiring practices and promotions that include women of all identities and backgrounds.
Leaders should also work to personally embody the respectful, inclusive behavior they expect from all members of their organization, since their own behavior sends powerful cues about organizational expectations. This includes creating and maintaining a workplace environment that values, practices, and respects authenticity and intersectionality without the fear of judgment or retribution.
Leaders should have a clear vision of success that is embedded into the operational practices of the institution as a routine, ongoing, and necessary part of its functioning.
Institutions making progress toward this vision might demonstrate the following:
- Salary equity studies, disaggregated by gender, race/ethnicity, and other variables, are conducted and acted upon every year.
- Effective hiring, recruitment, and retention practices have been implemented across the institution, not just in one department.
- Training is offered—and evaluated—regularly and as an ongoing part of onboarding, rather than a one-time event. This training is comprehensive, covering bystander intervention, allyship, implicit bias and microaggressions, sponsorship, and other related topics.
- The institution monitors data about its progress regularly and responds comprehensively to unique challenge areas.
- There is adequate space and opportunity for people with similar backgrounds to share experiences and concerns, including men, to promote open conversations about diversity, inclusion, and equity for everyone.
The Future Matters
These are unprecedented times, given the challenges and opportunities facing academic medicine both domestically and globally. The COVID-19 pandemic has underscored these challenges and opportunities and highlighted numerous areas for improvement within our health care system.
In particular, this pandemic has demanded that we have full access to all talent in science and medicine for today’s treatments and tomorrow’s cures. This includes leveraging the talent of all women and all who have marginalized identities in science and medicine who have been historically excluded and underrepresented.
We can no longer afford to maintain the status quo. We should no longer tolerate the exclusionary practices of the past and present. It is time to unravel the “systems problem” in academic medicine and remove the protection that preserves the status quo. It is time to achieve gender equity in science and medicine, not just for the sake of everyone’s health, but also for our collective human dignity and value.
The authors thank Kristin Zipay, lead writer for executive communications, Association of American Medical Colleges, for her editorial support for this piece.
2. National Academies of Sciences, Engineering, and Medicine. Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine. 2018. Washington, DC: National Academies Press; https://doi.org/10.17226/24994
3. Mack K. Advance: Increasing the Participation and Advancement of Women in Academic Science and Engineering. Alexandria, VA: National Science Foundation. https://www.nsf.gov/attachments/115706/public/ADVANCE.pdf
. Accessed June 7, 2020.
4. Westring A, McDonald JM, Carr P, Grisso JA. An integrated framework for gender equity in academic medicine. Acad Med. 2016;91:1041–1044.
5. Droogendyk L, Wright SC, Louis WR, Lubensky M. Acting in solidarity: Cross-group contact between disadvantaged group members and advantaged group allies. J Soc Iss. 2016;72:315–334.
6. Ong M, Wright C, Espinosa L, Orfield G. Inside the double bind: A synthesis of empirical research on undergraduate and graduate women of color in science, technology, engineering and mathematics. Harvard Edu Rev. 2011;81:172–208. https://doi.org/10.17763/haer.81.2.t022245n7x4752v2
7. Johnson TJ, Hickey RW, Switzer GE, et al. The impact of cognitive stressors in the emergency department on physician implicit racial bias. Acad Emerg Med. 2016;23:297–305.
8. Association of American Medical Colleges. AAMC statement on gender equity.https://www.aamc.org/system/files/2020-01/AAMC%20Gender%20Equity%20Statement_0.pdf
. Published January 2020. Accessed June 7, 2020.
9. Association of American Medical Colleges. Gender equity in academic medicine. https://www.aamc.org/news-insights/gender-equity-academic-medicine
. Accessed June 7, 2020.
10. Waldman JD, Kelly F, Arora S, Smith HL. The shocking cost of turnover in health care. Health Care Manage Rev. 2004;29:2–7.
11. National Academies of Sciences, Engineering, and Medicine. Promising Practices for Addressing the Underrepresentation of Women in Science, Engineering, and Medicine: Opening Doors. 2020. Washington, DC: National Academies Press; https://doi.org/10.17226/25585