Women in Critical Care Medicine

2017 - 4 August – Diversity
Roshni Sreedharan, MD; Silvia Perez-Protto, MD, MS
This article addresses the issue of gender disparity in critical care.

Gender disparity in the workforce is an age-old, yet unresolved, issue. We have heard a lot about gender parity in academic medicine since the turn of this century. What does parity really mean? Parity is defined as the quality or state of being equal or equivalent. Reflecting on this definition, is there true parity between the genders in critical care and academic medicine overall? In 2017, intuitively, the answer feels like it should be “yes.” Unfortunately the data do not support this statement.

The Reality of Gender Disparity 
The 2013-2014 Women in Medicine and Science benchmarking survey and the Association of American Medical Colleges faculty roster lend perspective into the entry, retention, and advancement of women in academic medicine. Critical care comprises an amalgam of different specialties, including internal medicine, anesthesiology, pediatrics, surgery, and emergency medicine. This data could be extrapolated to critical care as an extension of the component departments involved.

The percentage of female applicants to medical schools has increased since 2004 but is still only 46%—less than half.1 Women make up about one-third of the full-time academic faculty in U.S. medical schools. Despite these facts, the number of women in the higher echelons of the department and medical schools at the level of full professor is at a compelling low of 21%. Women make up only 15% of department chairs and 16% of medical school deans in U.S. medical schools.1 Focusing on critical care, 24.3% of physicians and 33.1% of trainees in 2014 were women.2 Although there has been some progress since 2003, there is a lot of work to be done to shift the focus toward advancement of women in all roles in academic medicine.

In 1981, Braslow and Heins highlighted the challenges women face in academic medicine. They found that the progress of women in academic medicine is hampered by the slow rate of advancement and lack of equal access to leadership positions.3 This predicament still exists in 2017. The lack of progression of women to higher academic ranks has been traditionally attributed to childrearing, household responsibilities, and a consequent lack of research productivity. Jena and colleagues looked at gender differences in faculty ranking in the United States using a comprehensive database of physicians with U.S. medical school faculty appointments in 2014. Despite adjustments for age, experience, specialty, and measures of research productivity, they found that women were substantially less likely than men to be full professors. This disparity was present across almost all specialties and irrespective of the medical school research ranking.4 A similar disparity exists in the representation of women on editorial boards of major medical journals. In 2011, Amrein and colleagues analyzed the genders of editorial board members of 60 top-ranked medical journals. The results were astounding. Only 15.9% of the editors-inchief and about 17.5% of all editorial board members (719 of 4,112) were female. Critical care had the lowest percentage of women on the editorial boards (7.3%) of all the specialties analyzed, even less than orthopedic surgery.5 Along similar lines, review of the authorship of critical care guidelines published between January 2012 and July 2016 found that only 13% of the authors of critical care guidelines were women.6 This paucity was especially notable on recent definition panels.7

The sluggish academic advancement also trickles down to leadership positions in the intensive care unit (ICU) and the institution as a whole. This situation is not restricted to critical care medicine in the United States. A similar situation exists in other developed countries as well. Only 10.5% of the directors of the ICUs accredited by the College of Intensive Care Medicine of Australia and New Zealand are women.8

The matter of gender pay gap in academic medicine has been looked at extensively. Recently, Jena and colleagues performed an analysis of sex-based difference in salaries of U.S. academic physicians, adjusting for confounders, including age, years of experience, scientific authorship, National Institutes of Health funding, and Medicare reimbursements as a proxy for clinical revenue.9 Despite adjusting for these factors, they found that the salary of female physicians was significantly less than that of male physicians and that this difference existed at all faculty levels. In fact, they found that the female full and associate faculty had adjusted salaries comparable to male associate and assistant professors respectively. To a large extent, this difference in pay between equally qualified male and female physicians remains unexplained.

To systematically solve a problem, it is important to recognize the depth and breadth of its existence. It is undeniable that a gender disparity exists in several shapes and forms in critical care medicine—academic advancement, career progression, leadership roles, and remuneration.​

The Root of Gender Disparity
An interview of 30 medical leaders in Australia to recognize perspectives on gender-based barriers to women taking on leadership roles brought forth three major reasons or justifications10:

1.Women have not been in the system long enough (the pipeline theory).
2.Women are not natural-born leaders. (Men inherently are more likely to appear as leaders.)
3.Women have family reasons for not seeking leadership roles.

It is onerous to determine the thought behind each of these reasons, but it is undeniable that unconscious bias is a major part of it. Unconscious bias is a belief or assumption about an individual without the knowledge of its occurrence or intention. Unfortunately, it leads to stereotyping and propagation of historical notions about gender. Unconscious bias occurs far too often, especially if the leaders of departments and institutions have not experienced it or are blind to it.11

Mentors play a very important and influential role in shaping the careers of their mentees. With the lack of equivalent academic advancement, there are fewer women at the higher ranks to serve as mentors and role models for the junior female faculty members. It is certainly not necessary for women to have only female mentors but senior male faculty members with the understanding and approach to mentor junior female faculty are few and far between.12,13

Women tend to underappreciate their capability and achievements. As a consequence, they are less likely than men to promote themselves, apply for a job, or ask for a promotion unless they meet 100% of the criteria.10,11 They tend to take on junior organizational roles and spend more time on those activities at the expense of other roles in research that may help with their career progression. These roles, although they may be fulfilling and important to an institution, do not necessarily lead to promotions or leadership opportunities.11 There is no specific explanation for the existence of a pay gap despite adjusting for research and clinical productivity, but these factors may play an important role in women being underrecognized.9

The editorial review conducted by Angell presents an interesting perspective. She points out that, irrespective of one’s stance on the issue, the fact remains that women, who bear children, make compromises more often on both the professional and the home front at an age when career advancement is expeditious.14 Also, daughters tend to provide more elder care than sons. Women might need to take a leave of absence or a part-time position at this juncture. There is a lack of support and opportunity when women commit to responsibilities at home or return from them, which leads to a stagnant career and slow progression up the higher rungs of the leadership ladder.

The issue of gender disparity in critical care is complex and multifaceted. There is no quick or immediate solution to it. The path to attainment of gender parity requires focused, deliberate, and sustained efforts from the entire critical care community.

Strategies for Attaining and Promoting Gender Parity in Critical Care Medicine
• Recognition and education regarding gender bias and unconscious bias. Such education should be mandatory for leaders of institutions and search and promotion committees
• Making deliberate attempts to combat unconscious bias by nominating qualified women when opportunities for leadership roles, speakers, or panelists in conferences arise
• Making the gender balance at conferences visible for attendees, speakers, and faculty so as to recognize and address bias if it occurs11
• Creating transparent appointment and promotion pathways to ensure a meaningful increase of women in senior professional ranks
• Regular institutional monitoring of the academic progress and remuneration of women to identify opportunities for early adjustment to assure parity with male counterparts
• Development of an effective coaching and mentorship program to help junior female faculty identify a mentor and develop a career plan early on
• Investing in early research career development and modification of promotion pathways for non-research career tracks
• Investing in leadership training tailored for women with special focus on strategies to build resilience and worklife balance
• Provision of a supportive environment for female faculty to realistically balance motherhood and an academic career and not have to make a choice between the two
• Development of pathways for women who choose a part-time career to still remain on a track of academic advancement
• Forming associations or societies within the institution to provide professional development, networking opportunities, and resources to support personal commitments for female staf

It is important to address concerns brought up by women faculty as a result of the needs assessment by the Women in Medicine and Science. These include providing a clear path of professional advancement, a work environment with equity and diversity, mentorship, faculty development programs, and opportunities for advancement.1

The Progress So Far
Efforts toward attainment of gender parity started decades ago. Although we have a long way ahead of us in attaining our goal, significant strides have been made. SCCM’s current president is a woman. Of SCCM’s 20-member Council, 10 are women. Professional societies, including SCCM, American College of Chest Physicians, American Thoracic Society, American Society of Anesthesiologists, American College of Surgeons, American Academy of Pediatrics, and American College of Emergency Physicians, have recognized and released statements supporting diversity and inclusion. Several of these societies already have standing diversity committees to promote diversity and inclusion. We need to create practices that will help us retain talented and competent physicians, mid-level providers, nurses, and pharmacists, regardless of gender, to achieve our mission of providing the best possible care to our patients.

The importance of gender parity in medicine is emphasized by the words of Catherine DeAngelis, the first female editor-in-chief of the Journal of the American Medical Association in their 116-year history, in a 2000 editorial: “We will waste half of our genetic pool of intelligence, creativity and critical insights and experience. Medicine simply cannot afford that loss.”

Diversity is a boon. We as a community have been endowed with it. The goal of the critical care community is providing the best care for our patients and their families. Embracing diversity—all forms of it—and using it to our advantage helps achieve that goal.​

References
1. Lautenberger DM, Dandar VM, Raezer CL, Sloane RA. The state of women in academic medicine. Washington, DC: Association of American Medical Colleges; 2014.
2. Association of American Medical Colleges. 2014 Physician Specialty Data Book. Association of American Medical Colleges; updated 2015.
3. Braslow JB, Heins M. Women in medical education: a decade of change. N Engl J Med. 1981 May 7;304(19):1129-1135.
4. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA. 2015 Sep 15;314(11):1149-1158.
5. Amrein K, Langmann A, Fahrleitner-Pammer A, Pieber TR, Zollner-Schwetz I. Women underrepresented on editorial boards of 60 major medical journals. Gend Med. 2011 Dec;8(6):378-387.
6. Merman E, Goldberg N, Luca S, et al. Differences in clinical practice guideline committee membership by sex [Abstract presented at ATS 2017]. Am J Resp Crit Care Med. 2017;195.
7. Mehta S, Burns KE, Machado FR, et al. Gender parity in critical care medicine. Am J Respir Crit Care Med. 2017 Feb 27. [Epub ahead of print].
8. Modra LJ, Yong S, Austin DE. Women in leadership in intensive care medicine. ICU Manage Pract. 2016;16(3). 
9. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016 Sep 1;176(9):1294-1304.
10. Bismark M, Morris J, Thomas L, Loh E, Phelps G, Dickinson H. Reasons and remedies for under-representation of women in medical leadership roles: a qualitative study from Australia. BMJ Open. 2015 Nov 16;5(11):e009384.
11. Bonomo Y, Zundel S, Martin JH. Addressing unconscious bias for female clinical academics. Intern Med J. 2016 Apr;46(4):391-393.
12. De Angelis CD. Women in academic medicine: new insights, same sad news. N Engl J Med. 2000 Feb 10;342(6):426-427.
13. Metaxa V. Is this (still) a man’s world? Crit Care. 2013 Jan 29;17(1):112.
14. Angell M. Women in medicine: beyond prejudice. N Engl J Med. 1981 May 7;304(19):1161-1162.