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Roshni Sreedharan, MD; Silvia Perez-Protto, MD, MS
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: