The systemic barriers preventing physician workforce equality

Deemed Women in Medicine Month by the American Medical Association (AMA), September  was spent celebrating the trailblazing achievements of female physicians.

As we look ahead, though, the momentum of these gains is stymied by lingering roadblocks preventing women from achieving true gender equality across all specialties, roles, and geographic locations. Although women matriculants now regularly exceed males and representation in the upper echelons of academia and leadership has slowly climbed – the AMA's three consecutive female presidents is one example of the latter – troubling gender imbalances continue to plague graduates as they move beyond medical school.

Only 36 percent of the nation's professionally active physicians are women,  and at the local level, females account for less than 40 percent of the physician workforces in 44 states, dropping as low as 24 percent in Idaho, a 2019 report from the Kaiser Family Foundation found.

In academia and leadership, the gender imbalance is even more prominent and points to enduring systemic issues.

"With each academic rank jump, we lose approximately 10 percent women. Only 20 percent  [of departments chairs] are held by women [and] specialties like surgery [have] less than five percent women chairs. The number is similarly low at the Dean level," says Jennifer Hunt, MD, a board-certified pathologist in Little Rock, Arkansas, Fellow of the College of American Pathologists, and chair of the Department of Pathology and Laboratory Services at the University of Arkansas for Medical Sciences. "There has been a slow increase, but nowhere close to where it should be for the demographics of practicing physicians. We continue to have a significant gap." 

Shortly after medical school enrollment, experts say women physicians encounter unique barriers to success that derail continuation into long-term clinical, leadership, and academic careers. From restrictive parenting roles rooted in an outdated societal structure to an undercurrent of implicit gender bias that discourages the pursuit of certain specialties and propagates hierarchical divisions, widespread disparities exist alongside the incremental improvements. Here's a rundown of barriers faced by female physicians and how to bridge the expanse. 

Pregnancy and parenthood barriers

Roughly 40 percent of physicians express plans to have children during graduate medical education (GME) programs, according to a 2016 Academic Medicine study. The cost of childbearing during this period, however, weighs considerably heavier on females, ultimately impacting the depth and trajectory of their training and careers.

"The pressure around the decision to have [and care for] children is a real thing. Women have been asked explicitly about their plans [and] definitely 'mommy tracked' if an interested is expressed," says LaTasha S. Perkins, MD, a board-certified family medicine physician in Washington, DC, and student health staff physician and director of outreach & engagement at Georgetown University. "This is done not only by others (i.e. attends, supervisors, directors, colleagues), but also by women themselves."

The Academic Medicine study discovered females pregnant during GME are more likely than their male counterparts to revise career plans both while pregnant and following childbirth, suffer from loss of research productivity, alter on-call and rotation schedules, and complete the program later than originally planned.

"Traditionally, women are still seen as the primary caregivers and the burden of raising a family and children is often seen as their responsibilities," says Evi Abada, MD, MS, a pathology resident physician in Detroit, Michigan, and member of the 500 Women Scientists and 500 Women in Medicine leadership teams. "Toward the end of their medical education, female students may find themselves grappling with specialty career choices. The act of balancing clinical responsibilities with caring for a family is often shoved in the faces of women, as though it is a crime to be both a caretaker/mother and physician at the same time."

Although the AMA urges residency programs to establish written family and parental leave policies covering birth, adoption, a six-week minimum leave allowance, and accommodations like modified rotations and permanent part-time scheduling, the availability of such offerings is inconsistent.

A 2018 JAMA study found just eight of 15 GME-sponsoring institutions affiliated with 12 prominent U.S.-based medical schools have paid childbearing or family leave provisions for residents. Even more troubling, the American College of Physicians (ACP) reports a mere 28.9 percent of physician contracts provide maternity coverage and taking leave results in an estimated $10,000 in lost income, disincentivizing this as a viable option for many females.

Women physicians are then forced to make tough decisions in an effort to achieve work-life balance.

"Many women choose to work part-time, which affects their productivity and ultimately their ability to be promoted," says Kate Killoran, MD, a board-certified OB/GYN in Camden, Maine.

Reduced work hours also limit access to leadership opportunities and curtails representation in the more competitive, time-intensive, and historically male-dominated specialties like orthopedics and neurosurgery.

The solution, Killoran says, is threefold and widely supported by physician organizations like the AMA and ACP. "[Stop] penalizing physicians who work less, [provide] universal access to paid medical and family leave, [and] expand paid leave to more than 6 weeks."

Implicit gender bias

Unfortunately, pregnancy and parenting barriers and the lack of equitable leave policies are simply the workplace manifestation of a broader societal belief system – implicit gender bias.

A 2017 WedMD/Medscape survey found 41 percent of women physicians experience gender bias compared to six percent of males. Female physicians regularly operate in less welcoming and supportive environments, which compromises their authority, promotes marginalization, and overshadows relationships with colleagues and patients.

"Women experience profound microaggressions on a daily basis," Hunt says. "There is one committee that I attend where the chair regularly refers to male committee members as 'Dr. [Last name]' while referring to each woman doctor only by her first name. This erodes the creditability and validity of the women at the table."

Hunt's experience aligns with the findings of a 2017 Journal of Women's Health study in which Grand Rounds speaker introductions were assessed for possible gender bias. Formal titles were used less than half of the time when males introduced female speakers versus 95 percent when the roles were reversed.

"I call this form of covert discrimination the 'fallacy of familiarity,'" says Hunt, who is also an Executive Leadership Coach and works with female physicians to overcome the self-limiting beliefs of Impostor Syndrome – a condition that often occurs as a result of ongoing gender bias. "The person talking thinks that they are demonstrating rapport and friendship with the woman they are introducing, but in fact they are just invalidating them as experts and specialists. When that happens day after day, the time [females] spent in training and their level of expertise feels diminished."

Patients may also proliferate gender bias. A 2018 Women's Health Issues study evaluated hundreds of Press Ganey patient satisfaction surveys, and after accounting for other variables, found female OB/GYNs were 47 percent less likely to receive top satisfaction scores than their male counterparts. The inferior scores are surprising given research that patients under the care of female physicians tend to receive more preventive counseling and screening, additional face-to-face time and enhanced patient-centered communications during medical visits, and boast lower patient mortality and readmission rates.  

The constant onslaught of gender bias from seemingly all directions can push women into less desirable and fulfilling roles or out of the workforce completely, potentially to the detriment of patients who miss out not only on arguably better care, but on unique perspectives too.

 "Women bring skills and viewpoints that are different, but equal to men, and for that reason our presence is essential. A practical example would be a pelvic exam," Perkins says. "A woman who has experienced that sensitive exam can be more empathetic when performing [it]."

Multifaceted solutions

These are intricate, complex problems with no simple solutions. The way forward, experts agree, is to expose the barriers and work toward a better balance. Actively and intentionally rooting out bias is a meaningful and critical first step, but it requires action from all sides and throughout the lifespan.

"It has to be multifaceted, [starting by acknowledging] implicit bias as early as elementary school, with special and specific training for parents [and] educators," says Perkins.

For Abada, postsecondary education is a prime time to address these sensitive topics.

"Curricula on career development and leadership should be incorporated into medical student's education [and] the notion that some specialties are well suited to males [instead of] females should be discouraged in training."

Initiatives by medical associations, accrediting bodies, employers–essentially all stakeholders–will be necessary to remedy the imbalance and increase retention of female talent. Introducing women by their hard-earned titles is just the start.

"Support programs for negotiation and leadership development, improve the visibility of female physicians' speaking and panel discussions [and] include women in search committees," Killoran says.

Male physicians may play the most pivotal role, Hunt says, based on a dynamic exchange she witnessed during a medical society meeting.

"A white middle-aged male, and good friend of mine, stood up and said, 'You all look pretty much the same to me. What are you going to do in your term to increase the diversity of the board? And more importantly, how are you going to support and promote people who don't look like you?' It electrified the room and [prompted us] to carefully examine the barriers to board diversity. Men of good conscious exercise their privilege to speak on behalf of those who are not speaking."

Steph Weber is an award-winning freelance journalist hailing from the Midwest. She writes about healthcare, human resources and small business.

Potential sidebars

Read the AMA's Policy: Parental, Family and Medical Necessity Leave H-405.960

Read the AMA's Policy: Principles for Advancing Gender Equity in Medicine

Wondering which specialties have the biggest gender imbalances? See the list.

An Infographic: Achieving Gender Equity in Physician Compensation + Career Advancement

ACP's Top 10 Things You Can Do to Impact Gender Equity in Medicine

Gender inequity and burnout "Women are regularly addressed more casually and have their orders and decisions questioned by other staff or colleagues," says Killoran. "This persistent challenge to knowledge and authority adds up over time, certainly eroding confidence and potentially resulting in earlier burnout." This National Academy of Medicine paper elaborates on why female physicians are at higher risk for burnout.

Pay disparities Pay disparities continue to plague female physicians. According to the 2019 Doximity Physician Compensation Report, male physicians earn $1.25 for every $1 earned by female physicians, resulting in a salary difference of $90,490. Although this is an improvement over previous years, the gap still stings. "Women are paid less and get smaller bonuses even when they have more experience and better credentials," says Killoran, who advocates for pay transparency to ensure equal compensation for physicians with similar skills and credentials. The ACP assumes a similar stance, discouraging financial penalties for physicians who work less than full time and recommending "routine assessment of the equity of physician compensation arrangements by all organizations that employ physicians." 

Resources and support for female physicians

American Medical Women's Association

500 Women in Medicine

500 Women Scientists

Physician Women in Leadership

Physician Moms Group (myPMG)

American Academy of Family Physicians: Medical School and Residency

Executive Leadership in Academic Medicine

AAMC Leadership Development

Executive Leadership Coaching – Dr. Jennifer Hunt