How gender matters in pediatric resident evaluations

In 2019, for the first time more women than men enrolled in medical schools in the United States, with 50.5% of new students being women. However, as Faculty Research Fellow Jessica Gold pointed out, “equality of numbers does not equal equity” –  gender disparities remain in academic medicine. Despite nearly half of new doctors being women, the percentage of women professors is only a quarter, and the proportion of deanships and department chairs is even less. In addition to this so-called “leaky pipeline” issue, the gender pay gap is troubling. In the field of pediatrics, which has more than 70 percent  female physicians, women receive 20 percent less pay compared to men. So, what are some of the contributing factors to women in academic medicine being under-evaluated, under-compensated and under-recognized? How might we think about and address possible causes for these persistent gender disparities?

In her recent talk to the Clayman Institute Faculty Fellows, Clinical Assistant Professor and Pediatrician Jessica Gold presented a critical study to examine whether there were differences in the language used to evaluate residents (medical trainees) in pediatrics with respect to their genders. As Gold illustrated, based on the medical training system, residents are evaluated by their supervisors and peers at different stages of their medical training in terms of their overall performance and professional activities, such as clinical reasoning and interpersonal skills. These evaluations are then used to identify the progress of the residents--whether or not they can be advanced to the next year of training--and also form the basis for letters of recommendation, which are crucial for residents’ applications to fellowship positions and jobs. Importantly, feedback received through these evaluations also could influence residents’ professional identity formation, their experience of imposter syndrome and their choices about career paths.

Could there be differences in the way residents are evaluated based on their genders? If so, how might that contribute to the gender disparities in academic medicine?

Are there inherently different characteristics that we as pediatricians value compared with surgeons or emergency medicine doctors, for example? I think the answer is yes… how do we actually have equity in our field?

There is a growing body of literature exploring the issue of gender differences in residents’ evaluations. However, the field of pediatrics has not been much studied in this regard. Gold and her team spearhead a qualitative content analysis of three years of evaluation of pediatrics interns (who are first-year residents) at Lucile Packard Children’s Hospital Stanford. Gold and her team demonstrated that women were more likely than their male counterparts to be described to have “soft-skill” traits, such as being “helpful,” “trustworthy”, “hardworking,” “caring” and “enthusiastic.” In contrast, men were more frequently praised for their “intelligence,” “independence,” “preparedness” and “efficiency.” Regarding feedback, Gold found similar results with previous studies where men received more constructive feedback which was specific either to them as individuals or with respect to the specific specialty through which they were rotating. However, women tended to get less actionable and less specific feedback, which was more difficult for them to incorporate.

Gold’s study demonstrates gender differences in the language used to evaluate pediatrics residents. However, many questions still remain unknown. For Gold and her team, they are curious to explore whether there is any relation between the gender of faculty members who are giving evaluations and the differences exhibited in their evaluations of female and male residents. Another urgent question is what can be done to address this issue of gender difference. One possible direction could be to design some devices, such as a gender bias calculator, to assist faculty in writing unbiased evaluations and letters of reference.

Toward the end of her presentation, Gold returned to an intriguing question of gender segregation and medical specialties: are there things that we inherently value differently for different medical specialties, such as between a primary care pediatrician and a cardiothoracic surgeon? To explain, she articulated how in her specialty, pediatrics, top characteristics of residents did not only include clinical skills, but also traits such as being “caring,” “compassionate” and “likable,” which were usually associated with femininity. In contrast, other specialties, like emergency medicine, would more frequently identify “decisiveness,” “confidence” and “leadership,” as the most desirable characteristics for residents. These traits are more likely to be associated with masculinity.

Following this deliberation on gender segregation and medical specialties, we may now ask: how could we build equity in spite of differently valuing variously gendered characteristics for different medical specialties? As many studies have shown, when the percentage of women in a specialty goes up, its average compensation drops. Meanwhile, health care for women and children is reimbursed at a much lower rate than other types of medical care. Clearly, the phenomenon of gender segregation and medical specialties has already generated disparities and inequities in the field of medicine. However, it is not easy to achieve an answer or find a resolution. As Gold reflected, “do we try to quote unbiased language which might involve removing many of the words which are actually positive characteristics which people may more frequently associate with women? Or do we somehow lean into these traits and try to simultaneously change how people understand and define them?” Although Gold may not have an answer yet, by raising questions and initiating discussions about gender segregation and differences, medical specialties and equity, her team is on the way to addressing these challenges.