A Journey Toward Gender Equity in Medicine.

Whereas Elizabeth Blackwell became the first woman physician in the United States in the 1840s, it was not until 1972, because of Title IX, that the United States saw an increase in the number of women matriculating into medical school. Fifty years later, women are a majority of medical students but remain underrepresented in the highest levels of leadership in academic medicine.1Matriculants to U.S. medical schools by race, selected combinations of race/ethnicity and sex, 2016-2017 through 2019-2020.www.aamc.org/system/files/2019-11/2019_FACTS_Table_A-9.pdfDate accessed: April 7, 2022Google Scholar,2Kaatz A. Carnes M. Stuck in the out-group: Jennifer can't grow up, Jane's invisible, and Janet's over the hill.J Womens Health (Larchmt). 2014; 23: 481-484Crossref PubMed Scopus (44) Google Scholar The number of women medical school faculty continues to lag, and issues of gender bias continue to plague the culture of academic medicine.3Newman C. Templeton K. Chin E.L. Inequity and women physicians: time to change millennia of societal beliefs.Perm J. 2020; 24: 1-6Crossref Scopus (9) Google Scholar Health care organizations and societies have sought to reduce gender inequity in medicine with recognition of the necessity of a multitiered approach.4McIlveen-Brown E. Morris J. Lim R. et al.Priority strategies to improve gender equity in Canadian emergency medicine: proceedings from the CAEP 2021 Academic Symposium on leadership.CJEM. 2022; 24: 151-160Crossref PubMed Scopus (4) Google Scholar In 2017, the Mayo Clinic all-staff survey revealed that women physicians and scientists at the Arizona campus had significantly lower scores than of prior years in the perception of safety and candor in the workplace, satisfaction with work, and resources to achieve career goals. Recognizing the gaps between what Mayo Clinic aspires to be as a diverse, equitable, and inclusive medical center and these findings, the Gender Disparities Taskforce (GDT) was commissioned to empower women physicians and scientists with the information and experiences needed to sustain a fulfilling career at Mayo Clinic in Arizona. This report explores the opportunities implemented for improvement of gender equity and inclusion that may serve as a model for other academic medical centers. Small-group listening sessions were convened with invitations to all female physicians and scientists on the Arizona campus. These sessions were part of our commitment to cultivating an inclusive, team-oriented environment to more purposefully converse, engage, and support one another. Leaders in administration and equity, inclusion, and diversity facilitated these sessions. The facilitators were consistent for all sessions to ensure safety and to minimize bias. To be inclusive and to allow flexible participation, the sessions were scheduled during 1 year at different times and campus locations. The facilitators believed it was imperative that the sessions be a safe space for discussion while recording the information accurately. A silent scribe was used to confidentially record themes and the categories within themes. These themes would serve as the basis of planning the actions to drive toward the desired outcomes of closing the gender gaps in satisfaction. The facilitators developed open-ended questions with assistance from human resources and professional development teams. Discussions varied slightly between groups, but 4 questions were answered by all groups:1.Describe what it is like to be a female physician/scientist at Mayo Clinic.2.What does it take to advance here?3.What does it take to be a leader here?4.What is one thing you recommend taking back to leadership for action? Other questions included motivation to come to work, how to reach midcareer physicians and scientists, and what brings you joy in the workplace. Discussions of microaggressions were initiated by the group participants during some sessions and not as leading questions from the facilitators. More than 500 responses were recorded and collated by theme. Based on the response themes, 4 main initiatives were developed: (1) promote academic advancement of women physicians and scientists, (2) develop tools to help women physicians and scientists navigate a complex matrix organization, (3) reduce gender bias in the workplace, and (4) educate women physicians and scientists on how best to advance their careers. Across academic medical institutions, the highest levels of leadership are held by those individuals who have been promoted to full professor and received tenure.5Nocco S.E. Larson A.R. Promotion of women physicians in academic medicine.J Womens Health (Larchmt). 2021; 30: 864-871Crossref PubMed Scopus (21) Google Scholar In 2019, women physicians represented 33.9% of Instructors, 41.5% of Assistant Professors, 27.4% of Associate Professors, and 23% of Professors at Mayo Clinic in Arizona. Whereas academic promotion is a critical component of professional success in academia, the need for mentorship was identified 80 times during the small-group listening sessions. Navigating the academic promotion process was incompletely understood by Mayo Clinic in Arizona’s women physicians and scientists while the recognition of its importance in leadership advancement remained clear. To address this gap, the GDT reviewed the curricula vitae (CVs) of all women physicians and scientists who had not reached Professor, had not been promoted in the last 2 years, and were working more than 0.6 of a full-time equivalent. A total of 153 CVs were evaluated, and based on the published criteria by the Mayo Clinic Academic Advancement and Promotions Committee (AAPC), 78% of women physicians and scientists were of the appropriate rank. The last academic promotion ranged from 2 years to more than 20 years before review. Although peer-reviewed publications are automatically updated in Mayo Clinic CVs, other items require a request for update from the physician or scientist. Some CVs had not been updated in more than 2 decades. The most common reasons cited for lack of CV updates included time limitations and lack of support from their department chair. For those who were close to promotion, the GDT recommended they follow up with their department chair or a member of the AAPC. For those without rank assigned, the GDT directly notified the department chair and female physician or scientist. Organizational structure changes were implemented to sustain these efforts in academic promotions by the consistent appointment of an Associate Chair for Research in each department to assist the Department Chair in monitoring the department members’ CVs regularly. In addition to these interventions, regular biannual interface with the AAPC leadership has been made available for CV review and recommendations. At the conclusion of the interventions of the GDT in 2021, women physicians and scientists had a 33% increase in the academic rank of Instructor (21 to 28), a 17% increase in Assistant Professors (108 to 126), a 16% increase in Associate Professors (32 to 37), and a 7% increase in Professors (28 to 30; Figure 1). For each academic rank, the final total number of faculty in 2021 was calculated as the algebraic sum of the number of faculty in 2019, the new hires in 2021, the 2021 attrition, and the number of faculty promoted to that particular rank. This final number of faculty in 2021 was then used to calculate the percentage increase for that rank and during the time frame from 2019 to 2021. Bias in various forms has led to inequitable treatment in the workplace. Bias against women physicians and scientists has several negative impacts, including slower career advancement, reduced financial remuneration, and psychological challenges of imposter syndrome and burnout.3Newman C. Templeton K. Chin E.L. Inequity and women physicians: time to change millennia of societal beliefs.Perm J. 2020; 24: 1-6Crossref Scopus (9) Google Scholar,6Kumthekar P. Dunbar E.M. Peters K.B. Brastianos P.K. Porter A.B. A broad perspective on evaluating bias in the neuro-oncology workplace.Neuro Oncol. 2021; 23 (489): 498Crossref PubMed Scopus (2) Google Scholar In 1995, in a survey of 1979 faculty from 24 different medical schools, 60% of women believed that gender bias had an impact on their professional advancement.7Carr P.L. Ash A.S. Friedman R.H. et al.Faculty perceptions of gender discrimination and sexual harassment in academic medicine.Ann Intern Med. 2000; 132: 889-896Crossref PubMed Google Scholar Similarly, in 2014, of 1066 women in academic medicine surveyed, 66% reported gender bias having an impact on their careers, including compensation.8Jagsi R. Griffith K.A. Jones R. Perumalswami C.R. Ubel P. Stewart A. Sexual harassment and discrimination experiences of academic medical faculty.JAMA. 2016; 315: 2120-2121Crossref PubMed Scopus (263) Google Scholar Although overt biases, including sexual harassment in health care, have been well documented, the insidious, implicit biases experienced by women physicians and scientists, notably from other women in the health care setting, remain prevalent with less widespread intervention.8Jagsi R. Griffith K.A. Jones R. Perumalswami C.R. Ubel P. Stewart A. Sexual harassment and discrimination experiences of academic medical faculty.JAMA. 2016; 315: 2120-2121Crossref PubMed Scopus (263) Google Scholar, 9Rihal C.S. Baker N.A. Bunkers B.E. et al.Addressing sexual harassment in the #MeToo era: an institutional approach.Mayo Clin Proc. 2020; 95: 749-757Abstract Full Text Full Text PDF PubMed Google Scholar, 10Brucker K. Whitaker N. Morgan Z.S. et al.Exploring gender bias in nursing evaluations of emergency medicine residents.Acad Emerg Med. 2019; 26: 1266-1272Crossref PubMed Scopus (20) Google Scholar Mayo Clinic has led in pay equity through a structured compensation plan,11Hayes S.N. Noseworthy J.H. Farrugia G. A structured compensation plan results in equitable physician compensation: a single-center analysis.Mayo Clin Proc. 2020; 95: 35-43Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar which raised this specific issue less in the listening sessions. Unfortunately, the listening sessions confirmed that Mayo Clinic in Arizona is not immune to issues of perceived gender bias experienced by women physicians from allied health staff (AHS). Common examples that emerged in the listening sessions included being addressed by first name as opposed to professional title and having one’s medical judgment challenged while on call, in the operating room, or on the floor, sometimes in the presence of patients. After approval by the institutional review board, a 19-question survey was developed to understand trends and behavior of AHS toward male and female physicians using a Likert-scaled response. For example, the question was asked, How likely is it to have heard a male physician called by first name by AHS? Answers ranged among 5 responses from “very unlikely” to “very likely” with a “neutral” option. Similarly, the question was asked with the same response options to reflect the likelihood of having heard a female physician called by first name. Responses were received from 434 of 1800 AHS (24%) and 136 of 660 (26%) physicians from November 30 to December 11, 2020, and March 4 to 22, 2021, respectively. The results showed that the perception of female physicians is very different from the perception of male physicians and AHS surveyed. The cultural norm at Mayo Clinic is for physicians to be addressed by their professional title rather than casually by first name. However, a majority (68%) of female physician respondents reported that female physicians were likely to be called by their first name. In contrast, a minority of female physicians (10%) thought this likely to occur to a male physician. The perception of the likelihood that a female provider would be addressed by first name was underestimated by male physicians and AHS in comparison to female physicians (P<.0001), but there was no such difference in the assessment of likelihood that a male physician would be informally addressed. Among male physician respondents, only 28% thought it likely a female physician would be called by her first name and only 10% thought a male physician would be addressed in a casual manner. For AHS respondents (P<.001), only 16% thought a female physician was likely to be addressed by first name and only 22% thought it likely a male physician would be addressed in this way. Both physicians and AHS were more likely to have witnessed inequitable treatment of female physicians than of male physicians by AHS (P<.0001; Figure 2). This survey confirmed that female physicians are having a different experience in the workplace than male physicians and AHS. Efforts for improvement are currently being implemented and include reminders to both physicians and AHS to be consistent in their practice of addressing physicians by professional title in the workplace. Training modules on unconscious bias in the treatment of female physicians for AHS with real examples of bias at Mayo Clinic in Arizona are also in development. Mayo Clinic is committed to the recruitment, retention, and advancement of top talent. In doing so, there is recognition of the challenge or organizational complexity in academic medicine that has disproportionately affected women physicians and scientists as well as colleagues of underrepresented backgrounds.8Jagsi R. Griffith K.A. Jones R. Perumalswami C.R. Ubel P. Stewart A. Sexual harassment and discrimination experiences of academic medical faculty.JAMA. 2016; 315: 2120-2121Crossref PubMed Scopus (263) Google Scholar,12Chukwueke U.N. Vera E. Acquaye A. et al.SNO 2020 diversity survey: defining demographics, racial biases, career success metrics and a path forward for the field of neuro-oncology.Neuro Oncol. 2021; 23: 1845-1858Crossref PubMed Scopus (4) Google Scholar In 2008, the National Institutes of Health reviewed and identified factors that can contribute to the promotion of gender equity in academic medicine: equal access to resources and opportunities, minimizing unconscious gender bias, enhancing work life balance, and leadership engagement.13Westring A. McDonald J.M. Carr P. Grisso J.A. An integrated framework for gender equity in academic medicine.Acad Med. 2016; 91: 1041-1044Crossref PubMed Scopus (65) Google Scholar Navigating a complex matrix organization is difficult. With that in mind, the GDT began a communication campaign to provide answers to the most-asked questions during the listening sessions. These resources were collated and emailed monthly. Ultimately, we developed the gender equity in medicine internal micro-website. Here, resources have been collated to help physicians and scientists navigate Mayo Clinic. On this microsite, the mission of the GDT is shared: to empower women physicians and scientists with the information needed to sustain a fulfilling career at Mayo Clinic. The microsite also lists upcoming events across the institution that were pertinent to the GDT mission and research by Mayo Clinic authors on this topic for education and inspiration. The GDT recognized the need for additional education that was aimed toward career satisfaction and development. The GDT therefore created a speaker series to bring institutional leaders to women physicians and scientists. These talks were entitled Career Development; Navigating a Matrix Organization; Giving and Receiving Feedback and Leading Teams; Financials 101; Negotiation, Communication, and Strategy; and Secrets of My Success, a panel discussion by senior women leaders. Each of these sessions was led by institutional leaders, increasing their accessibility to female stakeholders. Each was recorded and later posted to the gender equity in medicine microsite for additional viewing. During one of the sessions, participants asked for ongoing group coaching about giving and getting feedback. In follow-up, the GDT created three additional group coaching sessions with an executive coach. These coaching sessions were provided at different times during the workday to accommodate the schedules of physicians and scientists in surgical, inpatient, and ambulatory settings. The GDT at Mayo Clinic in Arizona served as a key resource in identifying the specific needs of our Mayo Clinic site in the goal of achieving gender equity in satisfaction, fulfillment, and advancement. This report highlights the major interventions and accomplishments of our GDT, many of which could be implemented at other institutions. The GDT empowered our female physicians and scientists through research, education, and the creation of sustainable resources. Through the listening sessions, group coaching, and speaker series, opportunities for networking, community, and comradery were created with the goal of sustainability. The result of this work reinforces the message that we value our women physicians and scientists and that diversity and belonging are essential components of personal and professional success and well-being. The momentum and impact gained from these efforts will inspire current and future Mayo Clinic staff members and assist others in achieving similar goals.