Historically, women in the United States have encountered many obstacles to becoming doctors. During the first half of the 19th century, women could be found among the ranks of “alternative” healers such as homeopaths, eclectics, and Thomsonians but not among the ranks of allopathic physicians. In January 1849, Elizabeth Blackwell received the MD degree from Geneva Medical College, thereby becoming the first woman in this country to do so. Subsequently, the number of women physicians grew modestly, averaging around 6% of the medical workforce for the first two-thirds of the 20th century. This compared favorably with the percentage of women in other professions—for example, 2% in law and less than 1% in engineering. The percentage of women doctors in the United States still trailed the percentage of women doctors in European countries, however. In Germany, 30% of physicians were women in the 1960s, while the proportion was 20% in the Netherlands, 25% in Great Britain, and 75% in the Soviet Union.1 Clearly, the opportunities for women to enter medicine reflected cultural norms.
Many explanations have been offered to account for the historically low representation of women in the U.S. medical profession. In an important early study, Mary Walsh attributed this to explicit barriers created by the medical establishment to limit the number of women physicians admitted to medical school. Many schools would not admit women; others established rigid quotas. This argument is embodied in her book’s title: Doctors Wanted: No Women Need Apply.2
However, women encountered obstacles in addition to overt discrimination in admissions. As Carol Lopate and Regina Markell Morantz-Sanchez have shown, societal expectations mitigated against the entry of women into medicine, as they did for the entry of women into all professions. The stereotypical woman’s role was that of housewife and homemaker. Women often received little encouragement from teachers, advisers, friends, or family members to enter demanding careers. The result was that relatively few women sought careers in medicine.1,3
Beginning in the late 1960s, as the revival of the feminist movement gained momentum, the number of women entering medicine rapidly grew. By 1980, nearly 30% of incoming medical students were women; by 1990, the proportion was roughly 40%; and by 2000, it was nearly 50%.4,5
However, women physicians aspiring to careers in academic medicine continued to encounter many obstacles. This represented nothing new, for women at medical schools had always experienced difficulties. Most institutions frequently appointed women as instructors or assistant professors, but recognition and advancement came very slowly, and salaries for women faculty were customarily lower than those for men of comparable rank and seniority. Consider the case of Alice Hamilton, the founder of the field of occupational medicine and a person considered by her dean as “greatly superior to any man” in the field. She was privately (though not publicly) frustrated at being Harvard Medical School’s only woman faculty member and at the school’s refusal to offer her anything more than a succession of temporary appointments. She retired in 1935 as an assistant professor, highly honored outside her institution but not within it.6 Before World War II, the only medical school in the nation that had appointed a woman dean was Woman’s Medical College of Pennsylvania.7
After 1970, women began to enter academic medicine in large numbers, with greater proportions entering internal medicine, pediatrics, psychiatry, obstetrics and gynecology, and family medicine. However, women were more highly represented at the early-career faculty level. In 1980, less than 10% of full professors and only 4% of department chairs were women. Many attributed this to the fact that most women physicians were still very young and that senior academic and administrative appointments generally went to older individuals. However, in 1995, the percentage of full professors and department chairs who were women was unchanged from 1980, and in 2015, the numbers were only slightly higher. The number of women deans was similarly low.8–12 Women encountered similar obstacles to obtaining leadership positions in other scientific and academic fields as well as in business, law, and other areas.13–15
What accounts for the significant underrepresentation of women in senior positions in academic medicine long after the pipeline of women medical students, residents, and junior faculty reached parity with men? Part of the explanation lies in the presence in medicine of “microinequities,” a concept arising from feminist scholarship of the early 1970s. This term refers to sometimes unapparent but real slights that are painful and destructive and that interfere with the professional development of women physicians.8 Examples include sexual humor disparaging to women, focusing on a woman’s appearance while downplaying her professional attributes, attributing a woman’s ideas to a man, and labeling women physicians as “overly aggressive” for behavior that in a man would be considered “forceful” or “strong.” These examples suggest that, given the prevalence of microinequities, the culture of medicine is simply unsupportive for all women. Other factors contribute to the underrepresentation of women in leadership roles, however. The literature is replete with examples of additional problems encountered by women faculty, including the lack of mentoring and sponsorship provided to junior women faculty by senior professors, the tendency of others to take credit for the work of women instructors, the frequency with which women faculty are asked to do time-consuming administrative or teaching tasks that do not directly advance their career, and the withholding from women (consciously or unconsciously) of institutional resources and opportunities for collaboration.
An even greater barrier to the professional advancement of women faculty arose from the structural organization of medical schools: the priority placed on research. From the beginning, at the U.S. medical school—as at the U.S. research university—research served as the primary determinant of promotion, faculty rank, and appointment to leadership positions. This was hardly a surprise, given that both the U.S. medical school and research university had their roots in the German university system.16 It was “publish or perish” for all faculty, women as well as men, and medical school leaders showed little concern for a professor’s home responsibilities.
The centrality of research to promotion, tenure, and leadership placed women at a great disadvantage relative to men. Academic success depended on a single-minded dedication to one’s projects and required 60- or 70-hour work weeks. Married men could often afford such single-minded devotion to work by virtue of not participating equally with their spouses in child-rearing and household chores. Married women, in contrast, typically had to assume their “second shift” of work on arriving home.9,17,18 The fact that few medical schools accommodated women faculty by providing sufficient parental leave, on-site child care, or the option of pausing the tenure clock only compounded the problem. So did a dearth of female role models for women junior faculty members aspiring to leadership roles to turn to for inspiration and guidance. In contrast, married women faculty without children published as frequently as men and rose through the academic ranks at rates comparable to their male colleagues.9,19,20
Many women physicians, of course, did succeed in combining motherhood with a fulfilling career in academic medicine. However, success often did not come easily and frequently took longer than for their male counterparts.9,10 Prominent women faculty members have described their difficult journey—writing manuscripts late at night, minimizing travel that might have enhanced their professional visibility, leaving the laboratory unexpectedly to tend to a sick child.10 The time following an initial academic appointment was the most vulnerable period, given that the need to demonstrate scientific “productivity” early on through grants and publications coincided with important childbearing years.17
In recent years, many medical schools and teaching hospitals have made efforts to improve opportunities and satisfaction for women trainees and physicians. Examples include training in gender sensitivity for administrators and senior faculty, clamping down on sexual harassment, providing more equitable pay and distribution of resources, creating mentoring programs for women, establishing women’s organizations to encourage social and professional relationships, and promoting strategies to eliminate gender discrimination and develop a healthy and nurturing work environment for women. Particularly notable are the efforts to address the challenge of reconciling professional with personal and family responsibilities. Many medical schools have taken important steps in this direction, such as implementing more liberal policies pertaining to parental leave, providing on-site childcare, eliminating after-hours meetings, creating part-time career tracks, and lengthening the tenure clock for faculty needing additional time because of family responsibilities.
Over the past 100 years, the position of women in medicine has changed dramatically. A century ago, women were not even permitted to vote. It took another 50 years for women to gain admission to medical school and appointments to medical faculties in non-token numbers. The overt discrimination of the past has disappeared, and microinequities, though still present, are no longer so easily overlooked or forgiven. Parity in leadership positions has yet to occur, however, even though the matriculation of women to medical school has long been essentially equal to that of men.9,21 Correcting this situation is a matter of great importance—not only from the perspective of social justice but also because the profession can be at its strongest only if it offers fulfilling careers to everyone in the workforce. Diversity has a positive impact on the performance of any organization or profession, including academic health centers.
The central challenge to women in academic medicine remains: achieving both professional success and personal fulfillment.22 This challenge affects all faculty. Today, male physicians have also become increasingly vocal about the problem of work overload and the resultant strains on personal and family relationships. Physicians of both genders have declared their interest in “lifestyle” fields with more predictable schedules, and many male physicians plan to participate actively in child-rearing and devote more time to personal interests. Although it is unlikely and undesirable that research will ever cease to be the currency of academic medicine, the medical profession, like all professions, is exquisitely sensitive to the mores and values of the society in which it exists. Should the drive to achieve better work–life balance become more generalized, it is possible that career paths in academic medicine might be restructured. It is plausible to imagine a future in which flexible time frames to achieve tenure and promotion are universally available to both women and men, with high scholarly standards firmly maintained. If this occurs, it will represent a profound legacy for women in academic medicine, for their generations of professional sacrifice and advocacy for a more equitable culture will have changed its culture.
The author wishes to thank M. Brownell Anderson and Renée C. Fox for the insights they have provided him on this and many other topics in medical education over the years.
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