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Article of the Month

 , June 04, 2019

Inclusivity in Academic Medicine: Practicalities at the Heart of Matter


Shanu Gupta, MD, FACP; Larry Hurtubise, MA; Linda Love, EdD, MA

Dr. Gupta (shanugupta@health.usf.edu; @shanumeister) is academic hospitalist and assistant professor at the University of South Florida. Mr. Hurtubise (hurtubis@ohio. edu) is an associate director and adjunct associate professor in biomedical education and anatomy at The Ohio State University College of Medicine. Dr. Love (lmlove@unmc.edu; @2lindamlove) is the director of faculty development and assistant professor in the department of psychiatry at the University of Nebraska Medical Center.
Personal stories are in italics.

“Which is to say that like a good theoretical objectified body, my identity was created not by me but by the various desires and beliefs of those around me.”
—Daniel Borzutzky

She was taken out of school after the 5th grade. The woman of an all-male household at age 15. Writing letters to her husband attending college in the city. Telling him everything was well back home, even when it wasn’t. She moved to the city to support him through his career in academics. She saved money for the future of their household while supporting those back in the village. She raised her son and daughters to excel in school. One daughter dreamed of becoming an engineer, she encouraged her husband to drive her to the boys’ school for mathematics class because the girls’ school didn’t teach it. She cared for grandchildren when her daughter returned to work immediately after giving birth. Maternity in the sciences was not seen or heard. She taught her 8 year old granddaughter to cook, clean, do the morning laundry before studying and heading to school. Woman needed to be able to excel at all of it, home, school, work, all of it.

Women have come a long way since my grandmother left her village to provide a meaningful life to her future generations. In academic medicine today, “she” still has room to grow.

Today, women join medical school making up about 50% of their cohort. On matriculating into residency, they make up 46% of residents. Once graduated from residency, female physicians make up 36% of the workforce.1 In Internal Medicine, female physicians earn up to $50K less than their male counterparts.2 And, as for professional progress, 19% of full professors and 12% of department chairs in Internal Medicine physicians are female.

Where Have All The Women Gone?
Peeling through barriers, you might be surprised (or not) to learn that patients rate male physicians higher than female physicians for the same level of patient-centered skills.1 Faculty raters, regardless of their gender, rate male residents higher when demonstrating the same level of competence.3 In residency, women are more likely to experience burnout and emotional exhaustion.4 As their careers progress, female physicians experience poorer job satisfaction and tend to experience role conflict and are more prone to career change to support children.5 Female physician-scientists don’t get the time and mentorship they deserve.6

She was a woman who responded to the needs of her family and knowingly tipped the scale toward family over career. She was a first generation working mother in her family. Guilt was inside, outside, and everywhere. There was no model, just a willingness to experiment with what seemed “right.” It is difficult to explain the disconnect between calendar years and academic advancement. Who am I? Now, when family needs subsided, new interests, relationships, opportunities are like candy. There is no model for growing a career later, just a willingness to experiment with what seems “right” and the people who seem “right beside” me.

The data are compelling, but if we listen to our stories, the human stories that make up the Academy, we know that the data alone do not reveal everything necessary to advance a better community. Rather than fear of talking and mentoring, we need to be more comfortable with the narratives of our lives and diversity over ONE model for a successful academic career.

What questions are we not asking? What is mixed in with the bricks and mortar in the house of medicine that until recently was home to only white men?

Returning to school to pursue a graduate degree after age 50, he found himself in a stats class with graduate students younger than his children. Faculty (younger than he is) are more like colleagues, first-name basis, laughing at their jokes, negotiating assignments to meet his needs. With some trepidation, he arrives for a pencil and paper midterm for the first time in more than 30 years. Half way through he rises, takes is papers to the young TA and explains, “I have to go to the bathroom.” As he gets to the door the scene from Hidden Figures forces its way into his consciousness. It never occurred to him that he would not be granted permission to go. To take the class, be accepted into the program.... It never even occurred to him.

They say that behind every successful man is a woman. What’s behind a successful woman? When you next see your female colleague, consider the space between you and her that carries the work of generations that has led her to where she is now—in your sight. Commit to having her back.

Assuring a Positive Climate in Academic Medicine
#MeToo, #BeEthical, and other movements have elevated the conversation around professional practice in academic medicine. At the same time, many faculty and leaders are skittish about what they can do and say to avoid missteps. The following are some general guides to serve as proactive development opportunities and dialogue starters in our everyday work. This advice is not specific to women exclusively and can help everyone work better together.

1. BALANCE
Make sure there is balance in voices at the table. Monitor your own behavior and power signals. Do you interrupt women more than men? Do you volley conversation with the same people at every committee meeting? Are decisions made in settings other than work?

2. CREDIT
Make sure credit is given where credit is due. Don’t lose track of original ideas based on whoever’s voice is last or latest.

3. NUMBERS
Make sure there is more than one woman or other underrepresented minority on both sides of the hiring equation. In both real world and controlled environments, research has demonstrated the likelihood of hiring a woman increased nearly 80% simply if two or more women were in the finalist pool.7

4. DIVERSITY
Move diversity from an intrinsic value to a transparent practice. Train your leader thinking to continually assess, “Where is the diversity in this?” “Is there someone’s perspective we need to hear on this topic?”

5. LISTEN
We can never truly understand what it is like to walk in someone else’s shoes. Check the accuracy of your own perceptions and ask women or other minorities about their experiences or stories. A better bridge to shared understanding can be built through personal stories.

6. EDUCATE
Continually educate yourself using national and organization data informing promotion rates for women and other minorities. Examine the progress made every six month or more frequent intervals. Agility in responding to data trends leads to greater organizational stability.

7. ASK
Routinely ask about professional and research interests. Use opportunities for hallway mentoring, coaching and advising to keep careers in forward motion.

8. ADVOCATE
Hone skills in advocacy and practice initiating dialogues as an ally for women or an array of other marginalized groups. Model and normalize advocating for others. Be especially alert at the patient’s bedside, in promotion decisions, and committee work.

References
1. Roter DL, Hall JA. Women doctors don’t get the credit they deserve. J Gen Intern Med. 2015 Mar;30(3):273-4. doi: 10.1007/s11606-014-3081-9.
2. Weeks WB, Wallace, AE. Race and gender differences in general internists' annual incomes. J Gen Intern Med. 2006 Nov;21(11):1167-71. Epub 2006 Aug 9.
3. Dayal A, O'Connor DM, Qadri U, et al. 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.
4. Spataro BM, Tilstra SA, Rubio DM, et al. The toxicity of self-blame: Sex differences in burnout and coping in internal medicine trainees. J Womens Health. (Larchmt). 2016 Nov;25(11):1147-1152. Epub 2016 Oct 12.
5. Warde C, Allen W, Gelberg L. Physician role conflict and resulting career changes: Gender and generational differences. J Gen Intern Med. 1996 Dec;11(12):729-35.
6. Holliday E, Griffith KA, De Castro R, et al. Gender differences in resources and negotiation among highly motivated physician-scientists. J Gen Intern Med. 2015 Apr;30(4):401-7. doi: 10.1007/s11606-014-2988-5. Epub 2014 Aug 12.
7. Harvard Business Review. Why so few "diversity candidates" are hired. https://hbr.org/video/4984622531001/why-so-few-diversity-candidates-are-hired. Released June 24, 2016. Accessed May 1, 2019.



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