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EQUITY AND SOCIAL JUSTICE

Gender Parity Does Not Equal Gender Equity: Continued Sexism in Medical Literature

Kattapuram, Taj M. MD; Patel, Tirath Y. MD; Solberg, Agnieszka O. MD

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doi: 10.1097/SLA.0000000000004765
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Abstract

A recently published and retracted article from the Journal of Vascular Surgery (JVS)1 created a viral social media movement using the #MedBikini hashtag. Medical professionals on social media were shocked at the authors’ judgment of surgeons’ appearance and actions on public social media profiles.2

The authors extrapolated that “potentially inappropriate attire included […] provocative posing in bikinis/swimwear.”1 The gender most associated with bikinis is female. Consequently, this sentence was interpreted as sexist, and this set off a tweetstorm. The Twitter hashtag #MedBikini quickly trended, with health professionals criticizing the article.2 The JVS article and the subsequent backlash highlight implicit bias and sexism in medicine.

Many organizations attempting to define professionalism in social media refer to platforms that physicians or other healthcare professionals use specifically for healthcare-related content.

Professionalism, as defined by the Accreditation Council for Graduate Medical Education (ACGME) in its common program requirements for residencies, says trainees must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles, specifically: “compassion, integrity, and respect for others; responsiveness to patient needs that supersedes self-interest; respect for patient privacy and autonomy; accountability to patients, society, and the profession; [and] sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.”3 As defined by the ACGME, professionalism does not describe specific attire or choice of appearance.

While the American Medical Association (AMA) Code of Medical Ethics opinion on professionalism in the use of social media states that “physicians must recognize that actions and content posted may negatively affect their reputations among patients and colleagues […] and can undermine public trust in the medical profession,” no specific statement is made regarding what is deemed appropriate – or inappropriate – attire.4

The aforementioned JVS article used questionable methods, including the creation of fake social media accounts to search and follow the public social media accounts of early-career male and female vascular surgeons without their permission.1 In addition, the database of vascular surgeons in question was inappropriately obtained.2

The methods used by the JVS authors are not novel, nor is the judgment of female physicians. In 2014, using publicly available rosters from general surgery residency websites, Langenfeld et al judged the public Facebook posts of Midwestern general surgery residents as “professional” or not.5 The authors explicitly stated, “a validated instrument this process [judging social media posts as ‘professional’ or not] does not exist.”5 In 2017, using a list of recent US urology residency graduates, Koo et al used similar methods to evaluate the publicly available Facebook posts of newly-trained urologists.6 Koo et al conceded that the definition of what is deemed “professional” or “objectionable” varies. However, an expansive definition was used.6 Despite the limitations described in Langenfeld et al5 and Koo et al,6 the JVS authors used the same process in their assessment of professional social media postings by vascular surgeons.1

In their professionalism statements, neither the ACGME nor the AMA define appropriate or inappropriate attire.3,4 The authors of the JVS study did not use the objective measures as defined by the ACGME or the AMA. Rather, they used subjective measures, and judged young professional females as having “potentially inappropriate” attire based on social media posts under the guise of professionalism.1

While Langenfeld et al and Koo et al used the term “attire,”5,6 the authors of the JVS article used the terms “swimwear/bikini.”1 Again, the gender most associated with bikinis is female. By using the specific term “bikini,” the authors made a clear reference to women's swimwear as opposed to men's swimwear. In the retraction statement, the editors of JVS admitted that “the review process failed to identify the errors in the design of the study with regards to conscious and unconscious bias” and “implicit bias found in the [study's] analysis.2

This should be unsurprising. In a recent study, 70% of female academic medical faculty respondents reported gender bias in their careers. In the same study, 30% reported sexual harassment.7 Given this background, it is unsurprising that the authors of the study used the term “bikini,” singling out females and perpetuating unconscious bias against female physicians.

It is important to note, there is a female author on the JVS paper, and the institution's academic department and IRB teams are richly populated with both men and women. Multiple review layers within the institution and the journal allowed this JVS article to move forward with publication. Because of this there is a larger concern that implicit bias against women is not single-gendered, and both men and women would likely benefit from self-awareness coaching and bias training.

It is also debatable whether or not studies identifying and cataloging “unprofessional” behavior on social media by physician trainees serve a larger benefit. On the one hand, they may demonstrate that there are issues with trainees posting unprofessional content, which would imply the need for additional awareness education. Unfortunately, there are no agreed upon definitions of professionalism, ones that are free of implicit bias and sexism. There are obvious, egregious examples of unprofessional conduct, such as violating patient privacy on social media postings. But if a more expansive definition is used – as was done in the JVS article1 – determination of professionalism is more subjective.

Outside of work hours, wearing swimwear such as bikinis or legally holding or consuming alcoholic beverages can be acceptable behaviors, but can be misconstrued as “unprofessional” if certain definitions are applied. Personal and off-duty time is different than work hours and applying the same definition of professionalism to both settings may not be constructive. A recent policy statement on online medical professionalism from the American College of Physicians and the Federation of State Medical Boards recommended keeping professional and personal identities separate.8 Therefore, applying the same definition of professionalism during work hours and during off-duty hours when evaluating and cataloging “unprofessionalism” seems inappropriate.

After the tweetstorm and public outcry, at least 2 of the authors posted apologies on Twitter.2 While the Twitter accounts of these authors have since been deleted, the apologies were reproduced elsewhere.2 These identical apologies, in the opinions of many, did not take accountability for their methods. While one could argue that there's benefit to speaking as a single voice, the identicalness of the apologies was interpreted as impersonal and disingenuous.

It is common for viral social media posts to quickly lose attention as new issues and events arise. However, we feel it is important not to forget this incident. It is a sad reminder that in 2020, after the #MeToo movement in healthcare and elsewhere, and proliferation of diversity and inclusion committees and initiatives in organizations, female physicians unfortunately have a long road toward equality, fairness, and acceptance in the house of medicine.

Today, in the United States, there are more female medical students than male medical students. It is a success on one level, as we have reached gender parity in terms of the pipeline of future physicians. Importantly, gender parity is not gender equity. Professionalism statements and standards are rooted in a time when medicine was male dominated, and, as exhibited by the JVS article, vestiges of that time – and the associated male dominated worldview – remain. We may have reached gender parity in terms of demographics of future physicians, but if a social media post of a female vascular surgeon wearing a bikini, a commonly worn piece of women's swimwear, is deemed “potentially unprofessional,” have we reached gender equity? In a word: No.

REFERENCES

1. Hardouin S, Cheng TW, Mitchell EL, et al. RETRACTED: prevalence of unprofessional social media content among young vascular surgeons. J Vasc Surg 2020; 72:667–671.
2. Phend C. Stalking trainees’ social media for unprofessionalism? #Medbikini back at ya. [MedPage Today website]. July 24, 2020. Available at: https://www.medpagetoday.com/publichealthpolicy/generalprofessionalissues/87743. Accessed September 17, 2020.
3. ACGME common program requirements (residency). [Accreditation Council for Graduate Medical Education web site]. February 3, 2020. Available at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/CPRResidency2020.pdf. Accessed September 17, 2020.
4. Professionalism in the use of social media. [American Medical Association web site]. Available at: https://www.ama-assn.org/delivering-care/ethics/professionalism-use-social-media. Accessed September 17, 2020.
5. Langenfeld SJ, Cook G, Sudbeck C, et al. An assessment of unprofessional behavior among surgical residents on Facebook: a warning of the dangers of social media. J Surg Educ 2014; 71:e28–e32.
6. Koo K, Ficko Z, Gormley EA. Unprofessional content on Facebook accounts of US urology residency graduates. BJU Int 2017; 119:955–960.
7. Jagsi R, Griffith KA, Jones R, et al. Sexual harassment and discrimination experiences of academic medical faculty. JAMA 2016; 315:2120–2121.
8. Farnan JM, Snyder Sulmasy L, Worster B, et al. Online medical professionalism: patient and public relationships: policy statement from the American College of Physicians and the Federation of State Medical Boards. Ann Intern Med 2013; 158:620–627.
Keywords:

equality; equity; ethics; gender; parity; professionalism; sexism; social media; surgery; unconcious bias; women

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