#107: Women in Medicine, Be Bold.

August 6, 2018 | By Leah Witt

“Women in medicine, be bold.” Medical World, powerful women are here to stay.  Women are entering medical school now more than ever, and are learning to provide the best possible care to patients (didn’t you see that patients of female physicians have significantly lower mortality rates than patients of male physicians? (Tsugawa et al., 2016)).  The modern medical woman wants to teach, mentor, and lead–and be fairly evaluated, and promoted. That’s where We In Medicine (both women and men) have some work to do.  Because gender disparities (and other disparities hinging on identity) do exist.

In this episode, Dr. Vineet (Vinny) Arora, an exemplary Woman in Medicine and Leadership, shares snippets of her own story, valuable advice to folks at all levels of training, and fascinating data about the gender disparities that exist in training, promotion, and pay.  We hope you’ll learn from this episode, whether you have faced or anticipate facing these struggles as a Woman in Medicine or as a member of another marginalized group, or whether you’re an ally and want to learn more about the issue.

A little about Dr. Arora: She is an academic hospitalist and Professor of Medicine at the University of Chicago. There, Dr. Arora also serves as Assistant Dean for Scholarship and Discovery, and as Director of GME Clinical Learning Environment– an exceptional example of a woman in medical leadership. Her interests include improving the learning environment for medical trainees and the quality, safety, and experience of care delivered to hospitalized adults. She’s also a social media superstar, and can be found tweeting @FutureDocs.

N.b. This episode is our inaugural in what we hope will be a Women in Medicine series for the Curbsiders.  We have many more topics with which we’d like to engage, from career trajectory to imposter syndrome to sexual harassment to balancing career and personal lives (as inequity is not only at work (Khullar. Being a Doctor is Hard. It’s Harder for Women. NYT 2017)), to conversations about race, gender, and LGBTQ identity in medicine.  We’re passionate, at The Curbsiders, about all these topics, and we want to dive deep into how to make Medicine a more welcoming and ceiling-less place for all.  We can’t wait to bring this series to you, not to mention to bring some more fabulous female experts on air.

Credits:
Written and produced by: Leah Witt MD, Shreya P. Trivedi MD, Nora Taranto AB, Sarah Phoebe Roberts MPH, Molly Heublein MD, Beth Garbitelli, Hannah R Abrams,
Images by: Beth Garbitelli and Hannah Abrams
Editor: Matthew Watto MD
Hosts: Leah Witt MD, Shreya P. Trivedi MD, Matthew Watto MD
Guest: Vineet Arora MD

Clinical Pearls

1. Don’t be afraid to be bold.  When you’re young and in the early part of your

career, it’s easier to make big decisions and changes. Use this time wisely, and take risks, before you will have to decide based on a long list of family and career obligations.

In-depth Show Notes
Dr. Arora’s Women In Medicine Moment of Awakening: “I was an accidental champion.”  

She was going up for promotion, after maternity leave, and was doing salary comparisons. She was surprised by how far behind she had fallen, given that she didn’t pay the Mommy Tax (since she had kids later).  

This piqued her interest, and then she was asked to review a paper on gender disparities and gender pay using large publicly available data from public universities. This paper (Anupam et al, 2016) attempted to take into account and adjust for all factors that could explain the pay gap, but at the end of the day, some institutions still did have a pay gap based on gender.  Dr. Arora wrote an editorial when the paper came out, for the NYTimes (e-front page!).

Which brought her back to her own questions about promotion and pay: “I’ve achieved all these things on the checklist but somehow, I’m still falling behind.” She realized that there are a lot of factors that could go into this, related to gender inequity, whether based on negotiation, unconscious/implicit bias, statistical discrimination, etc.

Advice to Her Younger Self: Don’t be afraid to be bold.
Dr. Arora was cautious, earlier on in her career, when it came to questions about taking a big job, or making a big move–with the nagging question of whether she should wait until things settled more in her personal and professional life.  “Those are not the types of decisions that I see young men thinking about that much.”

So her advice is this: Don’t be afraid to be a risk taker and be bold. in the early trajectory of your career you can do it. It’s later when you have a little more difficulty in being as bold in your decision making, because you may have a settled career and family. “It’s a delicate dance of where to live when you have a spouse who likely has another career.”

The Case: Resident Dr. Beth Blackwell, whose patients and staff members (even in Codes) often assume she is the nurse or a member of the team in training, and look to the male in the room as the leader (even when he’s the third year medical student!).

1. This is a common problem that women physicians face. Patients and other people in the workforce don’t recognize women as doctors.
2. There is a lot of implicit bias–that when you think of a doctor, you may not think of women. And even when you are acknowledged as a physician, you may not be not thought of in as formal a leading role as your male counterparts (See the 2017 study by a group at Mayo found that women introduced by men at Internal Medicine Grand Rounds were less likely to be addressed by their professional title (49.2%) than were men introduced by men (72.4%) (Files et al. 2017).
3. So how do you advocate for yourself in these situations? “Sometimes, you can make light of it.  But sometimes, you really have to advocate for yourself and correct people. There’s a line because as a female, there are gendered expectations about how people think you should behave. Women should be polite and more acquiescent and not as confident. The challenge is sometimes when you have to cross those lines and advocate for yourself, you pay a likability penalty that men do not pay.” (For more about the likability penalty: Quadlin, 2018;  Heilmen et al., 2004)  
4. And, even more than that, the system and those in leadership roles need to acknowledge this problem, and come up with creative solutions (posting pictures on the walls, faculty directors introducing female residents to staff), to elevate the problem so that it is not a problem you face as often as an individual

Gender Disparities at Different Stages of Training: In 2017, for the first time, women accounted for more than half (50.7%) of incoming U.S. medical students (AAMC 2017). Women are ⅓ of the active physician workforce (AAMC 2016) and 46% of all physicians in training (AAMC 2017)).

1. The gender disparity starts early, and it starts in part because women are not self- advocating as much as men. A recent Annals of Internal Medicine article discussed a disparity in the number of “shout-outs” (to announce publication, or accomplishment) that are self-submitted to residency programs for dissemination, despite equivalent levels of accomplishment between men and women (Rotenstein et al., 2018).  Women are not as comfortable discussing their accomplishments. Women often assume that the system will reward their hard work and accomplishment without their having to actively tell people about these accomplishments. Many women assume that the usual channels of information will carry information to their superiors. And in reality, this often doesn’t happen. Unless people hear from you, they will assume nothing is happening.
2. “Advocate for yourself. Put yourself up. Get the word out.” If you feel awkward about this, says Dr. Arora (as so many women do), establish a group of peers who can help you do this so you don’t have to cross the line of self-promotion. But, especially early in your career, you need to advocate for yourself. (And read the Art of the Brag!). You have to think about yourself as a role model and highlight to people what’s happening in your life, whether over social media, in person, on email, or in a “shout out” forum. Don’t think about what you’re doing as a self-promoting when you share with your family and friends and colleagues–instead, frame it as something that’s important to you and therefore worth sharing with others. This skill is much more widely talked about in Business: the use of your career network and being able to pitch yourself in a short amount of time is a very valuable skill.
3. Of course, it’s more complicated than that, because of the likability toll. Some recent work of Dr. Arora’s gets to the heart of this (Dayal et al., 2017, Mueller et al, 2017). She and her co-authors looked at gender bias within residency training evaluations in Emergency Medicine. Women started ahead of men at time zero when they joined residency. Yet, by year 3, they’re 3-6 months behind in milestone achievement. The only explanation was gender. In the second qualitative study, she found that women were getting incongruous feedback where they were told at one time to be more assertive, but then were told another time to be less assertive/paying a penalty for having taken the lead. Meanwhile, men were given coaching advice, that built upwards in a stepwise fashion (Here’s how you could improve this time). Women were getting these mixed messages from both men and women.  
4. Women pay a likability penalty, from early in training onwards. We know these biases are at play.  On way to overcome this, per Dr. Arora: We [women] need to ask for feedback much earlier, and make sure that the feedback is building on itself and not contradictory from one evaluation to the next.  This is also a faculty development problem. Those in leadership must let evaluators know that in the workplace this is a problem and have them acknowledge their implicit biases.
5. Until we fix trainee evaluations, the pay gap won’t narrow because the system is built against women from early in training onwards.

The Leaky Pipeline Issue:

1. In academia, you need to have a focus or specialty. You will be promoted on the basis of impact in a specific area. Along the way to developing this expertise and this niche, you need mentorship.
2. Unfortunately, promotion and tenure schedules are somewhat inflexible. They happen to overlap with childbearing years.  Many women start families in early faculty days, which can be very stressful and cause burnout unless they have a mentor who can help them to be very strategic about research and things that will help with promotion and get published. Men typically do not have the same pressures, or they have a wife at home who can help with the childcare. People are not talking about this–that women leave the academic workforce because they don’t see as many role models making this happen or talking about the real stresses of the promotional ladder at this time in their lives. The quintessential example: The 5 pm meeting. For most people it’s not an issue. Same with early morning. But after you have kids, it can be very difficult to figure out coverage, when you’re likely already overburdening your childcare options.
3. This is about a cultural shift: Can we make this system work for women who have kids? Because if so, we have a positive culture for everyone. This isn’t just a women’s issue. In today’s dual-career workforce, this is a problem for everyone who supports the family.

The difference between coaching, mentorship, and sponsorship

1. A Mentor is someone responsible for overall career and growth. This is a longitudinal relationship
2. A Coach is someone helping you with one aspect of career (e.g. working together on a poster, discussing how to negotiate first contract). This is more of a one time/time limited relationship
3. A Sponsor is more of a visible leader in your organization who is putting you up for opportunities. They typically have national influence. Women have mixed feelings about sponsorship (The Sponsor Effect): Women feel like sponsorship is getting ahead because of who you know, and believe it will be hard work alone that will advance them. Women wait to be recognized.  
4. Sometimes, your mentor and your sponsor will be the same person. But as you grow in your career, these folks tend to differentiate.  

Advocating for our trainees:

1. In writing letters, be careful with your wording. A pitfall–thinking about general flowery prose–women and men have different words in their letters. Men are confident, leaders. Women are “team players”, they “go with the flow”, they’re “nice”. Try to focus on the objective, and use examples and experiences you witnessed to get rid of implicit bias.
2. How to discuss confidence and speaking up with quieter trainees: Always ask have you heard this before, and what they have tried before if they have gotten this feedback in the past. Sometimes it’s a positional thing (where a student is standing on rounds), sometimes it’s a time thing (giving them unbroken time to talk without anyone interrupting them). The key is to figure out what the core problem is and how to minimize it so that they can do their best.

Dr. Arora’s Take Home Points:

1. Don’t be afraid to be bold. (We want to repeat this one, because it’s so good!)
2. Don’t assume that anyone is your mentor. Have the conversation so that you have a defined mentor who will have your back.
3. Stay in touch with your mentor; don’t fall off the grid. You get out what you put in, so make sure you’re aligned as time goes on so that you can do your best collaborative work together .
4. Don’t put all your eggs in one basket. Your mentor may have one agenda, and you come to have a different one for a particular facet of your career goals. You can diversify your deck by having a coach, a mentor, and a sponsor, with different goals for each.

Goal: Listeners will gain a better understanding of the challenges faced by women in medicine.

Learning objectives:
After listening to this episode listeners will…

1. Recognize that gender disparities widen throughout the length of a woman physician’ career
2. Define mentorship, sponsorship, and coaching
3. Identify that mentorship and sponsorship–or lack thereof–can make or break career trajectories  
4. Understand the importance of self-advocating, and advocating for one’s peers.  
5. Understand that disparities include wage inequity, promotion differences, and significant under-representation in leadership roles.
6. Be activated to engage with the Curbsiders on how we can sponsor one another in order to improve gender parity
7. Be bold!

Disclosures: Dr. Arora reports no disclosures. The Curbsiders report no disclosures.  

Time Stamps

• 00:00 Disclaimer and intro
• 03:15 Guest bio, and one liner
• 05:55 Dr Arora’s Women in medicine moment of awakening
• 11:05 Advice to young women, “Be bold”
• 13:20 Picks of the week
• 16:45 Mistaken identity. Women not recognized as physicians due to appearance
• 22:05 Gender bias starts early in training and why it’s important to shout-out accomplishments
• 31:24 Contracts, promotions and the leaky pipeline
• 38:32 Defining coaches, sponsors, and mentors
• 44:06 How to use your team and shout-out your accomplishments
• 52:04 How to write effective evaluations and letters that avoid gender bias
• 53:55 Take home points
• 57:00 Outro

Links from the show:

1. Vinny Arora’s Twitter
2. WiM chat, 9 pm EST: https://twitter.com/womeninmedchat?lang=en
3. Beyonce’s Flawless and Chimamanda Ngozi Adichie’s TEDx Talk “We Should All Be Feminists”
4. Unbreakable Kimmy Schmidt (TV show) on Netflix
5. Women of Impact Leaders in Health and Healthcare
6. Brag!: The Art of Tooting Your Own Horn without Blowing It (book) by Peggy Klaus
7. Tsugawa, Yusuke, Anupam B. Jena, Jose F. Figueroa, E. John Orav, Daniel M. Blumenthal, and Ashish K. Jha. “Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians.” JAMA internal medicine 177, no. 2 (2017): 206-213.
8. The Confidence Gap
9. Ann Crittenden, “The Price of Motherhood”
10. Jena, Anupam B., Andrew R. Olenski, and Daniel M. Blumenthal. “Sex differences in physician salary in US public medical schools.” JAMA internal medicine 176, no. 9 (2016): 1294-1304.
11. Dr. Paid Less: An Old Title Still Fits Female Physicians. NYT.
12. Files, Julia A., Anita P. Mayer, Marcia G. Ko, Patricia Friedrich, Marjorie Jenkins, Michael J. Bryan, Suneela Vegunta et al. “Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias.” Journal of women’s health 26, no. 5 (2017): 413-419.
13. Quadlin, Natasha. “The Mark of a Woman’s Record: Gender and Academic Performance in Hiring.” American Sociological Review 83, no. 2 (2018): 331-360.
14. Heilman, Madeline E., Aaron S. Wallen, Daniella Fuch, and Melinda M. Tamkins. “Penalties for success: reactions to women who succeed at male gender-typed tasks.” Journal of applied psychology89, no. 3 (2004): 416.
15. U.S. Medical School Applications and Matriculants by School, State of Legal Residence, and Sex, 2017-2018
16. 2016 Physician Specialty Data Report
17. Matriculating Student Questionnaire
18. Rotenstein, Lisa S., Rebecca A. Berman, Joel T. Katz, and Maria A. Yialamas. “Making the Voices of Female Trainees Heard.” Annals of internal medicine (2018).
19. Dayal, Arjun, Daniel M. O’Connor, Usama Qadri, and Vineet M. Arora. “Comparison of male vs female resident milestone evaluations by faculty during emergency medicine residency training.” JAMA internal medicine 177, no. 5 (2017): 651-657.
20. Mueller, Anna S., Tania M. Jenkins, Melissa Osborne, Arjun Dayal, Daniel M. O’Connor, and Vineet M. Arora. “Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis.” Journal of graduate medical education 9, no. 5 (2017): 577-585.
21. The Real Benefit of Finding a Sponsor. HBR.