番茄社区

In this video, Jeremy Faust, MD, editor-in-chief of 番茄社区, sits down with Arghavan Salles, MD, PhD, and Shikha Jain, MD, to discuss gender discrimination in the medical field. Their Instagram Live conversation covers the wage gap between male and female physicians, biases in funding and promotion, and the implicit biases we should be aware of in order to make intentional change.

The following is a transcript of their remarks:

Faust: This is Jeremy Faust, editor-in-chief of 番茄社区. Thanks everyone for joining us here as we discuss the topic of women in medicine here in Women's History Month.

I'm joined today by two experts in the field of equity in medicine -- specifically gender equity in medicine: Dr. Shikha Jain and Dr. Arghavan Salles.

How are we doing on the wage gap so far?

Jain: Oh, we're not doing well, Dr. Faust. We're not doing well at all. Unfortunately, we still see a significant wage gap between women and men physicians. We even see a wage gap between women and men nurses. So, the wage gap in healthcare is pretty bad.

Dr. Vineet Arora, one of our colleagues, actually published a with her colleagues last year showing that over the course of about 40 years, a woman physician would lose $2 million in comparison with a male colleague. That is taking into account maternity leave or time off or working part-time. That $2 million is a lot of money to lose over a career. So we're not doing nearly as well as we need to be on closing that pay gap in healthcare.

Faust: (I think either we lost Dr. Salles or Instagram's being weird, but we'll see if we can get her back.)

While we're waiting, I'm interested in the solution to this problem.

I have a friend, sort of a mentor, her name is Evelyn Murphy, here in Massachusetts. She was actually the lieutenant governor of the state back under [Gov. Michael] Dukakis. She is still active, she won't be mad at me for saying she's over 80, and she's still going after it. Her whole thing is transparency with respect to what everyone's getting paid. So if everyone is forced to show what their wages are across gender lines, and I assume also against other lines, that it shines a light on the problem. Do you think that's one solution to this?

Jain: Yeah, I think that's a huge part of the solution: transparency. We have been taught and trained not to talk about money. It's very uncomfortable to ask somebody, "How much are you getting paid? Am I getting paid the same as you?" It's a really difficult conversation to have. So transparency at all levels, both in talking about it yourself and then also transparency in what people are getting paid from a leadership standpoint, is super-important.

I think another huge component of working towards closing the pay gap is that the healthcare system was created when women weren't in the healthcare workforce. And so a lot of women are often doing work that is uncompensated. Things like citizenship tasks, doing committee work, doing DEI [diversity, equity, and inclusion] work, doing work that is for the mental health and wellness of the employees or of their colleagues.

There was actually something that came out from McKinsey a couple years ago looking at the invisible work that's been done by women during the pandemic, and it's the work that is keeping companies afloat, it's the work that's getting these organizations awards, it's the work that's retaining employees. Most of it is uncompensated.

Dr. Julie Silver talks about the huge amount of invisible work that women do. The AAMC [Association of American Medical Colleges] has come out with statements on this and the fact that we need to restructure how we think about compensating the work that people are contributing. There was a study that came out recently showing that women tend to spend and . That's uncompensated work.

We get paid in many systems based on RVU [relative value unit], so the number of patients you see and how complex they are. But a lot of times, women have less complications, less mortality, and less morbidity when they're taking care of patients because they take the extra time to communicate.

So I think that the transparency part is a huge component, but we also need to revisit and rethink how we're compensating our healthcare workers and what work is uncompensated and undervalued that's necessary for our healthcare systems to be successful.

Faust: And Dr. Salles, on the research side -- we're just talking about the gender wage gap -- there's still a lot of work to be done on who's getting funded, right? I don't want to put you on the spot, but what percentage of NIH-funded grants have women as PIs [principal investigators], that kind of thing, and where are we with that? It's not high enough, but give us some insights there.

Salles: I actually don't know what the proportion is of research that's funded by women PIs as opposed to men PIs. And of course we have no data at all on non-binary or other identifications of gender.

But what I do know is that there have been multiple studies that Molly Carnes and her group out of the University of Wisconsin have done looking at the grant review process -- specifically for federal grants. They've found a couple of different things basically all pointing to women's work being undervalued in the same way that it is when we look at CVs and how people evaluate CVs.

Specifically, they've looked at the words that are used in funded applications' grant reviews. They've found that the reviews that are about women for the ones that are granted, so the ones that are funded, which is meeting some specific bar, the ones that are by women PIs, will have more words like "outstanding" and "super" in them, which feels a little counterintuitive. But if you think about it, what that means is that to meet the same bar of performance -- meaning to have been funded -- they had to be that much better to meet that bar.

They've done other work as well looking at which ones get reviewed and so on and so forth. Basically, we know that women's work is just not valued in the same way.

I know we're talking about gender today, but there are multiple studies from the NIH themselves looking at funding with regard to race. They have shown over and over again that despite whatever efforts they have made, they're still much less likely to fund research proposed by Black researchers than research proposed by white researchers. They think that one has to do with what kind of research they as the NIH value, because Black researchers are more likely to propose research using human subjects as opposed to working in a lab on some mouse model or whatever, and NIH just doesn't seem to value that work as much.

Faust: It's interesting that you talk about the words that are used, whether it's on a letter of recommendation for promotion, which of course is money, or letters to the NIH, which is money, or whatever it is. It does matter about what words we use.

I, as a male, am very conscious of this and when I go to write letters of recommendation, [I think about] what adjectives am I using or what descriptors am I using? I haven't done this yet, but I intend to play this game with OpenAI and chatbots to ask it to write a letter of recommendation for a man and a woman and just make sure that I [think about] which words I'm using and run it against my own thing.

Because it's very easy to just look over that. You're on a deadline, you're doing a letter of recommendation, and you don't think, but these are very important things, and those studies are absolutely eye-opening, I think is the best way to put it.

Salles: You both saw, because I know you're both also very active on Twitter, that tweet from the urologist at a meeting where he shared a short video of a woman presenting research, and I forget exactly the words, but [he wrote] something like "pretty," "smart," "motivated," "involved," and "smiley."

Jain: And for the male that presented, he [the urologist] was literally talking about the research he was presenting. A lot of people have actually suggested he take it down, and he has doubled down on why he's stated these things.

Dr. Faust, you were talking about the words we use even in the recommendation letters, and I think Dr. Salles knows this as well -- there's a website you can use where you enter in the information that you're writing for the letter and it'll tell you if it's more male-dominated or female-dominated. Then the problem is that people don't realize how it impacts it.

As Dr. Salles was mentioning, the tweet she's talking about was drastic in how different he's describing these two individuals, and he doesn't seem to see a problem with that.

Salles: I'll just say one more thing on that point, which is that with letters [of recommendation] -- when I was talking about grant reviews, I mentioned people using "outstanding" more for women for funded grants, but what we see in letters of recommendation is the opposite.

Our team has looked at evaluations of trainees and we see the same pattern, which is that people are much less likely to use those superlatives to describe women than they are to describe men. Letters of recommendation in multiple studies have been shown to be shorter for women than they are for men.

And by the way, when we talk about feedback -- which is what we all need; feedback to improve -- feedback to women has shown to be more related to personality traits that are really unchangeable for the most part, versus feedback to men tends to be more actionable like, "you should have done this on your PowerPoint" or "your slides should look like this," or "when you show up to this kind of meeting, this is the type of contribution we're looking for," et cetera.

This does have, as you say, real-world consequences, because when they look at funding to venture capitalists and look at the conversations that people have about funding, they talk in these same ways about the women entrepreneurs versus the men, where if the men have less experience, they'll say, "Wow, he's got so much growth potential" and for the women they'll say, "Oh, she doesn't have much experience."

That's part of why women are so much less likely to get funded in that venture capital [VC] world, which means women's ideas and the solutions to a lot of women's problems are not coming because they're not getting funding, because most of VC is men.

Faust: I'm not someone who has a lot of gatekeeping in my life; I don't do a lot of gatekeeping. But I'm always interested in my own role. Again, I mentioned this idea of someone telling me please if I'm doing this wrong.

One of the things I think is super-interesting, it's not a gender thing, but when we get our metrics, like how many patients did you see per hour? And everyone's like, "Hey look, I am actually on average here" or "Oh, on this shift, I seemed to see fewer." I just think that it gives me that insight.

So I'd kind of like to know -- some leader at one point had said to me, check your retweets. Do you retweet women as much as you retweet men?

It's sort of like this gut check. No one's perfect; how are we doing? So I like this idea of the transparency of what words you're using or what you retweet or who are your co-authors on your manuscripts or are you on "manels," and all those sorts of things.

No one likes to feel attacked, but at the same time I like sitting there on my computer and getting some information on something I can do better on, or this is something I'm okay on but I have to keep it up because it didn't happen accidentally. So, I just like the transparency.

Anything else you want to add before I switch directions?

Jain: Yeah, I was going to add one thing to that. I think you made a really good point, is the fact that we all live our lives with implicit bias. It's kind of how we exist, right?

A lot of times we don't realize we're doing it, and sometimes it's good. Fight or flight is related to our implicit bias. I give the example, if I'm walking down a dark street and I see somebody coming at me wearing a hood, it could be a high schooler who is totally fine, but I will cross the street because I'm a female and by myself, it's dark, it's late. I use my implicit bias to decide what I need to do to be safe.

But on the same token, that implicit bias can directly impact how we are retweeting, how we are collaborating. I give my own personal example: I run the Women in Medicine Summit, and the first year I was super-proud of myself because I thought I'd made this really diverse steering committee. I was like, yes, I have people from all these institutions and all these divisions and all these different ages.

Somebody called me and said, Shikha, your entire steering committee is Indian women. And I said, that's totally impossible because I talk about DEI, there's no way that I am so blind that I didn't even notice that. I looked and I said, oh my gosh. I was so focused on the specialties and the ages and the hospitals and the divisions that I didn't even look at where my own implicit bias could be impacting who I was inviting.

Obviously, we fixed that very quickly and luckily somebody brought it up to me very early on so I could make a concerted effort to change who I was inviting and to look outside of just my normal circle or ask the same people over and over again.

I think it's really important that we all realize that if somebody does point something like that out to you, it's not because they're trying to attack you or complain about you or criticize you. It's how we live our lives. Until we realize that we are utilizing those kinds of implicit biases, the unconscious ways that we ask people to do things, we can't really make intentional change and really work towards fixing the system.

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