When I was applying to medical school, there was a sense of optimism about progress towards gender equity in medicine. The percentage of women in medical school had been gradually increasing, and there were rumors that a few medical schools were on the verge of having entering classes with 50 percent women. While there were very few women at the highest ranks of medicine, the pipeline was filling rapidly, and we believed parity would arrive with time. (I should note gender is a social, non-binary construct. The data on career advancement, however, are often collected using a binary framework, which I use here for consistency.)
More than two decades later, gender equity in medicine has proven to be elusive. Women now represent 51 percent of medical school applicants and 48 percent of graduates. Yet numerous barriers to advancement in academic medicine collectively force women out, resulting in the so-called “leaky” pipeline. Compared to men, women experience higher rates of gender bias and sexual harassment. Whether we look at promotions,leadership roles, authorship, endowed chairs or conference invitations, women have fewer opportunities than men. And despite providing excellent medical care, women physicians continue to be undercompensated compared to men, even after adjusting for specialty, academic rank, academic productivity and work hours. Intersectionality further exacerbates these trends for women belonging to groups underrepresented in medicine.
Now the disruptions brought about by the COVID-19 pandemic have the potential to amplify disparities in academics. In my roles as vice chair of basic science and co-director of the Translational Investigator Program in the Department of Medicine at the Stanford University School of Medicine, my priorities center on the recruitment, mentorship and support of physician scientists at all career stages. I worry that without interventions to mitigate the impacts of the pandemic, there will be lasting detrimental effects on diversity, equity and inclusion in academic medicine.
At the start of the pandemic, widespread closures around the world shifted childcare and schooling abruptly home to parents. In her remarkable book Invisible Women: Data Bias in a World Designed for Men, Caroline Criado Perez details how, even in the absence of a pandemic, women perform the vast majority of unpaid labor – such as childcare and domestic chores – around the globe. Not surprisingly, women have continued to bear the brunt of these duties as well during the pandemic. In an October 2020 survey of women in academia, the National Academies of Science, Engineering and Medicine found the most common negative impacts of the pandemic were increased workload (reported by 27.8 percent of respondents) and decreased productivity (reported by 25.4% of respondents).
These challenges have also affected faculty at Stanford. The Stanford Faculty Women’s Forum (FWF) surveyed all women faculty as well as male faculty with dependents on health insurance. Among faculty with dependents, 50 percent of women faculty compared to 33 percent of men faculty reported spending more than four additional hours of caregiving per day compared to before the pandemic, translating into less time available for professional endeavors.
If unchecked, the disproportionate effects of the pandemic on academic productivity among women physicians could further exacerbate disparities and burnout in medicine.
Other pandemic-related demands at work have also disproportionately impacted academic productivity for women. Women faculty already spend more time on campus service, student advising and teaching, and less time on research, than men faculty. During the pandemic, the FWF survey found that women faculty at Stanford were spending more time than men faculty on advising, mentoring and service. Together all of these factors yield less academic time for women, especially for those with younger children. This is reflected in a decline in women’s authorship on preprints and manuscript submissions during the pandemic, and on COVID-19 publications in the medical literature, the Lancet, and high-impact cardiology journals.
Prior to the pandemic, sustained efforts to enhance gender equity across the university have yielded impressive results thus far at Stanford, where more than 40 percent of department chairs in the School of Medicine are women. In the Department of Medicine, the commitment to diversity and inclusion is evident in leadership appointments, equitable compensation policies and funding to support programs and research.
Early in the pandemic, department leadership sought to identify a metric by which to monitor for disproportionate impacts on women faculty. Publications can be a lagging indicator, reflecting work done months or even years earlier. Therefore, we instead focused on grant and funding proposal submissions, reasoning that if women faculty had less available time for research, they would submit fewer proposals. And indeed, the number of proposal submissions by Department of Medicine faculty during the first 12 months of the pandemic increased by almost 20 percent over the two previous years for men but decreased slightly for women.
This is our opportunity to recognize the barriers to gender equity in academic medicine and how they have been magnified during the pandemic and to institute meaningful changes.
If unchecked, the disproportionate effects of the pandemic on academic productivity among women physicians could further exacerbate disparities and burnout in medicine. The effects of the pandemic could jeopardize the careers of trainees hoping to become junior faculty. Prior to the pandemic, 22.6 percent of women physicians (compared to 3.6 percent of men physicians) were no longer working full time within six years of completing clinical training, and that proportion was even higher among women with children.
Those who are now at the start of their careers are particularly susceptible to pandemic impacts on academic productivity coinciding with intense pressure to generate publications and funding. Compounding this, many have struggled to find jobs due to faculty searches being paused or cancelled by universities due to financial uncertainties. For those at mid-career, the barriers to promotion and advancement into leadership ranks already contribute to the “invisibility” of mid-career women. The risks are especially high for women belonging to minority groups underrepresented in medicine, who are already more likely to leave academic medicine.
What can be done to mitigate the effects of the COVID-19 pandemic on women in academic medicine? Several months into the pandemic, the Department of Medicine held listening groups with women assistant and associate professors. We heard about challenges at work – grants drained to pay for salaries despite stoppage of work during the early months of lockdown, increased competition for funding, increased time spent on clinical duties and mentoring/supporting trainees, and staffing issues due to international travel and immigration restrictions. We also heard about challenges at home – lack of accessible and affordable quality childcare, financial stresses from job losses, and competing demands of caregiving and online schooling. Most importantly, we heard about potential solutions – flexible funding that could be used for caregiving, tutoring or housework; increased administrative support for writing manuscripts and submitting funding applications; and increased awareness among promotion and tenure committees of the disproportionate impact of the pandemic on women.
The inequities highlighted by the pandemic have given us the opportunity to think critically about the status quo. This is our opportunity to recognize the barriers to gender equity in academic medicine and how they have been magnified during the pandemic and to institute meaningful changes. Although solutions will be institution-specific, potential actions include monitoring pandemic impact on productivity by gender, setting aside (or raising) funds to support caregivers, encouraging COVID-19 impact statements on CVs, and ensuring the inclusion of women on research teams.
Concordance of patients and their providers with respect to gender and race/ethnicity has been linked to improved patient satisfaction, adherence and health outcomes, so retaining women in medicine directly benefits patients. We simply cannot afford to lose the skills and talent of half of our physician workforce. We must act now.
Joy Wu, MD, PhD, is an associate professor of medicine (endocrinology) and vice chair of basic and translational science in the Department of Medicine.