Early in my first year as a resident, I (Shannon) was treating a young female patient with complex medical issues who had a headache. After talking to and examining her for over an hour, I asked her bedside nurse to administer Tylenol. The nurse replied, “She has to be seen by her doctor before I can give her any medicines.” I asked what other physicians had been consulted on the patient, and the nurse answered, “Just internal medicine.” Confused, I informed her that I was internal medicine. “Oh!” she said, “I thought you were one of the patient’s friends!” I was wearing scrubs, a stethoscope, and a white coat embroidered with my title and name.
Four years later, I led a resuscitation in which I placed an emergency intravenous line into a man’s neck while he vomited blood, directed the team when to start and stop chest compressions, and provided instructions to a room of at least 10 members of the health care team. At the end, the patient’s wife who witnessed the entire event asked me if I was a physiotherapist.
Medicine sees itself as progressive when it comes to gender equity, especially compared to the other STEM fields. Since 1995, the proportion of females admitted to medical schools has been more than 50 percent; it approached 60 percent in 2008. Today, women comprise 41 percent of all Canadian physicians, and outnumber men in the under-45 cohort. But these numbers, along with a payment model that appears to not discriminate by gender, contribute to a false sense of equality in medicine. Shannon’s experience of being mistaken for anyone other than a patient’s doctor—which happens routinely, particularly to women of colour—reflects the fact that women are simply not considered men’s equal in the field. The idea that medicine is above sexism and gender discrimination results in burnout and perpetuates inequity, distracting us from acknowledging and addressing the barriers that continue to exist.
Career growth is an uphill battle for women in medicine
The absence of women in influential positions in medicine is well documented. One study found that there are more men with moustaches than there are women in departmental leadership roles at American medical schools. Presently, only two out of Canada’s 17 medical schools have a female dean.
As medical students and residents, female trainees receive poorer quality feedback that focuses on personality traits rather than demonstrable skills, while their male counterparts receive constructive evaluations on how to improve. A well-accomplished female physician* with a sub-specialty practice and leadership roles in education and research told Shannon about the time a male colleague—whom she had trained—was promoted and she was not. When she asked her boss why she had been passed over for promotion, he told her she “just wasn’t ready” and could not give concrete examples. Another anecdote we heard was from a senior resident, who, after a week of working overnight in her institution’s emergency department, was told by her supervising physician that clinically she was very good, and that the staff never worried about her judgment or medical management, but there was “just something that he couldn’t put his finger on” about her that made her “rough around the edges.” Devastated, the resident repeatedly sought further details on how to improve her performance, but the male staff physician was unable to provide examples or advice. Importantly, the resident had never worked directly with this staff. She had only ever reviewed cases with him over the phone.
A lack of recognition
At a recent Women in Medicine summit hosted at the University of Calgary, a speaker asked the audience who had been unprofessionally introduced when speaking at an event—for example, introductions that excluded professional titles, roles, and expertise. Nearly every female in the room raised her hand. Some women have recounted being introduced according to what they are wearing. Recently, a female colleague received mail from a professional society whose membership is only open to physicians that was addressed to her by the honorific “Ms.” Another story we heard was about a team of female trainees working with a male attending being referred to as a “harem” by another male physician. And this is not just anecdotal. A 2017 study out of the U.S. found that female physicians presenting at grand rounds were less likely to be introduced with their formal credentials than male presenters. The language that we use to describe female physicians matters: Constantly being signalled that you are “different” and less important than a male physician is taxing.
Surprisingly, the gender wage gap remains problematic in medicine. In Canada and the United States, the predominant pay model is “fee-for-service,” in which physicians submit billing codes for every patient that they see or procedure that they perform. Each billing code is assigned a dollar amount for service rendered; male and female physicians should be paid equally for seeing the same patient or performing the same procedure. Despite this standardized payment structure, American data demonstrates that both in academic salaried positions and fee-for-service positions, female physicians earn less than male physicians, even after adjusting for hours worked, choice of specialty, academic productivity, years of experience, practice setting and clinic revenue. It is not clear why there is a wage gap in medicine at all, and yet American data suggest the difference in earnings between female and male physicians is nearly $20,000 per year.
Next steps toward equity
The first step in addressing this inequity is acknowledging that there’s an imbalance, despite our commitment to the idea that things are equal between men and women in medicine. But acknowledgment is not sufficient. Instead of being defensive, we must be productive. We must nominate women for awards and leadership positions, and insist on external or blinded committees in the selections for these honours and roles. We must advocate for implicit bias training (education on diversity, stereotypes and unconscious biases) for faculty members who supervise trainees and who sit on committees for promotion and hiring. We must stop referring to female trainees as “enthusiastic” and “pleasant” in evaluations and instead provide high quality, constructive feedback. We must advocate for changes to the medical school and residency application systems that reduce the opportunity for bias, including removing photographs and blinding applications for name and gender in order to reduce the influence of racial- and gender-based discrimination from the selections process. We must insist upon a standardization of the pathway to promotion in academic medicine to avoid the subjective assessment of “readiness” for promotion that allows discrimination to creep into leadership decisions. We should stop assuming that female doctors who have children are less serious and provide flexibility to meetings and rounds schedules that preclude women with families from attending. We should invite our female colleagues to present at grand rounds or sit on conference panels, and then introduce them according to their titles. We should decline to participate in all-male panels or plenary speeches and recommend a female expert instead. We must call out inequality when we see and hear it.
*The stories included were shared with the authors for this article. Details have been altered to protect the anonymity of all individuals mentioned. The anecdotes are from physicians from different Canadian institutions and from different medical and surgical specialties. The authors believe that gender inequity is a systems issue, not an individual one.
Conflict of Interest
Brown and Ruzycki conducted this work during their free (unpaid) time, and also recognize that female physicians of colour and other visible minorities in medicine face even more hurdles than those described above.