Michelle Romeo, MD Congratulations to Dr. Michelle Romeo for her winning submission to the Essentials of Emergency Medicine Fellowship Blog Competition. Check out her winning blog post on “Equity” below!
Would you believe it if I told you that by having me, a female, as your physician, that you’re statistically more likely to stay out of the hospital and less likely to die in the next 30 days? You may if you recently read an article published in JAMA(1). Now, would you believe that, as a resident, I’m consistently evaluated as inferior and slower to achieve markers of competency compared to my male colleagues, solely, because I’m female?
Gender aside, residency is a driving force in medical education that molds, inspires and drives physicians to become who they are. The centerpiece of this process involves our apprenticeship with attendings. Their teaching, evaluations and feedback are indispensable to our growth through reinforcing our strengths and recognizing our weaknesses. So, if the question I posed to you was true, that men are “rated” higher than female colleagues in a generalized performance of residency (spoiler alert: they are), do you think it would lead to a discrepancy in the molding of female physicians(2)?
I do.
Emergency Medicine adopted the “Milestones” for assessing resident progress throughout training(3). While these should be clear and blind to gender, the reality doesn’t align. A study by Dayal et al. looking at 3 year EM programs found that by graduation, female residents were consistently evaluated lower on all 23 sub-competencies of EM. Based on these evaluations, the authors believed it would take female residents 3-4 more months of training to be considered equal(2).
Hmm, there must be a confounder. Perhaps something before residency explains this discrepancy? Nope. This same study suggested residents were evaluated at a similar level at the beginning of training but assessments quickly widened between sexes(2). Not only did attendings score performance of males higher, but feedback was found to be more concrete. Males were consistently directed on specific agendas, while females were left with discordant feedback; i.e. “She acts as a leader” vs. “She comes across argumentative”(4). Icing the cake, research says focused feedback directly improves future accomplishments(5). Quick recap: I’m considered subpar and I’m not getting dependable feedback. Great.
Somewhere in the back of my mind, the phrase “implicit bias” is screaming. You know, that unconscious bias for gender (race, ethnicity, sexual preference, etc.), or more accurately, the prejudice against one. What is it about me that causes perception of feeble performance? I keep patients alive and out of the hospital! Alas, my sex precludes me from being fairly evaluated on traits that have long been considered masculine, in a field that has long been dominated by men(4).
Let’s hypothesize.
There is abundant evidence of gender gaps in the world of medicine. Women are 50% of medical school graduates yet only compromise 1⁄3 of the workforce. They reduce patient mortality in a statistically significant way but have lower incomes1. Male academic positions far surpass female(4). Female grand round speakers fall below 35%5. Speaking of 35%, it’s the percentage of female EM residents currently. We rank 21st out of 34 specialties with the highest percentages of females(6). Hypothesis: This gap exists due to more than just the tried-and-untrue “women have babies” argument(1). Women are repeatedly subjected to implicit biases throughout training and by later years, are left severely disadvantaged.
What happens when this cycle exists?
Women are deprived from believing they can be leaders in medicine and academia.
Women are systematically rated below male counterparts.
The next generation of young female physicians lack relatable mentors.
What happens is disparity for women in medicine.
How does this cycle break?
Residencies have to take gender bias seriously. Implementing trainings specifically tailored towards confronting it would allow for more inclusivity in departments as a whole1. In addition, mentorship itself plays a strong role in many aspects of career building8. The gender and mentor gaps in medicine should be targeted by actively pairing women together. Or just maybe, we start with awareness. The simple idea of having a conversation and accepting the idea that residency training isn’t perfect, but that with time, recognition and action, change is inevitable.
Equity; the quality of being fair and impartial.
It’s also something that I still have hope for as a female physician.
Please, let’s start talking.
For further reading:
Research: Vague Feedback Is Holding Women Back
Patients Cared For By Female Doctors Fare Better Than Those Treated By Men
Why Female Physicians Achieve Better Outcomes Than Males
Should You Choose a Female Doctor?
Resources:
1. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA Intern Med.2017;177(2):206–213. doi:10.1001/jamainternmed.2016.7875
2. Dayal A, O’Connor DM, Qadri U, Arora VM. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training. JAMA Intern Med. 2017;177(5):651-657.
3. Emergency Medicine Milestones.
4. Mueller AS, Jenkins TM, Osborne M, Dayal A, O’Connor DM, Arora VM. Gender Differences in Attending Physicians’ Feedback to Residents: A Qualitative Analysis. J Grad Med Educ. 2017;9(5):577-585.
5. Boiko JR, Anderson AJM, Gordon RA. Representation of Women Among Academic Grand Rounds Speakers. JAMA Intern Med. 2017;177(5):722-724.
6. ACGME Data Resource Book, 2017-2018.
7. Levine RB, Mechaber HF, Reddy ST, Cayea D, Harrison RA. “A good career choice for women”: female medical students’ mentoring experiences: a multi-institutional qualitative study. Acad Med. 2013;88(4):527-534
8. Correll S, Simard C. Research: vague feedback is holding women back. Harvard Business Review. April 29, 2016. Accessed August 3, 2017.
In spite of a male dominated workforce, I do think things may be on their way to changing. More females than males entered medical school in 2017 according to the Association of American Medical Colleges (see https://news.aamc.org/press-releases/article/applicant-enrollment-2017/). I see opportunities in the future! Maybe these women, like yourself, can shift the paradigm and create your own, and perhaps improved, feedback to residents of all walks of life. There is the problem of women not always being solid supporters of other women, but people like you can be a catalyst for change in a more complicated world.
Love your blog!