Gender inequity in academic medicine is a pervasive challenge. Disparities exist across multiple categories including compensation, research funding, authorship, advancement and promotion, evaluations, and wellness.1 Disparities may begin as early as medical school matriculation and persist throughout residency training and beyond. While the percentage of female residents has increased from 42% in 2005 to 46% in 2015, there are still fewer women than men in emergency medicine (EM), anesthesia, and surgical subspecialty residencies.2 According to the Association of American Medical Colleges (AAMC), the percentage of female EM residents remained relatively stagnant from 36% in 2005 to 37% in 2015, while almost all surgical subspecialties observed more robust increases. Several specialty-specific organizations use best practice strategies to recruit and retain women faculty in academic medicine. However, there are no well-established strategies for the recruitment and retention of female residents.
As mentioned above, gender disparities occur during residency training. For example, differences in evaluations include the rate of milestone attainment and type of feedback female residents receive in comparison with their male counterparts.3 Female trainees report a higher level of stress due to pregnancy and motherhood, higher burnout rates, and lower well-being scores than their male counterparts.4 Additionally, female trainees report a higher prevalence of sexual harassment and gender discrimination than male trainees.5
The recognition of gender-specific stressors and diligent examination of recruitment and retention strategies are necessary to address gender disparities in residency. This Innovation Report highlights an innovative set of professional development strategies, including events and initiatives, implemented by EM residents and faculty at one institution to address this problem. We propose that other institutions and specialties can effectively implement similar strategies to address gender inequity and promote female resident recruitment and retention.
Prior work indicates that women-only leadership development groups provide a unique type of psychosocial and professional development support.6 To address challenges faced by female physicians and support the recruitment and retention of female residents, female EM residents and attending physicians at the Hospital of the University of Pennsylvania formed a professional development group (PDG) in July 2017. The PDG was formed via a bottom-up approach with resident leaders, supported by faculty sponsors, engaging junior residents early on to facilitate future leadership roles. Initially, the PDG operated with a limited budget, identifying events that were inexpensive with financial assistance from faculty supporters. We (the authors and leaders of the PDG) created the hashtag #Shemergency to name, empower, and promote our PDG.
The primary goals of the #Shemergency PDG were to foster a sense of community, inspire mentorship, and elevate awareness of gender bias. The secondary goals were to develop events and initiatives that targeted gender disparities described in the literature to reduce and eliminate inequities and promote recruitment and retention. A robust literature review highlighted disparities in the following areas: mentorship, speakership and conference representation, compensation, evaluations, wellness and service, and award recognition. Thus, in July 2017, we began to develop events and initiatives for female residents that address methods to improve awareness of and develop skills relevant to these specific areas (Chart 1).
PDGs provide developmental relationships through mentors, coaches, and peer coaches.6 In medicine, role models are sources of support and career development. Furthermore, female mentoring programs are valuable in addressing gender-specific challenges.6 Therefore, we implemented “speed dating” as our inaugural event to facilitate introductions and establish mentorships among female attending physicians and residents. Attending–resident pairs spent 10 minutes on a discussion topic of the resident’s choice before the resident moved on to a new attending physician.
Speakership and conference representation
Speakership and conference representation is another contributory factor to disparities in academic promotion. National conference presentations advance physicians’ careers by engaging collaborators in research projects and stimulating opportunities to pursue new academic endeavors. However, female physicians are frequently underrepresented as speakers at national academic conferences. An observational study noted that female EM physicians comprised only 30% of speakers and 28% of speaking time at national EM conferences over the course of a year.7 Women who attended a conference were more likely to receive a promotion or pay increase, and conference attendees in general felt more optimistic about their future.8 Given this, we invited a professional speaking coach to organize a workshop on presentation skills for residents. Participants learned methodical approaches to presentation planning and worked through exercises to practice these skills. We also spearheaded departmental sponsorship of female residents so that they could attend a national conference focused on gender equity.
The gender wage gap is prevalent throughout medicine. While female residents are shielded from this disparity during training, the gender wage gap in medicine is well described in the literature. For example, a 2016 survey reported a persistent $20,000 pay differential between male and female physician salaries after adjusting for faculty rank, age, years since residency, specialty, National Institutes of Health funding, clinical trial participation, publication count (total as well as first- or last-authored articles), total Medicare payments, and medical school training.9 Thus, our PDG organized a session on contract negotiation to help senior female residents navigate their job search. We also organized an informal panel of female attending physicians to share their own experiences with gender disparities encountered during job negotiations. During this panel, these attending physicians, who were at various career stages, provided advice on the importance of the nonsalary components of an offer package, including protected time, benefits, and continuing medical education support. Additionally, they advised female residents on the appropriate timing of their negotiations and encouraged them to research median national salaries through the AAMC benchmark data on compensation.
Female residents often experience gender discrimination in residency evaluations and feedback. In a 2-part study, Mueller and colleagues3 examined both Accreditation Council for Graduate Medical Education milestone evaluations and qualitative feedback received across 3 years of EM residency. The authors noted that while first-year male and female residents received similar milestone scores, third-year female residents were evaluated at lower milestone levels and subcompetencies than male residents. A qualitative analysis demonstrated that successful EM residents were defined by stereotypically masculine characteristics, including being confident, being a team leader or taking charge, and taking initiative, regardless of their gender. Additionally, female residents more frequently received inconsistent comments about their leadership skills, personalities, and receptiveness to feedback across attending evaluators.3
Because providing feedback is a topic that affects all trainees, we organized a journal club that was open to male and female colleagues to discuss strategies for providing objective and constructive feedback. In small groups, participants reviewed the literature, reviewed podcasts on feedback biases, and discussed feedback strategies. Together, the journal club devised ideas for providing objective feedback and disseminated these strategies to all EM physicians via email and dialogue to improve feedback techniques.
Wellness and service
Gender discrimination against female physicians permeates outside the workplace and has significant impact on female retention in medicine. Female residents report higher rates of burnout and lower well-being scores.4 Furthermore, in addition to daily work–associated gender bias, female physicians also experience bias during pregnancy and face limited maternity leave, a lack of resources for breastfeeding, and unbalanced household responsibilities.4
Our PDG recognized that sharing experiences outside of work was important to foster a sense of collegiality and informally share strategies for addressing gender-specific challenges at work and home. Accordingly, we organized fitness events such as dance and yoga classes to promote health, wellness, and a sense of community. Another important component of our wellness initiative was serving our community. One of our community activities involved volunteering to cook a meal together for the guests of a winter shelter. All wellness events were child friendly, allowing residents to witness how their mentors navigate work–life integration. As a sense of community can foster open discussion around challenges outside the hospital, our wellness events broke down barriers of formality between residents and faculty and encouraged conversations about financial planning, maternity leave, and resources for managing household responsibilities. Our PDG also inspired the creation of monthly female faculty dinners to promote mentorship and wellness at the faculty level.
A major barrier to academic advancement is gender disparities in award recognition. A study of faculty awards revealed that women received 28% of research awards, 29% of teaching awards, and 10% of clinical awards.10 Female physicians receive fewer individual achievement awards. The highest proportion of female award winners occurs within group awards, but even then, females are still significantly underrepresented in award recognition compared with male colleagues.10
Our PDG implemented an awards working group to nominate female residents and attending physicians for local and national awards. The leaders of the awards working group developed a list of awards and paired individuals with appropriate awards. They cowrote nominations and worked to improve letter writing skills. Residents shared the responsibility of developing applications to minimize the burden on any one individual. Additionally, the working group leaders sought opportunities to serve on national awards committees.
Over its first year (July 2017–July 2018), our PDG successfully created a professional community and enhanced mentorship through our events and initiatives. As a result of our PDG, our department sponsored 5 female residents to attend the annual FemInEM (Females Working in Emergency Medicine) Idea Exchange, a conference aimed at promoting gender equity in medicine. In addition, more female residents attended and presented at EM conferences than in prior years. We also nominated 5 female residents and 2 female attending physicians for professional organization awards, and 4 of these nominees received awards. The PDG leaders acknowledged award winners within the institution and nationally with press releases and social media announcements using the #Shemergency hashtag.
We plan to distribute pre- and postevent surveys for future events and initiatives to measure their effectiveness and strive for improvement. Furthermore, we will measure the effectiveness of the PDG in the future by evaluating measurable outcome metrics, such as needs assessment surveys, conference attendance, award recognitions, speaker applications and invitations, and social media reach. Finally, we plan to collect career and job satisfaction data from our alumni to measure the PDG’s longitudinal impact.
We recognize that our EM residency program may be unique in that it has a large number of female residents and attending physicians and is located in a major urban area with several other EM programs nearby. For residency programs that do not fit these demographics, we encourage collaboration with other residency programs or fellowships, as many of the benefits of a PDG could be reaped by many specialties. We also encourage residency programs to host e-activities using platforms such as Google Hangouts to achieve similar goals. As previously mentioned, our group was formed via a bottom-up approach; however, a top-down approach of residency program or departmental leaders organizing events and initiatives could also be highly successful if they follow strategies similar to those highlighted in this Innovation Report.
There is evidence that female physicians continue to face significant gender-specific challenges. Recognizing that gender disparities in many areas, including advancement, are prevalent during residency training, we have outlined an innovative resident-driven PDG to equip female EM residents with the tools necessary to tackle these challenges and advance their careers. Future work will focus on sustainability, generalizability, inclusivity, and outcome assessments (Table 1).
To ensure sustainability of the PDG, we recognize the need for identifying future leaders and securing ongoing funding. Thus, the PDG resident leaders recruit and engage female residents early in their training with the hope that they will take on leadership roles and carry the group forward. Thus far, the PDG has operated on a limited a budget. We have structured our events to be free or inexpensive to residents and have benefitted from the generous support of our female attending physicians during social gatherings. We recognize that we will need to establish a consistent budget to expand the scope of our events and initiatives. Accordingly, we plan to hold fundraising events and solicit alumni donations.
After the first year, we expanded the number of joint activities with our male colleagues and organized a citywide #Shemergency leadership event with 5 other local residency programs. We will continue to expand the number of joint activities with male colleagues. We will also continue organizing citywide events by alternating program ownership of the event from year to year to promote a sense of community. We plan to address additional gender inequity areas, including research funding, authorship, leadership skills, and promotion. We will also develop specific policies for breastfeeding, family leave, and sexual harassment. We recognize the importance of male mentors and sponsors and hope to raise awareness and identify male allies for our future endeavors.
The authors would like to acknowledge the emergency medicine residents and faculty at the Hospital of the University of Pennsylvania for their continued support and participation in #Shemergency. The authors would also like to acknowledge the Academy for Women in Academic Emergency Medicine and FemInEM (Females Working in Emergency Medicine) for their continued leadership and inspiration in addressing gender inequities in emergency medicine.
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