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Admin & Clinical Operations Addressing Sexism in Emergency Department Operations
By Tehreem Rehman, MD, MPH on behalf of the ED Administration and Clinical Operations Interest Group The Role of Sex and Gender in the 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 stereotypical view of women over-reporting or exaggerating their pain symptoms.
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.”
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. 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.”
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.” 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.” 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. 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 a fewer number of consultations provided.
Bias in Patient Satisfaction
Despite evidence suggesting that patientphysician 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. 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 in 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. 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 the Journal of the American Medical Association (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 U.S. were significantly less likely to be full professors compared to male physicians, even after adjusting for age, experience, specialty, and measures of research productivity. 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.”
Persistent Unequal Compensation
Within academic emergency medicine, Dr. Jennifer 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.” Dr. Wiler’s research also found that an unacceptable gender salary gap has remained unchanged in emergency medicine these past several years. In addition to investment in leadership development for female physicians, emergency departments will need to need to actively call out institutionalized sexism in medicine and its impact on internalized bias among emergency physicians themselves. Evidence suggests that such gender bias among emergency physicians is present as early as during residency, with one study demonstrating emergency medicine residents negatively biased against women in positions of leadership. Such bias likely informs persistent gender disparities in leadership and compensation in emergency medicine.
Unique Work Demands and Unacceptable Risks
Both implicit and explicit gender biases influence the unique work demands and unacceptable risks experienced by female emergency physicians. This disproportionately hurts 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. According to one study, married female physicians spend more than 100 minutes per day on household chores and childcare compared to male physicians. 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. One 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 ten female emergency physicians reported at least one encounter of sexual assault by a colleague or supervisor during their career. 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 even worsen these next
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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.” 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 who disproportionately receive inconsistent feedback are more vulnerable to “poorer-quality mentoring and instruction,” thus hurting their ability to progress and improve clinical performance.
Bias in evaluations is seen even before residency, thus impacting medical students as well. In a standardized patient interaction exam, “female medical students were viewed as significantly less confident than
male medical students.” 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.”
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. 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 health care setting, particularly in the emergency department. 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.
Increased Risk for Burnout and Depression
Greater stress and lower psychological safety can hurt well-being and selfconfidence while increased exposure to gender-based discrimination and violence incurs trauma; this all contributes to higher rates of burnout among female physicians. Unsurprisingly, female physicians are more likely to experience depressive symptoms, although preliminary evidence suggests that this disparity can be partially alleviated by reducing work-family conflict that stems from gendered societal norms and power dynamics.
Recommend Next Steps
Unfortunately, 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. 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 microaggressions 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 men to “encounter rudeness, be dismissed [and] face issues with procurement of supplies,” as noted in Dr. Michelle Suh’s presentation at a recent national emergency medicine conference. Department leaders can also leverage data analytics and visualization through dashboards to explicitly call out gender disparities in wages, shift categories such as weekend shifts, and membership in paid versus unpaid committees.
Mentorship and Sponsorship
Mentorship and sponsorship are other ways to address sexism in emergency medicine, by supporting the career development of women and helping 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. 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 have 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.”
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.” In a recent issue of AEM Education and Training journal, Dr. Pooja Agrawal and her coauthors delineate strategies for recruitment, retention, and promotion of women in emergency medicine. These strategies include necessary policy reform and system redesign.
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. Kimberly 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. Other similar interventions include providing 6-8 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. Additionally, it is imperative that EM leaders proactively counter the impact of bias in patient interactions and patient satisfaction measures that disproportionately hurt women. 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. 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.
ABOUT THE AUTHOR
Dr. Rehman is an emergency physician and clinical instructor at the University of Colorado Anschutz Hospital. Her interests include quality improvement, informatics, and clinical operations and she is developing deep expertise in system redesign to improve transitions of care and linkages to care. Dr. Rehman is also invested in leveraging population health frameworks to develop high-impact and equitable interventions in health care.
