#225 Women in Medicine: COVID Edition

July 16, 2020 | By Leah Witt

Pro Tips for Life & Career Success in the Midst of a Pandemic

Listen as our expert guests, Kelly Graham, MD, MPH (@KellyGrahamMD) and Lekshmi Santhosh, MD MAEd (@LekshmiMD), detail the professional and personal challenges faced by women in medicine during the COVID-19 pandemic.

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Credits

Produced by: Leah Witt MD & Shreya Trivedi MD 

Written by: Molly Heublein MD, Isabel Valdez PA-C, Leah Witt MD & Shreya Trivedi MD

Infographic & Cover Art: Edison Jyang

Hosts: Leah Witt MD & Shreya Trivedi MD, Justin Berk MD, MPH, MBA

Editor: Molly Heublein MD and Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Guests: Kelly Graham, MD, MPH; Lekshmi Santhosh, MD MAEd

Sponsor

We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for more information.

Time Stamps

• 0:00 Intro, disclaimer
• 2:04 Introduction and bio for Kelly Graham, MD, MPH
• 2:30 Introduction and bio for Lekshmi Santhosh, MD MAEd
• 3:54 One-liner for Kelly Graham, MD, MPH
• 4:41 One-liner for Lekshmi Santhosh, MD MAEd
• 5:12 Gender Awakening Moments
• 10:08 Advice to their younger selves
• 13:15 Picks of the Week*
• 18:02 Case from Kashlak: Dr. Blackwell
• 20:10 Difficulty with lack of childcare while working
• 22:52 Hippocratic Oath paradox
• 26:02 Physician, educator, researcher, household manager & zoom homeschool teacher
• 27:14 Dr. Santhosh’s 3 Ps
• 28:08 Motherhood penalty-fatherhood bonus
• 32:00 Emotional Labor
• 35:10 Two Pandemics, One Response 
• 36:25 Breadwinner-homemaker bias
• 39:34 Impact of pandemic on women physician productivity
• 39:58 Female physician burnout
• 41:38 Minority Tax
• 48:03 Silver Linings
• 55:35 Suggestions for addressing pandemic-related inequity
• 67:10 COVID contributions on CV
• 68:50 Take home points and Outro

Women in Medicine: COVID Edition Pearls

1. The COVID-19 pandemic is exacerbating gender inequities (e.g. caregiving responsibilities, manels, differences in publication rates, and burnout)
2. The keys for success in these challenging times are: institutional support, flexibility in your schedule, and gender equity at home.  
3. In responding to work challenges during the pandemic, institutions should listen to employees about challenges that they have faced and brainstorm around the key pain points such as child care for essential front-line workers.

The COVID-19 pandemic is creating a double double shift for women and exacerbating gender inequity.

• Atlantic: The Coronavirus Is a Disaster for Feminism
• NYT: When Mom’s Zoom is the One to Wait
• Nature: The pandemic and the female academic
• Fortune: Sheryl Sandberg: The coronavirus pandemic is creating a ‘double double shift’ for women. Employers must help)

The silence is deafening: caring for our families while caring for our patients

Dr. Graham: Caring for children at home while also working on the front lines during  the COVID-19 pandemic is exceedingly difficult.  There is little national dialogue around this challenge– there has been silence regarding the practicalities of being an essential worker while having unreliable and difficult-to-find childcare.

The Hippocratic Oath neglects any call to protect the families of health care providers (we need a rewrite with the perspectives of women physicians!).  In order to do our best, we need support in caring for our own families.

“If we had been there writing it, we would have said something about the fact that we need to take care of each other and our families so that we can go and do this high-risk work.” 

(Do we need a new “Blackwell Oath”?)

Physician, educator, researcher, household manager & zoom homeschool teacher

Dr. Santhosh: Let go of mom-guilt!  Women overwhelmingly bear the burden of caregiving for relatives/children/partners with illnesses, and carry many additional roles beyond clinician, researcher, teacher. In addition, women are often household managers, childcare coordinators, and now home-school teachers (Caregiving in the US).  This creates a significant mental load (emotional labor). 

Emotional labor =  invisible cognitive decisions that women mentally juggle at all times such as the microtasks of maintaining a home and family.  (Dr. Graham’s example– it’s the fact that she knows exactly when her children’s socks need to be replaced).

Dr. Graham: Name the labor! Writing down mental load tasks and sharing these with your partner can help name your workload and perhaps you can work toward a re-distribution. Look into Fair Play by Eve Rodsky to use on your next date night.

Dr. Santhosh’s 3 Ps: 

Partners: Women disproportionately shoulder the burden of organizing the household.  Motherhood penalty, fatherhood bonus: Women often suffer a loss of pay after childbirth, while men often experience a “halo effect” and a subsequent pay raise (NYT 2014, EconLife 2018) 

Patients: Women are disproportionately in the clinician-educator roles in academic medicine (Science 2014). The clinical burden of the pandemic is falling on this exact group and women are being asked to care for more patients, and in some locations taking pay cuts and losing jobs.

Panels:  In the COVID-19 crisis, the “man-el” (“expert” panels of mostly senior, often Caucasian, and all-male faculty members) has had a resurgence, as leaders may be relying on old models of expertise. The cure? Think of all who would be qualified to speak and would create a diverse group, then ask who would appreciate the opportunity to participate. Manels prominently highlight men as experts, and neglect the significant work women are often doing “behind the scenes”.

The Exacerbation of Inequity During COVID-19

• Two pandemics, one response (CDC 2020):  The additional pandemics of structural racism and gender bias are centuries old.  The COVID-19 crisis highlights these inequities– minorities suffer more from the economic and health consequences of this pandemic (Price-Haywood et al. NEJM 2020). Women bear much more of the caregiving responsibility (and economic consequences) of changing work and school schedules (NYT 2020).

• Breadwinner- homemaker bias:  Most of the structures that we operate in our society come with an implicit bias that there is someone managing the home full-time while someone is at work full-time (this framework is outdated, inequitable and not even economically sustainable in most cities). You won’t be able to unsee this bias once you’ve seen it: it’s why the school day ends at 2:50pm and the national conversation centers on people returning to work without a conversation about schools or daycare reopening (NYT 2020).  Because of this bias, the childcare structure in the US was never designed to give women a successful launch into the workplace, and this pandemic is uncovering the very thin margins of this structure.

• Publication bias during the pandemic: Because of lack of childcare, even senior women scientists have had difficulty prioritizing academic productivity. This has resulted in fewer women first author publications during the pandemic than male first authors (Andersen et al 2020). The research productivity of early-career women has been affected in particular.

• Female physician burnout: Women are more likely to experience burnout and suicidality (Schernhammer et al 2004, Templeton et al 2019).. This is a particular risk for women with intersectional identities, at risk of experiencing the minority tax. We are enough!  Take time for self care.

• Minority Tax: physicians and scientists burdened by bias (e.g. people of color and women) are being pulled into institutional initiatives to run town halls, write policies around inclusivity, and come up with solutions to the very problems that disproportionately impact them (Nature 2020). Assuming women and people of color should be the face of an institution’s efforts further exacerbates burnout. Call to action: institutions should take a proactive instead of reactionary approach, and consider the tax on people being asked to serve in these initiatives. Don’t assume when making decisions for other people and ask people what works for them.

Are there any silver linings to the change in work during the pandemic?

Quarantine has changed us — and it’s not all bad (Vox 2020)

Dr. Graham: The pandemic has encouraged telehealth and video conferencing–these are essential for working parents because they reduce commute and allow flexibility for childcare. More broadly, Dr. Graham sees a few keys to success in medicine:

1. Flexibility: Control over your schedule is paramount
2. Institutional trust: value of your productivity rather than face time bias 
3. Gender equity in the home: (particularly if you are in a heterosexual relationship–data shows homosexual relationships have more equity in home duties).

Dr. Santhosh: Another silver lining– be more clear and firm with boundaries: “no, I can’t make that meeting on Friday, that is the day I am responsible to care for my children”.  During the pandemic, there is a shared acknowledgment that we are all in this together. 

When the second wave comes, how can institutions (and society) do better?

• Institutions should take a time-out and reflect with employees about what the challenges were, in order to problem solve together. This dialogue would help employees feel seen and treat the shame that can come from feeling invisible.
• Hospitals could increase availability of emergency child care.  For example, physicians are pooling resources to create nanny shares– perhaps this is something that employers/health systems could help with.
• Health systems could consider how can we make our MAs/clinical staff work in a telehealth environment
• Innovate!
  • Virtual hospitalist shifts (e.g. Cornell). 
  • COVID contributions on your CV- explain the extra duties on (Vineet Arora, Shikha Jain, Avital O’Glasser, & Charlie Wray. Covid19 Contributions On A Professional CV. 2020).

Take homes:

• Women bear the disproportionate caregiving burden, and the COVID-19 pandemic has further exacerbated this inequality.
• At a structural/institutional level, we should ask what people can or want to participate in rather than making assumptions. 
• Do what you love, follow your heart and make your decisions result in a career that brings you joy
• The keys for success in medicine during these challenging times are: institutional support, flexibility in your schedule, and gender equity at home.  

Links*

1. Dr. Santhosh’s recently published McSweeney’s piece: “THANKS FOR ASSUMING I’M NOT THE FACULTY AND THAT MY FACULTY IS MALE”: TEXTS FROM FOUR WOMEN ICU PHYSICIANS ACROSS THE COUNTRY CARING FOR COVID PATIENTS”
2. Leah’s pick of the week: Paint by Sticker book 
3. Shreya’s pick of the week: Dr. Giselle Corbie-Smith A Different Kind of Leader podcast
4. Justin’s pick of the week: 13th movie
5. Kelly’s pick of the week: When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics (Journal of Hospital Medicine) by Dr. Kimberly Manning,  Conan O’Brien Needs a Friend podcast.
6. Lekshmi’s pick of the week: The Nocturnists podcast and Smitten ice cream delivery

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Discuss how the new challenges of COVID and working from home mean that women are often doing extra double duty         

Learning objectives

After listening to this episode listeners will…

1. Discuss the impact of COVID-19 on the workload and productivity of women in medicine
2. Anticipate the long-term implications that this pandemic will have on gender inequity
3. Recognize areas where medicine may improve to promote gender equity when the second wave hits

Disclosures

Kelly Graham, MD, MPH and Lekshmi Santhosh, MD MAEd report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Graham K, Santhosh L, Trivedi S, Berk J, Witt L, Valdez I, Heublein M, Watto MF. “#225 Women in Medicine: COVID Edition”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. Original air date: July 16, 2020.