<p>Image courtesy: Caroline Giroux</p>

Image courtesy: Caroline Giroux

The lives of women and men have always been multifaceted. Though specific demands have evolved over time, the load of responsibilities carried by female physicians has remained largely the same. While multiple daily stresses can add up and lead to chronic stress among physicians, the duty to care for a patient can transform into a burden that is added to pre-existing obligations of a physician. Research has shown that women in medicine have higher rates of burnout than their male counterparts, with detrimental consequences on psychological health, including depression and suicide (Canadian Medical Association, 2018; The Physicians Foundation, 2018). One reason that has been hypothesized and would warrant further research based on observations at University of California, Davis, is that women are more likely to have a physician spouse than their male counterparts. Female physicians whose spouse is also a physician might feel that they are the ones to try to do it all (also perhaps a remnant of patriarchal values). If so, this might, at least partially, explain the higher burnout rates in female physicians who may feel overwhelmed by the “double-shift” (Hategan et al, 2018). Burnout prophylaxis and interventions for physicians should be adopted as routine initiatives similar to quality improvement measures. Organizations should persevere in promoting non-gendered settings and equal opportunities for today’s female physicians to become an essential part of the leaders of tomorrow and of generations to come, while taking into account the realities women face as a group. (See section Integrate New Lifestyles, topic Practicing Resilience in the Era of Sustainable Medicine.)

A. Clinical teachers in medicine: the other half of us

Sex differences in academic ranks have remained a systemic problem in medicine. Compared with male physicians, the proportion of females declines as one moves up the academic ladder (Jena et al, 2015). This hierarchical academic disparity also appears to be influenced by women leaving the academic environment at earlier career stages and at a more expeditious rate than men (Jena et al, 2015). In a 2014 cross-sectional database of U.S. academic physicians (n = 91,073 subjects; 9.1% of all U.S. physicians), the proportion of female full professors remained below that of men (absolute difference -16.7%; 95% CI -17.3% to -16.2%) after accounting for age, experience, specialty, and measures of research productivity (Jena et al, 2015). This situation continues and has not changed over the past three decades (Jena et al, 2015).

Not only women but also minorities, such as African Americans and Hispanics, are underrepresented in academic medicine (Yu et al, 2013). In a retrospective cross-sectional study conducted almost one decade ago using data from the Association of American Medical Colleges on faculty at medical schools, women represented only 14.7% of professors, 9.2% of chairpersons, and 9.3% of deans (Yu et al, 2013). Additionally, whites accounted for 84.7% of professors, 88.2% of chairpersons, and 91.2% of deans. In order to establish a diverse work environment, a significant culture shift needs to occur at multiple levels.

Did you know?

Although there was a noted increase in the percentage of minority academic physicians in the study done by Yu et al (2013), at this pace of change it would take nearly 1,000 years for the proportion of African American physicians to draw close to the percentage of this race in the general population (Yu et al, 2013).

B. Common gender-based challenges physicians face in academic medicine

a. Academic promotion

Studies have shown that women have a lower rate of scientific publishing, which is one of the important factors affecting promotion in academic medicine (Fridner et al, 2015; Reed et al, 2011). Good “academic citizenship” requires academicians to have an active engagement and participation in the university’s life, awareness of the institution’s strategic goals, and a willingness to meaningfully integrate the demands of the medical field with the trainees’ needs and expectations of teaching roles. Starting a scholarly culture early on during medical training is essential in stimulating interest and productivity in the context of an increasingly performative medical culture.

b. Caregiving and academic clock

About academicians. The persistent gender gap in academia, if not rectified, continues to lead to an imbalance up the promotion ladder. The now-ubiquitous gender-neutral tenure clock stopping policies have been adopted by the majority of research-intensive universities in North America in recent decades and are a good example of an administrative initiative to address gender gap issues. These policies were designed in part to allow assistant professors to qualify for promotion to associate professor, sometimes with tenure after a child joins their family, typically by a year. This is not necessarily a “gender issue;” however, this option was likely believed to help women complete academic products to qualify for promotion to associate professor (sometimes including tenure) and thus to help to close the gender gap in academia.

Nevertheless, recent research has called attention to redraft these policies, because they appear to have primarily benefited men (Antecol et al, 2016). Antecol et al (2016) have shown that before adopting stop-the-clock policies, about 30% of men and women at the top-50 economics departments acquired tenure from 1985-2004. After adopting those policies, there has been no empirical evidence showing that these policies helped women. On the contrary, these policies showed to substantially reduce female tenure rates by 22% points in their first job, while substantially increasing male tenure rates by 19% points (Antecol et al, 2018). Since other academic professionals are promoted based on early measures of success, physicians are also likely to be affected. Gender-neutral policies in medicine that attempt to level the playing field by adjusting measures of academic productivity to account for early child-rearing sound promising (Antecol et al, 2016); however, poorly designed policies could backfire, having unintended consequences that actually could hurt women.

Did you know?

In North America, depending on institution, there have been different types of stop-the-clock policies:
  • Those that approve requests by any parent to pause the tenure process for the birth or adoption of a child.
  • Those that automatically stop the clock for birth mothers, but require application process, including explanation of responsibilities and approval.
  • Those that allow only the primary caregiver to stop the clock.
  • Those that allow anyone with equal or primary caregiving responsibilities or who provides at least 50% of the caretaking time.

Despite variation of these policies, they aim to achieve the same goals, namely to update the definition of the ideal academician, and that of the ideal caregiver. Merging the two goals imply that the mothers are not always necessarily the “ideal caregiver” and that male faculty members can also be caregivers worthy of institutional support. Institutions do not believe pregnancy is gender neutral. It is not a man-versus-woman issue. However, in addition to adopting gender-neutral policies on caregiving, because women must recover postpartum from a physiological standpoint, there should be other policies designed specifically for women who give birth (e.g., post-birth time off commonly for four to six weeks for employed females). In Canada, the pregnancy and parental leave benefit program for physicians is managed by the Ministry of Health and Long Term Care. It provides eligible physicians with a pregnancy leave benefit for nine weeks and a parental leave benefit for eight weeks of up to a maximum of $1,000 per week.

About residents. Canadian residents are legally entitled to pregnancy and/or parental leave. According to the Professional Association of Residents of Ontario (PARO), pregnancy leave, which applies only to a birth or surrogate mother, is 17 weeks. Regarding parental leave, there are two options available: standard or extended.

c. Remuneration

Research has shown that, at many places, women still earn less than men. Recent findings have shown that significant sex differences in salary still existed among academic physicians even after accounting for age, years of experience, specialty, academic rank, and measures of research productivity and clinical revenue (Jena et al, 2016).

Did you know?

A 2016 study analyzing sex differences in earnings among 10,241 U.S. academic physicians at 24 public medical schools has shown that female physicians (n = 3,549) had lower mean unadjusted salaries than male physicians ($206,641 vs $257,957; absolute difference $51,315, 95% CI $46,330-$56,301) (Jena et al, 2016). A significant sex gap in salary remained even at the associate professor level when controlled for productivity, structural factors, and human capital (Claypool et al, 2017).

d. Recognition/validation

Beyond academic citizenship and remuneration, the moments of validation, and opportunities to prove our own self-worth to others and, more importantly, to ourselves, are essential factors to prevent burnout. Yet, academic women appear to be held back in comparison to their male peers regarding their struggle to achieve academic advancement and highest positions within institutions. Although women possess the skills for successful leadership in academia, there could be a negative view of the workplace culture perceived as an obstacle to progress and promotion in comparison to their male peers. In some places, the cultural expectations of women may continue to act as a significant barrier to academic progression.

Moreover, women’s own perception of themselves tends to be about underestimating their capabilities. For instance, in a TED talk called “Teach girls bravery, not perfection,” Reshma Saujani mentioned a survey that revealed that women will not apply for a job unless they meet 100% of the qualifications, compared to 60% of men. Women tend to gravitate towards careers that they know they will be perfect in. Why is that? Inner insecurity on the part of women, boldness on the part of men, or both? According to the TED speaker, most girls are taught early on to avoid risk and failure. They also tend to internalize the problem. Again, the shift has to occur internally for women, and some widespread cognitive restructuring needs to occur for men and women about the myth of perfection. Growth involves risk-taking and imperfection.

Did you know?

Gender stereotyping and cultural expectations women have of themselves and that others have of women may have been with them from earlier formation age, which can affect their inner dialogue when making choices about their working lives, which may contribute to uncertainties in their confidence and self-belief.

e. Harassment

Workplace harassment, including sexual harassment, certainly adds to the discrimination experiences and burnout of physicians. In a 2014 survey of U.S. clinician-researchers (n = 1,066 respondents, 62% response rate), 30% of women reported having experienced a form of sexual harassment compared with 4% of men (Jagsi et al, 2016). Almost half of women reporting harassment stated that these experiences negatively affected their career advancement, and almost two thirds perceived a negative effect on their confidence as professionals (Jagsi et al, 2016). Even in the #MeToo era, reporting sexual harassment remains stressful. Women who report sexual harassment can experience retaliation and marginalization, potentially leading to chronic stress and burnout (Jagsi, 2018). Imagine the life of the resident physician. If one adds potential harassment by patients to that by peers, supervisors, and individuals in other superior roles, the problem in medical training and practice is especially concerning.

What should you do if you are being harassed at work? Where to go for help?

Skill building exercise: reflections of the resident physician

1. As you reflect on your career path, did you feel like you were treated differently or offered less opportunities because of your gender or ethnicity? Describe the situations in the space below and contemplate a more favourable outcome if given different opportunities in the past.
2. What were the myths or stereotypes you grew up with and how would you challenge them now?
3. How will you approach your superior in the future regarding issues like equal pay and sexual harassment prevention at work?

C. The myth of the “dress code” and effects on gender roles

Snapshot dialogue between a psychiatry resident and her supervisor:

A fifth year psychiatry resident had confided in her former faculty supervisor about an incident, and asked for guidance. Her situation elicited the deepest sympathy in her supervisor, a female academician. The resident disclosed that recently she was asked by a hospital administrator to reconsider her overall wardrobe as per the hospital dress code regulation because she, as she was told, was wearing “too high” heels, as well as a sleeveless shirt, and a “too short”, above the knee skirt.

The faculty physician asked the resident physician how that encounter had affected her. The resident replied:

“Edith Head, the American costume designer, used to say: ‘Your dress should be tight enough to show you are a woman and loose enough to show you are a lady.’ It affected me because I was left with the impression of my inappropriateness of crossing rules and regulations. On the other hand, I viewed that as a matter of identity, and I felt that commenting on my personal appearance was, in itself, crossing boundaries. Yes, sexy is often unduly extrapolated into being sexualized. We often see individuals who react to women’s dress code and the double-bind they have been caught in: women have to be attractive, sexy, yet not look like a promiscuous individual. I feel like sometimes women are objectified. I pondered over the question: ‘Would it be possible to think that society at large is to be responsible, not the professionals, in the way they dress?’ A female physician can be sexy, but still be professional. In fact, it might even make her patients happy to see a confident, harmoniously dressed individual.”

Snapshot dialogue between two academic psychiatrists:

Two friends and female academic psychiatrists, one living in Canada and the other one in the U.S.A., have exchanged ideas on gender roles and the dress code ethics in medicine. The two friends have had the following FaceTime conversation.

Physician A initiated the conversation:

“I try to dress the way I feel like; when we are happy in our clothes, we are also more self-confident, and the rest of the world is happier (I feel valued when colleagues or patients compliment my outfit, for instance). It is about prioritizing esthetics too, which is an important element for healing. Obeying an inflexible code (external or internal) would make me feel more lugubrious. I love flowery dresses, mini-skirts, patterned stockings and some sleeveless dresses. I admire those women who dare being themselves, with gusto, and who refuse to let fear dictate their identity, their persona. There is a psychiatrist who was my supervisor in my last year of training (she is a year younger). She is a strong advocate of the native populations in our country. I always thought she wore “very nice” clothes, but “sexy” to others, and it got even more revealing as she became invited to speak in the media, but she is extremely respected in her field, and I reflect now more with curiosity than judgment on this issue, and perceive her attire as a possible defiance or protestation of the way native women have been treated. When I hear that in certain U.S. schools people teach girls to “cover themselves”, I want to scream. Instead of addressing a rape culture where perpetrators (often males) must be held accountable, girls are encouraged to develop a fear-based culture, which is not taking care of the problem. Moreover, to me, it is about celebrating femininity, the human body, refusing to engage in this dichotomy of thinking about what is “acceptable and unacceptable” regarding the dress code, and refusing to surrender to fear. I live with the hope that respect of differences and harmony will prevail.

Physician B replied:

“I think it tells more about the person who is bothered by this… Many people appear to dress in questionable ways to others, but most observers are able to control themselves and move on beyond their critical thinking. This topic elicits strong feelings in me too because of the problem with sexual victimization that we so often encounter in our psychiatric population living with past experiences of trauma; the blame is still often put on the victim (“What was she wearing? What was she thinking wearing such revealing clothes?”). I don’t know if I shared this with you…”

She exclaimed in a soft tone and felt almost ashamed,

“… but when the sex of our son was revealed to us after amniocentesis, my husband (a family physician), in relief, said: ‘At least we won’t have to go through the slut phase of sexy clothes in adolescence.’ This comment affected me deeply! I felt offended, thinking, ‘is this how he views women, femininity, me?’ I told him several times later on how damaging such a comment was, but I was not sure he fully understood it; he insisted a clear definition of rape was needed in order to move forward with this important problem in society. I often wondered why manhood was not doing more about helping institute a balance between the gender roles. Starting with a ‘clear definition of rape’ cannot fix the problem since trauma is perpetrated at different levels. For victims of sexual assault, the minor versus major distinction to define the assault is irrelevant (Muldoon et al, 2016). The shock experienced is the same. The thing is, predators often use ambiguity and take advantage of it, so not all situations will fit in a clear-cut definition. My dad (a surgeon) once told me while I was preparing for a grand rounds talk that he thought it was inappropriate for a speaker to dress in a sexy way because it would distract the audience... he was likely referring to my choice of clothes at the time, while I thought I was just ‘fashionable.’ That makes me think now: ‘I wish I could find strong male allies on this topic’… See how much we have to say about all this?”

Skill building exercise

Which myths about clothing, seduction, and consent are pervasive in your environment?

The dress code says what it means: a code, or language that is the form of clothing. Clothing has evolved and undergone many permutations since the times the descendants of homo erectus lost their ape fur. The concept of dress code is a set of written and, more often, unwritten rules with regard to clothing. Clothing, like other aspects of human physical appearance, has a social significance, with different rules and expectations applying depending on circumstance and occasion. Within a single day, an individual may need to navigate between two or more dress codes. Cultural and religious denominations will prescribe specific colour or type of clothing during funeral ceremonies for various reasons (e.g., symbolism, tradition, sobriety). In certain countries, female tourists are warned that they should cover their arms and legs because of cultural machismo or higher rates of assault against women.

Even in our somewhat libertarian societies, the dress code issue can be a source of contention. It emerges whenever we believe some people violate it. Historically, there have been more concerns about the minimalist side of it, not the excess, or decorated version. Over the recent years, there has also been a growing debate over the restrictions of “too much” covering, such as a hijab, as some governments are attempting to laicize their institutions. But in general, people tend to feel uncomfortable if certain parts of the body are exposed. Unless we are walking on a nudist beach, it is obvious that genitalia and breasts should be covered. But what about cleavage? Armpits? When is a mini-skirt considered too short?

If clothes are a code or convey a message, they are therefore a statement about various aspects of a person. Dress can be political, esthetic, thought-provoking, experimental, or purely practical. The priority should be about the person’s main (physical and emotional) comfort level. Being forced to wear a daily uniform (e.g., scrubs in the emergency department) could not only make us physically and mentally uncomfortable but could affect our mood because we would feel alienated from our own self, identity, which are reflected in our personal tastes and, yes, wardrobe. Furthermore, women are faced with an additional challenge: their hormonal contingencies. Think about a lactating woman who has to feed her screaming baby on a train or the perimenopausal woman who suddenly can barely stand pieces of clothing in certain areas due to hot flashes. Having a rigid dress code is not supportive of that person’s normal physiology.

Many people have specific prejudices about certain dress styles and it is unfortunate because just like the fashions have evolved, the script attached to a specific accoutrement also has changed. Wearing “sexy clothes” nowadays can mean various things (self-confidence, attunement to one’s own tastes, desire to please, or simply climate or hormonal contingencies).

Time to revise our thinking: male, female. What if a female likes ties? Now that we acknowledge not only male, female, but also non-binary genders, how do we define what is “acceptable” or “appropriate” for each gender to wear? Maybe residents should survey their peers about the dress code, their level of comfort in dressing according to their identity, and how judgment or misconceptions about attire play a role in gender-related issues in the workplace.

Skill building exercise: reflections of the resident physician

Imagine you are the director of a training program and you also run an outpatient clinic. Your institution has a dress code in place.

How will you interpret and use its stipulations, and which recommendations would you make?
As the training program director, how would you approach a situation where a colleague complains to you about a trainee’s “revealing” clothing?
As the training program director, how would you work at preventing and addressing sexual harassment?
By colleagues towards colleagues:
By patients towards clinicians:

Key points

  • National efforts must be rallied to support physicians seeking help for physical and psychological health problems.
  • Institutions can, and do, cause burnout, and only a concerted effort of an institution can deal with it.
  • Sexual harassment is a major source of stress in the workplace; it affects more women than men, yet sexist attitudes or rigid dress codes in the environment can create extra barriers.
  • Efforts to recruit, retain, and advance women, especially minority women, in academic medicine, must grow. They will serve as role models to the generations of medical trainees to come, and by their diversity, their presence can ensure that a variety of needs from diverse populations are acknowledged and more effectively addressed.
  • Having a dialogue among men, women, non-binary genders, and ethnic minorities on the topics of sexual misconduct and burnout is long overdue.
  • Some have recommended that medical leaders find time to ask medical professionals what they believe is working in order to mitigate work-related stress and burnout (Eckleberry-Hunt et al, 2018).