Blast from the Past
When Fe del Mundo first applied to Harvard medical school in 1936, the admissions committee did not know that she was a woman because of an oversight. It was not until she showed up to her assigned all boys dormitory that the committee realized their mishap. They had inadvertently admitted the very first and only woman to the prestigious medical institution. Some male colleagues protested that her admission ought to be rescinded solely because of her gender. Prior to Dr. Mundo, several applications by women to Harvard medical school had been rejected. Never mind that some decades earlier, Dr. Elizabeth Blackwell had paved the way as the first woman MD in the United States.
At the time, it was so common to discriminate against women that even the trail-blazing Dr. Blackwell’s medical school admission to Geneva Medical College in the 1840s was meant to be a prank. The prevailing thought regarding women was that they were “lacking in sense and mental perception, contemptuous of logic, immodest and morally unfit to practice medicine.” Women’s pursuit of medicine was limited then by legal, moral and social practices of the era. Today, however, the tide seems to have turned. A recent report by the AAMC indicates that for the first time more women matriculated into medical school than men.
While this may signal progress since the days of Drs. Mundo and Blackwell, many of the century-old gender biases and prejudices against women in medicine continue to persist today. Take, for example, emergent reports highlighting the prevalence of a gender pay gap (1–2). In some states and depending on the specialty, there’s almost a 10-fold gender pay gap even after adjusting for age, professional rank, clinical work hours, productivity, and experience. Women physicians in the U.S. earn on average a staggering $20,000 to $105, 000 less than men. From when they first enter medical school ’til they become independent practicing physicians, women face gender-based discrimination (3–4). And this is in 2018, more than 150-years after women first entered the medical profession.
As a male physician, I find the gender disparity deeply disconcerting. Everyday I see and hear stories from women — including my wife — about some of the struggles they deal with as women in medicine across the entire healthcare spectrum: from harassments by patients to poor evaluations for pregnant physicians. That 1 in 3 women physicians are harassed is a double jeopardy considering they will be also paid less than male colleagues with the same qualifications (5–6). This is a betrayal of medicine’s most sacred values of dignity and respect. In some ways the era of #MeToo has affirmed what many have known all along: that medicine as a profession is not impervious to societal ills, stereotypes and biases.
The pervasiveness of gender inequities within medicine and across several other professions underscores a fundamental problem: there is a great divide between how we value men vs. women. This raises serious concerns regarding the origins of this divide, underscores why women and particularly men must rally to find solutions, and what a failure to close the gender chasm could mean for the future of medicine. While we struggle to salvage a profession that is currently under siege by myriad problems, it will take the collective effort of strong-willed women and men to dismantle discrimination within medicine.
Searching for Answers
But, how do we get ourselves to the promised land — to a future of equal opportunities, no gender pay gap, and equitable valuation of men and women’s skills, attributes and talents?
We need all doctors — not only women doctors — to care about gender discrimination in medicine. Since people generally only care about things they identify with, how do we get all doctors to care about the issue of discrimination?
The answer may lie in developing a new mental framework of discrimination that ascribes to something that all clinicians care about: practicing excellent medicine.
Whether we realize it or not, we all have cognitive schemas — mental maps — of how the world works; this informs our views on what is right vs. wrong, what is good vs. bad. It is through these schemas that we conceptualize social issues of injustice and inequities and their impact on targeted groups. Few of us, however, are aware that discrimination itself is a manifest expression of something more insidious — implicit bias.
The dangerous thing about implicit bias is that it is a supra-phenomenon, something that occurs beyond our intention. It acts as the invisible hand that shapes our mental maps and influences our actions.
Until recently, how implicit bias influenced clinicians in their various roles had not fully been explored. Emerging research suggests that implicit bias leads to bad medicine, with gender based differences in outcomes, which are usually worse for women. Most doctors — the good ones — care about practicing good medicine and improving patient lives. So what happens when good doctors realize that implicit bias is making them practice bad medicine by unconsciously offering gender-biased and discriminatory treatments?
They find immediate solutions and change their clinical practice to eliminate harm to patients.
I learned this as a patient safety fellow at the Johns Hopkins Armstrong Institute. We discussed a disturbing trend in which female — compared to male — trauma patients at Hopkins were at increased risk of dying from blood clots because they were significantly undertreated with medications for blood clot prevention. The hospital responded immediately to the gender disparity by institutionalizing the use of a computerized checklist and a smart-order set. Backed by institutional leadership, this systematic strategy worked so well that it completely eliminated the gender disparities in outcomes.
Almost by serendipity, the Johns Hopkins hospital discovered a solution for gender-biased treatments: standardization of care as a way to tackle implicit bias head on. Driven to provide excellent care, its doctors found a way to dismantle gender discrimination in blood clot prevention among trauma patients.
While reflecting on ways to engage male allies in the campaign against gender bias in medicine, I had this crazy thought: what if we applied the same mindset that eliminated gender disparities in blood clot outcomes to the gender pay gap and other forms of discrimination against women physicians in medicine?
If it is the case, as this JAMA study seems to suggest, that elderly patients treated by women physicians fare better than those treated by men (based on lower 30-day mortality), then, perhaps, we can reframe the value-proposition for gender equity in medicine: support for women in medicine is support for excellence in medicine.
This is not to say that men don’t practice clinical excellence, rather it is a recognition of the important role that women doctors play in the profession. Women bring a unique perspective and approach to problem solving, which helps drive the engine of innovation. So, why not make it possible for all women to shine alongside their male counterparts? Rather than supporting systems that allow subtle forms of discrimination — which over a lifetime can have disastrous health consequences — maybe we can take a cue from how Hopkins dealt with one form of gender bias. It is high time we implemented standardized practices that reflect that we value female physicians as much as we do male physicians.
At a time when public opinion of physicians seems to be at an all time low, and when all other industries seem to be mired by one public scandal of sexual harassment after another, medicine has a rare window of opportunity to become a beacon of hope, to lead the charge of men supporting women (doctors), and to find and systematize solutions that eliminate gender disparities within our medical institutions.
Not only is this a worthy goal, it gets at the core of what we are about in medicine, and what most clinicians care about: excellence. Implicit bias is pervasive — we all have it to one degree or another — but promoting systems that support gender equity would minimize its effect. Parity in how we treat each other benefits everyone: men and women doctors alike. In the long run, the benefits spill over to our patients.
Undoubtedly, there are examples of good male physicians and mentors out there supporting women, but in order to dismantle legacy structures that have discriminated against women for decades, one thing is crystal clear: it will take more than a few good men.
Something transcendent and beautiful occurs when individuals in a dominant group act in solidarity with an oppressed group. In that regard, if you’re a male physician, how are you using your sphere of influence to eliminate discrimination? If you’re a female physician privileged with male sponsors, how are you helping those less fortunate?
For all of us who care about practicing good medicine and clinical excellence, we must not and cannot settle for anything less than a profession that champions equity. Our shared common fate means supporting equal pay for equally qualified physicians, as well as finding solidarity in promoting a culture that supports women and values their talents as much as those of men.
Reframing the gender discrimination dialog in a way that calls out the good in all of us may lead to a new dawn of allyship, one in which discrimination against women is no longer just a “woman issue,” but also, “our issue.” Should we pursue this together in solidarity, rest assured that the work of pioneers like Drs. Mundo and Blackwell would not have been in vain.
Charles A. Odonkor, MD, began his love affair with medicine at Yale and is now a fellow at Stanford. He enjoys traveling, cooking and spending quality time with his wife. He is a Doximity Scholar and tweets@kcodonkorGH