At the bedside of a patient in the ICU, a woman physician stands at the head of the bed preparing to intubate. Suddenly, an older male physician approaches and says, “Honey, step aside, the doctor’s here.” This scenario is not uncommon, and demonstrates the implicit gender bias that can pervade medical schools and hospitals. For a moment, imagine a work environment where your expertise is second-guessed or your academic advancement halted due to your gender, or your pay less than your male colleague to complete the same task. Women physicians are often confused for another member of the team, such as a nurse or technician or, more disconcerting, information is intentionally redirected toward a male provider who fits the more “traditional” critical care physician description.
In the World Economic Forum’s 2017 Gender Gap Study, the United States ranked number 1 in educational attainment for women, exemplified in part by the successive increase in women physicians in the medical community.1 Women comprise approximately half of all medical school applicants and graduates. However, the United States ranked 49th of 144 countries for overall parity between men and women, showing significant gender disparity in areas such as health, economic participation, and political empowerment.1 This paper will review current gaps in gender equity in critical care medicine, offer insight into what we know about current gender gaps, and offers opportunities for leaders within the specialty to address the gender gaps listed in Figure 1.
Current Gaps in Gender Equity in Critical Care
As of 2016, women comprised 24.9% of attending anesthesiologists and 25.5% of attending intensivists (including intensivists in internal medicine, anesthesiology, emergency medicine, and/or surgery).2 Women are entering medical school and specialties with advancement to critical care fellowships in increasing numbers each year. However, the increased numbers of women entering critical care medicine is not generating an expected parity in academic rank, leadership positions, salaried compensation, grants, or publications.
Gaps in Promotion and Leadership
Although 37% of women physicians graduating from medical school pursue a career in academia, only 19% of women faculty advance to full professor and even less in surgical subspecialties.3 In 2000, Nonnemaker published a retrospective study of US female medical school graduates from 1979 to the mid 1990s in the New England Journal of Medicine evaluating advancement of academic faculty positions. More women faculty were found to pursue an academic career than expected, but disappointingly, did not meet expected projections for advancement to associate and full professor. Of 519 associate professors who were promoted to full professorship, 59 were women; on the basis of projections for expected promotion, given their proportion within the candidates (anticipated number 109), this was more than a 5 SD discrepancy compared with their male counter parts.4 This study found that although more women were participating in academia, the overall percentage of full professor women faculty has not increased in a linear correlation as anticipated, challenging the previously held “pipeline” theory that women do not advance simply because they do not exist in academia.
A 2013 article published in The Laryngoscope utilized a bibliometric analysis of research productivity in addition to correlation with advancement within academia. Over 9990 academic physicians across 34 specialties were included in the report and evaluated for total number of publications along a time continuum correlated to promotion within professorship and leadership positions. The results favored a predominance of male physicians at the professor level and department leadership positions in comparison with women physicians who held mainly assistant and associate professor rank.3
Although men are promoted significantly over women, data suggest that women desire promotion and leadership. In the 2016 Gallup Report Women In America, although women account for only 23% of senior business roles in the United States, 45% of women surveyed stated that they would like to become a chief executive officer or have a senior position in leadership versus 54% of the men.5 There was no difference between women (69%) and men (68%) who stated that they were “extremely” or “very” serious in obtaining such a role, suggesting that women today desire top-level leadership positions.5 Not only do studies suggest that women desire leadership, but other studies show that in organizations where there are women in leadership, there are trends toward the hiring of women employees.6
Gaps in Academic Publication and Research
In 2011, Amrein and colleagues analyzed gender distribution among 60 editorial boards of top ranked medical journals. As of 2011, only 15.9% of editors-in-chief were female. At that time, 5 categories were notable for not one current woman holding the Editor-In-Chief designation; among these were both anesthesiology and critical care medicine.7
Gender equity in task force and international clinical expert working groups in critical care medicine is also lacking. The “Taskforce on Sepsis” convened by the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) did not include a woman on the 19-member senior advisory panel. The same phenomenon existed when an expert task force convened to create the Berlin Acute Respiratory Distress Syndrome definitions.8 During a period from 2012 to July 2016, practice guidelines from major societies both nationally and internationally were examined for gender diversity. Of the 413 guidelines examined for authorship, only one quarter of them had female physician participation. Only 13% of critical care medicine guidelines listed included women authors. Although women comprise 30% of critical care trainees currently from Canada, the United States, France, Australia, and the United Kingdom, trainees are more likely to see males as sole authors on expert consensus statements and practice guidelines, suggesting a lack of women with expertise in the field.9
Medical education speakerships and dissemination of research has also demonstrated an imbalanced proportion of men versus women physician contributors. A retrospective analysis of 5 national and international critical care annual conferences from 2010 to 2016 for female faculty speakers showed that overall, male speakers outnumbered female speakers, with women representing 5% to 26% of speakers. Interestingly, several nonphysician speakers were female, with >50% of allied health speakers being female.
Are women being equally represented throughout academic medicine as it relates to peer-reviewed original research?10 Aware that publishing and productivity are intimately related to promotion, a group of women physicians and scientists examined the gender of first and senior authors from six prominent medical journals from the 1970s through 2004. While female authorship increased from 5.9% in 1970 to 29.3% in 2004, the growth of women authors tended to rely more heavily on contributions from specialties that traditionally have more women such as Obstetrics and Pediatrics.
In an article published in the Postgraduate Medical Journal in 2016, reimbursement data for 2014 Medicare Fee for Service Provider Utilization were analyzed for numerous items, highlighting primary medical specialty, gender, reimbursements paid, and patient time invested.11 This study showed that across 13 specialties, a negative reimbursement differential against female providers, including critical care physicians, existed after adjusting for confounding variables. Greater than 880,000 providers were evaluated in the study, which showed a male to female physician ratio of 70:30 within all medical subspecialties, and a female reimbursement differential that was statistically significantly lower across all specialties. Previous analysis from the 1970s had hypothesized the reasons for pay differential to be related to undervaluing women’s care, and women physicians working less hours overall and therefore being less productive. Dr Desai and colleagues adjust for confounding variables in their analysis including productivity (as described by number of services provided) and hours worked (defined as number of beneficiaries seen). Once again, the evidence showed that critical care medicine had a lower ratio of female to male providers and additionally those women experienced “statistically less reimbursement than male providers irrespective of the amount worked, level of productivity, or years of experience.”11
An April 2017 US-based physicians survey by Doximity, a self-reported survey on 2016 physician salaries in the United States on the basis of varying factors such as location, specialty, and gender, highlighted once again a gender pay differential, where female physicians reported earnings on average 26.5% less than their male colleagues.12 In an updated survey for 2017, US physicians reported a 27.7% salary gender gap.12 Additional analysis showed that compounding statistical variation was a lack of female ownership of private practice groups. Eighty-five percent of men reported owning private groups, suggesting greater gender inclusion among not only leadership roles, but that practice ownership may be imperative to establishing salary parity within community practices.
Bridging the Gaps
Despite ample literature identifying gender disparities in medicine, there is a paucity of implemented and effective solutions. Several authors from multiple countries and critical care medicine societies have offered suggestions for improvement, ranging from increased representation of women within critical care society leadership to social accountability.9 In response to concerns raised by the exclusively male composition of the Sepsis Definitions Taskforce, the SCCM and ESICM have announced their intention to “ensure improvements in representation on future task forces and in diversity within the field.”13 An article in Critical Care Connections, published online in 2017 through SCCM, put forth additional strategies for improving the pervasive inequalities in women’s academic advancement and publication.14 Paramount to bridging the gaps in critical care medicine was creating mentorship programs that foster personal and professional growth.
Mentorship and Sponsorship
Implementation of cultural change toward transparency and accountability in terms of leadership, research, and physician reimbursement in the critical care specialty are ways suggested to bridge the gaps. One suggestion to improve these gaps has heavily relied on removing the previous era of the “boys club” through mentorship and sponsorship of women faculty. Increased visibility of womens’ research and publications, and equity in financial reimbursement, may begin with intentional mentorship and sponsorship of women physicians.
Women do not achieve career advancement in parity with men, and mentorship is considered a cornerstone for promotion.15 During the process of career planning, quality mentorship and sponsorship are invaluable assets. Mentorship provides guidance on trajectory and planning, whereas sponsorship provides specific opportunities. This may be provided through formal programming that exists both within institutional faculty development programs and external avenues such as national societies or conferences. The Association of American Medical Colleges (AAMC) conducts career development programs for women that provide opportunities to develop mentors and sponsors at different institutions, or even in different subspecialties.16 There are no hard and fast rules requiring mentors and sponsors to be from the same institution or specialty, and in fact, there may be a benefit from a pool of several different mentors and sponsors providing different expertise and perspective. These roles can be amplified positively with formal mentor/sponsor training as a first step in creating an institutional pool of committed, skilled mentors and sponsors for junior faculty.16 In addition to career advancement, mentorship is associated positively with increased career satisfaction among junior faculty.14,17,18
Unfortunately, multiple studies have reported a paucity of both mentors and role models for women.19,20 With mentorship for promotion lacking, women physicians may face increased difficulty in creating and executing career development plans, and in fact, one study shows that women are more likely to believe that poor mentorship impeded their career.14,15 Formal programming as mentioned above, extending to external programs as needed, can help fill the gap in available mentors and sponsors for women.
In considering career advancement, many physicians assess whether or not certain achievements seem feasible or would require “breaking a glass ceiling.” The noted lack of involvement of women on critical publications, such as the task force for the Third International Consensus Definitions for Sepsis and Septic Shock, is a key example of potential perceived limitations and begs the following rhetorical question: “If there is no woman on the current task force, who would be willing to sponsor me for that role?”21
A key aspect in career advancement requiring sponsorship are invited lectureships both at Grand Rounds and at society conferences. Grand Rounds speakers are recognized for their expertise and leadership in their field; however, women are not equitably represented as speakers compared with proportions of faculty (or trainees and students).22 The data for women speakers at critical care medicine conferences are similarly bleak, with less women presenters overall and the greatest negative impact observed for women physicians, who represent a lower overall percentage of speakers.23 Increased sponsorship extending such invitations to women faculty to promote the evolution of equity in these opportunities would continue to advance women’s careers in critical care medicine.
Given the increasing potential attrition rate for intensivists, mentorship has been suggested as a possible avenue for improving longevity of critical care careers. Formal career development programs have shown success in both retention and advancement of women physicians.24 If attrition rates persist, there may be a scarcity of available mentors for both men and women in critical care medicine.18
Critical care medicine is a diverse, multidisciplinary subspecialty that demands team-based support in the high-stress environment of the intensive care unit (ICU). Life and death decision-making, complex comorbid conditions, and the global burden of critical illness combined with the drive to improve patient processes and outcomes all contribute to the culture of medical practice in the ICU. We recognize that a culture can shift based on diversity of the population of both patients and providers, geographic regions, and even between organizations in the same city. However, there are several opportunities that suggest that organizations can positively impact culture change by decreasing gender disparities. By increasing diversity and inclusion, organizations can thereby improve the culture of critical care medicine.
Recognizing Gender and Implicit Bias
Gender bias is an intentional prejudice that can result in frank discrimination. Women physicians currently report higher rates of discrimination compared with men.16 Implicit, or unconscious, bias includes the unintentional attitudes, actions, and beliefs toward a person or a group of individuals, including implicit gender bias.9 Gender bias can influence who is chosen or invited for leadership, speaking, authorship, and other career-advancement activities. Gender bias, conscious or subconscious, can thereby negatively impact the careers of women in critical care medicine. Social media campaigns have recently highlighted bias through images of all male panels, called “manels,” thus driving the commitment to ask “where are the women?” at such events.9
Of increasing concern is the negative impact that implicit bias has on health care of female patients. Gender bias has been implicated in less aggressive care, both medically and procedurally, for women with coronary artery disease and trauma victims. Providing the best patient care demands that we address the implications of implicit bias for both the critical care workforce and our patients.25
Implicit bias demands an increased awareness and education surrounding biases to effect change. Education on implicit bias has been found to significantly decrease bias against women and should thus be a focused strategy to improved gender equity in critical care medicine.9 Societies such as the American College of Physicians (ACP) now recommend formal training and education to decrease bias.16
Decreasing Bias through Language
Gender bias has been demonstrated simply within the titles used for introductions of speakers. In a study of Grand Rounds speakers, women were less likely to be introduced using their professional title, and if introduced by a man, women’s professional titles were used <50% of the time.26 Ensuring that all speakers, colleagues, and trainees are addressed with equitable respect in terms of their professional titles is one way to ensure parity in the visibility of expertise within critical care medicine.
Clinical Burnout and Health of the Workforce
The epidemic of clinical burnout is pervasive in medicine, with women reporting higher rates of burnout and moral distress than men.27–29 Among the medical professions, critical care physicians report one of the highest rates of burnout, with estimates ranging as high as 70%.27,30 Clinical burnout can decrease provider health, but also negatively impact patient care. Burnout, compassion fatigue, and moral distress are all prevalent among critical care providers and the presence of one may increase the likelihood of another.16
Studies have shown an increase in physician-reported rates of reducing clinical duties or leaving the critical care profession entirely. The longevity of the critical care workforce demands multimodal, equitable solutions for men and women and a decrease in gender inequities.27,31 There is literature to suggest a correlation between gender inequity and clinical burnout. Linzer and colleauges describe the association between gender-based expectations and stereotypes of women physicians, particularly as manifested in work conditions, with increasing levels of burnout among women physicians.27 Work-life balance, or work-to-family conflict, is noted to negatively impact genders differently, with the greatest negative impact among women physicians.16 The authors postulate that the cost of this association is women transitioning away from full-time appointments. This may, at least in part, explain the known greater attrition of women from academic medicine compared with men.18 This raises many concerns for the future of critical care medicine, given the current intensivist shortage, and poses the question of whether gender inequity may accelerate the loss of women physicians.32
Advancing Medicine Demands Diversity
The creation of guidelines and best practice statements is best served with a diverse group of individuals representing different practice arenas. Inclusion of diverse perspectives lends itself to innovation in medical care. Dr De Angelis highlights the need for gender equity best with the following quote: “we waste half our genetic pool of intelligence, creativity, and critical insights and experience. Medicine simply cannot afford that loss.”33 The SCCM and ESICM recently released a joint statement of the serving presidents of each society, committing to improve diversity to advance the field.9,12
Steps to Improve Gender Equity in Critical Care
In their landmark paper “Where are the women?” published in 2017, Silver and colleagues evaluated the underrepresentation of women in specialty awardees of major medical societies and issued a call to action: 6 steps that medical societies should take to improve gender equity.34 The steps focused on the top, calling for leaders of organizations, departments, and societies to recognize gender inequity as a threat to a high-demand physician workforce. Silver and colleagues suggested starting with the data, encouraging organizations to examine their own gender diversity and inclusion, and investigate the causes of low representation of women in every level of leadership. The authors encouraged implementation of steps to improve inclusion and suggested tracking the outcomes of such steps.
Similar suggestions have been published by Choo and colleagues, who developed recommendations to advance women in emergency medicine through a working group with representatives from 2 national societies.35 Although anesthesiology and critical care medicine-specific recommendations do not exist, the authors suggest that initial steps to close the gaps described in this paper start with recognition by top leaders within individual institutions and organizations with intentional commitment of resources. Similar to Silver’s recommendations, Choo recommends a focus at the top to evaluate, describe, collect, and publish individual organization and department data on gender diversity and inclusion.
A 2018 recent publication by Shillcutt and Peterson-Layne36 described suggestions to change anesthesiology culture challenges related to gender inequity. Small, intentional steps involving women in not only educational initiatives (common academic appointments for women physicians) but also decision-making initiatives (less common appointments for women physicians), and moving from mentorship to sponsorship of women in departments can be subtle, yet important, steps to ensure the inclusion of women throughout department ranks.
Table 1 lists the recommendations to improve current gaps in critical care medicine on the basis of the authors’ review. Creating transparency of gender inequities within individual cultures, departments, and organizations takes intentional focus and recognition of the problem. We recommend appointing leaders to examine, study, and publish internal gender equity metrics, while increasing institutional rather than individual-based approaches to advance women in medicine. Sharing of such data can help other departments identify trends and noted suggestions.
Gender gaps in critical care medicine occur in several areas: promotion, publications, salary, mentorship, national societies, and leadership. Significant opportunities exist to improve the critical care medicine workforce by improving gender equity. Prioritizing gender equity within individual institutions and health systems is important and timely. Using metrics to measure gender equity within departments and strategies to intervene at the institutional level, rather than the individual level, are warranted.
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