Do Women in Academic Infectious Diseases Need to Win Nobel Prizes to be Promoted?

Image: rubberball / Shutterstock

Compared to men, women physicians are less likely to be recognized with medical society awards, less likely to be invited to speak at grand rounds, less likely to be addressed as "doctor", less likely to be in advanced academic leadership positions, and generally paid less. A Texas physician was recently made infamous during Women in Medicine Month for a quote printed in a journal that "nothing needs to be done" about the gender pay gap, stating that women physicians "don't work as hard" because they prioritize "family, social, whatever."

His opinions sadly are not isolated, and many national societies have been responding to calls for action to embrace diversity, equity, and inclusion. At the Infectious Diseases Society of America (IDSA) Annual Meeting (IDWeek 2018), 41% of members are women. Our board of directors is increasingly more gender diverse, with 10/16 board female board members, and 11/19 committee chairs being women. Dr. Jeanne Marazzo, a professor of medicine and ID Division director at the University of Alabama, commented that #IDWeek2018 program organizers have put a "laser focus on trying to diversify the program committee and those on stage".

Because our society membership and leadership has a reasonable representation of women, we may think we are not prone to gender equity concerns. But what protects Infectious Diseases (ID) as a specialty from gender inequity?

Dr. Jen Manne-Goehler, a Harvard Infectious Diseases fellow, presented the featured oral abstract at IDWeek 2018, "Sex differences in academic achievement and faculty rank in academic infectious diseases". I had pinned this as a must-attend oral presentation and arrived early to ensure I had a seat. As I waited, the time of her presentation passed, prompting me to reach out frantically to the #IDWeek2018 organizers, hoping that I had not missed the presentation in another location. Fortunately, I did not have to go far, as she was still to present in that room, but with a change in presentation order. Let's assume this schedule change was a "save the best for last" situation, because what Dr. Manne-Goehler delivered was well worth the wait.

The Harvard research group partnered with Doximity to assess gender differences in rank and promotion of academic ID physicians. Doximity has an online professional network for physicians. Using this cross-sectional database, as well as cross-validation with several other platforms (American Association of Medical Colleges/AAMC, PubMed, Licensing boards, etc.), the team studied 2,016 academic ID specialists (of a total 91,073 academic physicians). They found that men published more peer-reviewed articles, especially first/last author publications, which are often given more credit for promotion. Although clinical trial activity was generally equitable, men received more NIH grant funding. Male academic ID doctors outnumbered women as full professors by 24%, regardless of when they graduated. This disparity persisted despite adjustment for publications, NIH grants and clinical trial activity.

These results were fascinating but not unexpected. In fact, a similar study performed in Cardiology by Dr. Manne-Goehler's mentor, Dr. Anupam Jena, briefly mentioned that this disparity in academic ID promotions existed. As a woman in academic ID, I am always pleasantly surprised when I encounter more than one woman professor in a division, despite interacting with hundreds of associate professors with national/international recognition and holding leadership positions within their academic institutions. But surely Infectious Diseases, a more female-dominant Internal Medicine sub-specialty, would be better at promoting women than other subspecialties? In Cardiology, even after adjusting for age, subspecialty training, postgraduate experience and productivity, women were half as likely to be full professors as their male colleagues. Only a quarter of academic Gastroenterologists are women, and of those, just over 10% are full Professors. Infectious Diseases must be better off than that right? WRONG.

Here is the biggest surprise of Dr Manne-Goehler's analysis: the gender gap in academic promotion was actually THE WORST in Infectious Diseases, when compared to other subspecialties, including Hematology, Gastroenterology, and Cardiology! This got people talking. Because of the nature of our specialty, we spend a lot of time discussing disparity in healthcare delivery, but how can we strive for parity in healthcare delivery when we cannot achieve parity in promotion of those delivering the care? What drives this imbalance? Because it was a cross-sectional database, it simply was not designed to answer the question fully, although they did adjust for factors that could possibly drive differences (such as publications and NIH grants). Division chiefs need to dissect their promotion processes; are women being recommended for promotion at the same rate as men and not succeeding, or are the recommendations not even happening? Maybe we need a survey of current associate professors themselves, assessing their own self-awareness of their promotion-readiness. Perhaps we need to evaluate the individual promotion applications themselves – assuming similar CV's, does a woman's nomination letter/personal statement differ from her male colleague's? If it were ever possible to blind the promotion process, would this phenomenon still persist?

In the first week of October, Dr. Donna Strickland was announced as a 2018 Physics Nobel Laureate. She was awarded this monumental achievement as an associate professor at the University of Waterloo. People all over the world questioned why a woman clearly qualified for one of the highest awards in Science was never promoted to Professor. When questioned about why she was not a Professor, she simply answered "I never applied". Why didn't she apply? Was she encouraged to apply? Did she think she didn't qualify? Was she not interested? How much does gender bias play a role in the creation of gender inequity in science and medicine?

The inequity discussion is not all doom and gloom, and there are very concrete actions that can close equity gaps. If you are on social media, you may have recently heard about the #BeEthical campaign, launched by Dr. Julie Silver, an associate professor and the associate chair of the Department of Physical Medicine and Rehabilitation at Harvard Medical School. The campaign is a call to action for leaders in medical schools, hospitals, healthcare organizations, medical societies, medical journals and funding sources to prioritize gender equity, and implement strategic interventions to intentionally close gender gaps. The campaign recommends the following strategy to achieve this goal:

  1. Examine gender data through the lens of an organization's mission, values, and ethical code of conduct.  
  2. Report the results transparently to all stakeholders.
  3. Investigate causes of disparities.
  4. Implement strategies to address disparities.
  5. Track outcomes and adjust strategies as needed.  
  6. Report/publish results.

As a woman in ID, I was energized by Dr. Manne-Goehler's results to keep speaking up about these issues, but I was thrilled to hear my male colleagues speaking up too. Dr. Carlos del Rio, a professor and chair at the Department of Global Health, and professor of medicine in Infectious Diseases at Emory University, had tweeted, "As a physician in academic medicine I see my major legacy the levelling of the playing field by promoting the advancement of women and minorities through mentorship and sponsorship. Academic medicine, healthcare and societies like IDSA will be better if we achieve this."

This is key. Gender equity is not a #WomenInMedicine only issue. It is an issue that we ALL should champion, for the good of society.

Dr. Jasmine R. Marcelin is an assistant professor in the Department of Medicine, Division of Infectious Diseases, Infectious Diseases (ID) faculty member at University of Nebraska Medical Center (UNMC), and the associate medical director of antimicrobial stewardship and infection prevention & control at Nebraska Medicine. Dr. Marcelin's antimicrobial stewardship interests include diagnostic stewardship and ambulatory stewardship. She is a member of the Society for Healthcare Epidemiology of America (SHEA) and Infectious Diseases Society of America (IDSA). Dr. Marcelin is a member of several national medical society committees including the IDSA Diversity, Inclusion & Equity Taskforce, SHEA Awards committee and SHEA Journal Club Committee. She is a passionate advocate for gender and racial/ethnic diversity, inclusion and equity in Medicine. Dr. Marcelin contributes to several multidisciplinary blogs and is one of the co-directors of the UNMC ID Blog and social media accounts. Dr. Marcelin has no financial disclosures. You can follow her work on twitter @DrJRMarcelin.

More from Op-Med