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    Tehreem Rehman
    Tehreem Rehman, MD, MPH

    Emergency physician leaders have a role to play in addressing sexism in the workplace and avoiding the pitfalls when caring for female patients in the ED. Sexism adversely impacts female physicians and those in training, requiring guidance on individual and system-level interventions to mitigate these adverse impacts on physician burnout and patient care.

    Role of sex and gender in patient experience

    Disparities in care delivery

    Significant disparities in care of women continue to exist, such as with respect to pain management, diabetes care, and treatment of acute coronary syndrome. Gender disparities in pain management could be partially attributed to the stereotypic view of women over reporting or exaggerating their pain symptoms.1

    Within diabetes care, “women with type 1 diabetes have a 40% higher excess risk of premature death than men with the disease, and those individuals with type 2 diabetes have up to 27% higher excess risk of stroke and 44% higher excess risk of coronary heart disease.” There is concern that “many drugs used in patients with diabetes have different adverse effects in men versus women — particularly for outcomes such as fractures and urinary tract and genital infections — which might affect adherence, yet guidelines rarely offer sex-specific recommendations on treatment.”2

    With respect to management of cardiac risk factors, there are known sex differences in the prescription of cardiovascular medications among patients at high risk or with established cardiovascular disease in primary care such as with women less likely to be prescribed aspirin, statins and ACE inhibitors compared to men.3 Researchers have also found that women found to have a STEMI have higher mortality rates than men with results suggesting “Sex difference in mortality following STEMI persists and appears to be driven by prehospital delays in hospital presentation. Women appear to be more vulnerable to prolonged untreated ischemia.”4

    Patient-physician gender discordance

    Patient-physician gender discordance can exacerbate these disparities. For instance, one study demonstrated higher mortality among female patients admitted to the hospital with a heart attack when treated by a male physician. At the same time, authors of this study also noted that “male physicians with more exposure to female patients and female physicians have more success treating female patients.”5 On the other hand, patient-physician gender concordance may equate to better health outcomes for female patients. According to one study, “elderly hospitalized patients treated by female internists have lower mortality and readmissions compared with those cared for by male internists.”6 Such findings have implications about assessing potential gender differences in practice patterns and the merits of behaviors that may not traditionally be rewarded in a male-centric work environment. Growing research shows that female doctors spend more time with patients during consultations, which may equate to improved communication, trust and care experience.7 Efficiency of course is a balancing measure that operations leaders must consider, such as with longer consultation times improving patient experience but potentially reducing revenue through fewer consultations.

    Bias in patient satisfaction

    Despite evidence suggesting that patient-physician gender concordance benefits female patients, it may inadvertently penalize female physicians. A recent study found that while female patients were more likely to choose a female physician, women who chose a female physician were the least satisfied.8 Conversely, male patients of female physicians were the most satisfied. One reason for these results may be heightened expectations of gendered stereotypical behavior such as “warmth” or “compassion” by female patients choosing female physicians, which in turn leads to a greater risk for dissatisfaction. Such gendered expectations may explain other disparities such as female physicians consistently receiving worse online reviews compared to male physicians even after adjusting for specialty.9 Additionally, patients still disproportionately misattribute female physicians to nursing or other staff, which may impact their perception of the care they received as well.

    Challenges faced by female physicians

    Underrepresentation in leadership roles

    Despite growing numbers of women in medical school, female physicians remain underrepresented in leadership roles. A recent study in JAMA pointed out how “the proportion of women at the rank of full professor in U.S. medical schools has not increased since 1980 and remains below that of men.” Authors of the study found that female academic physicians in the United States were significantly less likely to be full professors compared to male physicians, even after adjusting for age, experience, specialty and measures of research productivity.10 Intentional development of female physician leaders leads to greater institutional gender equity. There is evidence that “an academic EM department was more likely to have a higher proportion of female faculty and a female residency program director when the department chairperson was female.”11

    Persistent unequal compensation

    Within academic emergency medicine, Dr. Wiler and team discovered that, “Female physicians hold fewer leadership roles. … and when they do, they work more clinical hours and are paid less than male physicians.”12 Dr. Wiler’s research also found that an unacceptable gender salary gap has remained unchanged in emergency medicine for several years.13 In addition to investment in leadership development for female physicians, emergency departments will need to actively call out institutionalized sexism in medicine and its impact on internalized bias among emergency physicians. Evidence suggests that such gender bias among emergency physicians is present as early as during residency, with one study demonstrating emergency medicine residents are negatively biased against women in positions of leadership.14 Such bias likely informs persistent gender disparities in leadership and compensation in emergency medicine.

    Unique work demands and unacceptable risks

    Implicit and explicit gender biases influence the unique work demands and unacceptable risks experienced by female emergency physicians. This disproportionately affects the work-life balance and mental well-being of women in emergency medicine. For example, female emergency physicians are not immune to problematic gendered norms on household work. A recent study found that married female physicians spend more than 100 minutes per day on household chores and childcare compared to male physicians.15 This gendered imbalance in household work remains even after adjusting for each spouse’s expected work hours outside the home. At work itself, female physicians experience unique stressors, such as those related to barriers to breastfeeding during work or the heightened adverse health effects of night shifts during pregnancy.

    Female emergency physicians are also at greater risk of experiencing trauma at work through sexual harassment and assault. A recent study involving women in academic emergency medicine across eight different institutions found that 68.4% of women experienced gender discrimination and almost one of out every 10 female emergency physicians reported at least one encounter of sexual assault by a colleague or supervisor during their career.16 Greater work environment demands, and egregious risk of violence may partially explain why female emergency physicians have disproportionately left clinical practice over the past decade. We have yet to see the downstream effects of the COVID-19 pandemic on women in the workforce with gender disparities in emergency medicine likely to worsen in the next few years unless institutions invest in policy and system redesign advancing gender equity.

    Adverse impact of sexism on learners

    Bias in evaluations impede training potential

    Assessments and feedback are intrinsic components of physician training, but there is now compelling evidence of significant gender disparities in evaluations of medical students and residents. One study found that although male and female trainees receive similar evaluations at the beginning of emergency medicine residency, “the rate of milestone attainment throughout training was higher for male than female residents … leading to a gender gap in evaluations that continues until graduation.”17 Another study found that female emergency medicine residents received more discordant feedback compared to their male counterparts, especially with respect to conventionally masculine traits such as autonomy and assertiveness. The authors go on to stress that female residents disproportionately receiving inconsistent feedback renders them more vulnerable to “poorer-quality mentoring and instruction” thus hurting their ability to progress and improve clinical performance.18

    Bias in evaluations is seen before residency, impacting medical students as well. In a standardized patient interaction exam, “female medical students were viewed as significantly less confident than male medical students.”19 Female medical students are also more likely to receive evaluations with descriptors such as “caring” and “empathetic” concentrated under the “compassion” skill-domain as opposed to the “ability” and “grindstone” skill-domains in which female medical residents were most frequently described as “bright” or “organized.”20

    Diminished psychological safety in teamwork

    There is also evidence demonstrating gender disparities in evaluations of EM residents by non-physician colleagues, such as nurses. Even when there is a lack of difference in ability or competence as measured by in-service exam scores and milestone evaluations, nurses evaluate female residents lower in their abilities and work ethic compared to male residents.21 Having crucial partners of your care team, such as nurses, judge you more harshly because of your gender naturally leads to a diminished perception of psychological safety at work. This has significant quality and safety implications when working in a fast-paced and dynamic healthcare setting, particularly the ED. Additionally, exhibiting effective leadership during medical resuscitations is a vital component of being a successful emergency physician. Despite assertiveness being deemed an ideal code leader behavior trait, female residents report greater discomfort and stress with adopting assertive behavior compared to their male counterparts.22

    Increased risk for burnout and depression

    Greater stress and lower psychological safety can hurt well-being and self-confidence while increased exposure to gender-based discrimination and violence incurs trauma. This all contributes to higher rates of burnout among female physicians.23 Unsurprisingly, female physicians are more likely to experience depressive symptoms although preliminary evidence suggests that this disparity can partially be alleviated by reducing work-family conflict that stems from gendered societal norms and power dynamics.24

    Recommended next steps

    Sexism continues to permeate the field of emergency medicine, and it is incumbent upon everyone, especially those involved with operations and systems design, to address sexism head on.

    Allyship and being an upstander

    First, all emergency physicians can and should engage in allyship. You can achieve this through seemingly small but powerful acts such as intentionally referring to female colleges as “doctor” to mitigate any micro aggressions against them or by elevating a suggestion that a female colleague makes in a meeting. However, allyship does not end there and compels you to act as an upstander when female physicians are significantly more likely than male physicians to “encounter rudeness, be dismissed [and] face issues with procurement of supplies” as noted in Dr. Michelle Suh’s presentation at the American College of Emergency Physicians conference.25 Department leaders can also leverage data analytics and visualization through dashboards to explicitly call out gender disparities in wages, shifts, and membership in paid versus unpaid committees.

    Mentorship and sponsorship

    Mentorship and sponsorship are other vehicles to address sexism in emergency medicine, by supporting the career development of women and help close that persistent “leaky pipeline” in leadership. Mentorship can entail providing guidance on knowledge and skills such as negotiation, networking, communication, team dynamics and the promotions process.26 Meanwhile, sponsorship can involve thoughtfully nominating women for leadership roles and other promotions. Sponsorship can be effectively institutionalized “by following a standardized process grounded in leadership characteristics and competencies “that has been shown to increase numbers of women and racial/ethnic minority leaders.” Such standardized processes enable medical institutions to “see changes in their leadership that mirror the populations they lead and serve.”27

    Policy reform and system redesign

    To maximize impact of efforts to counter sexism in emergency medicine, it is imperative as Dr. Carnes and team point out “to move beyond ‘fixing the women’ to a systemic, institutional approach that acknowledges and addresses the impact of unconscious, gender-linked biases that devalue and marginalize women and issues associated with women, such as their health.”28 In a recent Society for Academic Emergency Medicine (SAEM) publication, Dr. Agrawal and her co-authors delineate strategies for recruitment, retention, and promotion of women in EM. These strategies include necessary policy reform and system redesign.29

    For instance, in response to literature showing “that working nights or on call can lead to pregnancy complications” and that “infant-parent bonding in the postpartum period is crucial for breastfeeding, health, and well-being,” Dr. Chernoby and team developed a new policy for scheduling pregnant and new parents in EM residency that proved to be feasible to implement while improving trainee satisfaction and reducing risk for adverse pregnancy outcomes.30 Other similar interventions include providing six to eight weeks of parental leave and ensuring easy access to private and comfortable lactation accommodations at work.

    There is also a need for greater transparency and accountability in reporting mechanisms of gender-based discrimination and violence in the workplace.31 Additionally, it is imperative that EM leaders proactively counter the impact of bias in patient interactions and patient satisfaction measures that disproportionately hurt women.32 One low-cost intervention is the use of role identity badges with clear demarcation of doctor “to reduce role misidentification and address burnout” among female physicians.32 Moving forward, it is paramount that emergency medicine leaders, especially those involved with clinical operations, implement targeted interventions to promote female leadership, as well as psychological and physical safety at work.

    MGMA and CAHME

    This article was one of two finalists in the winter 2022 call for papers around diversity, equity, and inclusion (DEI) and health equity, sponsored by MGMA and the Commission on Accreditation of Healthcare Management Education (CAHME). To learn more about MGMA student memberships for individuals enrolled in CAHME-accredited programs of study, visit mgma.com/cahme.

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    Notes:

    1. Wesolowicz DM, Clark JF, Boissoneault J, Robinson ME. The roles of gender and profession on gender role expectations of pain in health care professionals. J Pain Res. 2018 Jun 15;11:1121-1128. doi: 10.2147/JPR.S162123.
    2. The Lancet Diabetes Endocrinology. “Sex disparities in diabetes: bridging the gap.” Lancet Diabetes Endocrinol. 2017 Nov;5(11):839. doi: 10.1016/S2213-8587(17)30336-4.
    3. Zhao M, Woodward M, Vaartjes I, Millett ERC, Klipstein-Grobusch K, Hyun K, Carcel C, Peters SAE. “Sex Differences in Cardiovascular Medication Prescription in Primary Care: A Systematic Review and Meta-Analysis.” J Am Heart Assoc. 2020 Jun 2;9(11):e014742. doi: 10.1161/JAHA.119.014742.
    4. Bugiardini R, Ricci B, Cenko E, Vasiljevic Z, Kedev S, Davidovic G, Zdravkovic M, Miličić D, Dilic M, Manfrini O, Koller A, Badimon L. “Delayed Care and Mortality Among Women and Men With Myocardial Infarction.” J Am Heart Assoc. 2017 Aug 21;6(8):e005968. doi: 10.1161/JAHA.117.005968.
    5. Greenwood BN, Carnahan S, Huang L. “Patient-physician gender concordance and increased mortality among female heart attack patients.” Proc Natl Acad Sci U S A. 2018 Aug 21;115(34):8569-8574. doi: 10.1073/pnas.1800097115.
    6. 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 Feb 1;177(2):206-213. doi: 10.1001/jamainternmed.2016.7875.
    7. Jefferson L, Bloor K, Birks Y, Hewitt C, Bland M. “Effect of physicians’ gender on communication and consultation length: a systematic review and meta-analysis.” J Health Serv Res Policy. 2013 Oct;18(4):242-8. doi: 10.1177/1355819613486465.
    8. Schmittdiel J, Grumbach K, Selby JV, Quesenberry CP Jr. “Effect of physician and patient gender concordance on patient satisfaction and preventive care practices.” J Gen Intern Med. 2000 Nov;15(11):761-9. doi: 10.1046/j.1525-1497.2000.91156.x.
    9. Thawani A, Paul MJ, Sarkar U, Wallace BC. “Are Online Reviews of Physicians Biased Against Female Providers?” Proceedings of the 4th Machine Learning for Healthcare Conference. PMLR.106:406-423, 2019.
    10. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. “Sex Differences in Academic Rank in US Medical Schools in 2014.” JAMA. 2015 Sep 15;314(11):1149-58. doi: 10.1001/jama.2015.10680.
    11. Cheng D, Promes S, Clem K, Shah A, Pietrobon R. “Chairperson and faculty gender in academic emergency medicine departments.” Acad Emerg Med. 2006 Aug;13(8):904-6. doi: 10.1197/j.aem.2006.01.025.
    12. Wiler JL, Rounds K, McGowan B, Baird J. “Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians.” Acad Emerg Med. 2019 Mar;26(3):286-292. doi: 10.1111/acem.13694.
    13. Wiler JL, Wendel SK, Rounds K, McGowan B, Baird J. “Salary disparities based on gender in academic emergency medicine leadership.” Acad Emerg Med. 2022 Mar;29(3):286-293. doi: 10.1111/acem.14404.
    14. Hansen M, Schoonover A, Skarica B, Harrod T, Bahr N, Guise JM. “Implicit gender bias among US resident physicians.” BMC Med Educ. 2019 Oct 29;19(1):396. doi: 10.1186/s12909-019-1818-1. PMID: 31660944; PMCID: PMC6819402.
    15. Ly DP, Jena AB. “Sex Differences in Time Spent on Household Activities and Care of Children Among US Physicians, 2003-2016.” Mayo Clin Proc. 2018 Oct;93(10):1484-1487. doi: 10.1016/j.mayocp.2018.02.018.
    16. Graham EM, Ferrel MN, Wells KM, Egan DJ, MacVane CZ, Gisondi MA, Burns BD, Madsen TE, Fix ML. “Gender-based Barriers to the Advancement of Women in Academic Emergency Medicine: A Multi-Institutional Survey Study.” West J Emerg Med. 2021 Oct 26;22(6):1355-1359. doi: 10.5811/westjem.2021.7.52826.
    17. 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 May 1;177(5):651-657. doi: 10.1001/jamainternmed.2016.9616.
    18. 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 Oct;9(5):577-585. doi: 10.4300/JGME-D-17-00126.1.
    19. Blanch DC, Hall JA, Roter DL, Frankel RM. “Medical student gender and issues of confidence.” Patient Educ Couns. 2008 Sep;72(3):374-81. doi: 10.1016/j.pec.2008.05.021.
    20. Ross DA, Boatright D, Nunez-Smith M, Jordan A, Chekroud A, Moore EZ. “Differences in words used to describe racial and gender groups in Medical Student Performance Evaluations.” PLoS One. 2017 Aug 9;12(8):e0181659. doi: 10.1371/journal.pone.0181659.
    21. Brucker K, Whitaker N, Morgan ZS, Pettit K, Thinnes E, Banta AM, Palmer MM. “Exploring Gender Bias in Nursing Evaluations of Emergency Medicine Residents.” Acad Emerg Med. 2019 Nov;26(11):1266-1272. doi: 10.1111/acem.13843.
    22. Kolehmainen C, Brennan M, Filut A, Isaac C, Carnes M. “Afraid of being ‘witchy with a ‘b’’: a qualitative study of how gender influences residents’ experiences leading cardiopulmonary resuscitation.” Acad Med. 2014 Sep;89(9):1276-81. doi: 10.1097/ACM.0000000000000372.
    23. Blanch DC, et al.
    24. Ibid.
    25. Dotinga R. “For Female Emergency Docs, Lack of Respect Is Part of the Job.” MedPage Today. Oct. 5, 2022. Available from: http://bit.ly/42fXAlo.
    26. Lee LK, Platz E, Klig J, Samuels-Kalow ME, Temin ES, Nagurney J, Marsh R, Rouhani S, Huancahuari N, Dubosh NM, Boyle KL, Stack A, Dobiesz VA. “Addressing gender inequities: Creation of a multi-institutional consortium of women physicians in academic emergency medicine.” Acad Emerg Med. 2021 Dec;28(12):1358-1367. doi: 10.1111/acem.14361.
    27. Holladay CL, Cavanaugh KJ, Perkins LD, Woods AL. “Inclusivity in Leader Selection: An 8-Step Process to Promote Representation of Women and Racial/Ethnic Minorities in Leadership.” Acad Med. 2023 Jan 1;98(1):36-42. doi: 10.1097/ACM.0000000000004956.
    28. Carnes M, Morrissey C, Geller SE. “Women’s health and women’s leadership in academic medicine: hitting the same glass ceiling?” J Womens Health (Larchmt). 2008 Nov;17(9):1453-62. doi: 10.1089/jwh.2007.0688.
    29. Agrawal P, Madsen TE, Lall M, Zeidan A. “Gender Disparities in Academic Emergency Medicine: Strategies for the Recruitment, Retention, and Promotion of Women.” AEM Educ Train. 2019 Dec 12;4(Suppl 1):S67-S74. doi: 10.1002/aet2.10414.
    30. Chernoby KA, Pettit KE, Jansen JH, Welch JL. “Flexible Scheduling Policy for Pregnant and New Parent Residents: A Descriptive Pilot Study.” AEM Educ Train. 2020 Aug 5;5(2):e10504. doi: 10.1002/aet2.10504.
    31. Zeidan A, Patel J, Dys G, Dean L, Curt A, Lin MP, Samuels-Kalow M. “‘Why bother?’: Barriers to reporting gender and sexual harassment in emergency medicine.” Acad Emerg Med. 2022 Sep;29(9):1067-1077. doi: 10.1111/acem.14544.
    32. Foote MB, Jain N, Rome BN, DeFilippis EM, Powe CE, Yialamas MA. “Association of Perceived Role Misidentification With Use of Role Identity Badges Among Resident Physicians.” JAMA Netw Open. 2022 Jul 1;5(7):e2224236. doi: 10.1001/jamanetworkopen.2022.24236.

    Tehreem Rehman

    Written By

    Tehreem Rehman, MD, MPH

    Dr. Rehman can be reached at tehreem.rehman@cuanschutz.edu.


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