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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. Part 2 of their Instagram Live conversation covers the lack of women in leadership roles, a bullying culture that keeps women silent, and a call for all physicians to receive human working conditions. Part 1 of this conversation can be viewed here.

The following is a transcript of their remarks:

Faust: Let's talk about representation in specialties. So Dr. Salles: surgery. This is your field. Tell me about where we're at with equity in surgery, and also just your sense of how the field has changed.

I mean, when I was a medical student, it felt pretty male dominant. I've had surgery on myself a couple times and I've had female surgeons, so to me it's like, "Oh, whatever." But if you actually look at the numbers -- I remember being scrubbed in and it was a boys club over there, right? That was 10 or 15 years ago; I haven't been in the OR in a while. What's the culture?

Salles: I think there is maybe some very small, gradual change in the culture despite pretty massive shifts in the gender dynamics.

Even this morning I was looking at some of the programs announcing their Match results, and there were a number of programs, like University of Washington was one that I definitely saw, but many that had more women than men in their Match class for general surgery. Some, one of them, I think, was University of Washington, had like seven women and one man. By the way, my intern class was five women and one man, but back a million years ago.

The point that I'm trying to make is that even though we do have a lot more women going into general surgery now than we have really ever before, the culture has not really changed enough to keep pace with that.

So I really actually worry about what these trainees are stepping into. Even though in residency they might see a lot of women around -- there are many programs in this country that now have 50% women residents in their general surgery program -- that changes pretty drastically once you go to be faculty or even if you go into private practice.

The majority of surgeons in this country identify as being men, and the culture is still driven by that. It's the same issue, I think, that we see in every specialty, including the ones where there are majority women like pediatrics and ob/gyn, because the culture that we've inherited is the culture of the practice of medicine, which was created by and for men at a specific point in time when we were not thinking about any of the issues that we're all discussing today, for a lot of reasons.

The change is slow. I mean, if you look at simple things like parental leave, we obviously don't have federal paid parental leave, but even in healthcare, we don't have really clear policies in most places. It was only last year that the ABMS [American Board of Medical 番茄社区] came out with a policy requiring that trainees get six weeks, which is well short of what AAFP [American Academy of Family Physicians] recommends, right?

It's just in the 2020s that we've gotten to that point. Whereas Google and all these other tech companies, which I always like to use as a foil, have been doing that for years. Why are we in healthcare not providing health support to our own employees? That's just parental leave.

Then, there's obviously lactation support and the time that it takes and having places where people can actually pump while they're at work without financial penalties, which gets back, by the way, to the pay gap.

There are so many things that are going on that we're not paying attention to in healthcare. One of the things I do a lot of research on, I think you both know, is related to fertility and family planning. Most places do not provide any insurance coverage for their trainees or for their staff to get those kinds of treatments, even though we know that women physicians are about twice as likely as other women to experience infertility.

So I think we're very behind, and that's true in surgery as much as it is in other specialties in medicine. But I think you would be right to say that maybe surgery lags even a little bit further behind in many ways.

Faust: So there's the issue of where people self-triage because they see the culture and they see themselves as part of it, or they feel welcome or unwelcome. Then once they're within their fields, there's advancement as we briefly already touched on. Dr. Jain, I want you to talk about that a bit.

When the dust settles, everyone is Matched and they're in the field and they're going along, but that's not the end of it. Even in the fields where you have maybe a little more equity or even more than equity, overrepresentation, there's still not equity in leadership. Can you talk about how you've seen that play out, and has anything gotten better there?

Jain: It's a great question and it's a really sad point. Over 50% of matriculating medical students are women, but we are not even close to seeing that representation in leadership. When you look at Deans and Chairs and C-suite, it's all less than 20% women.

It's not because the women aren't ambitious, we all enter into medical school wanting to be great doctors, and many people enter into medical school wanting to be leaders. The problem is there's, they call it a 'leaky pipeline', but I really think it's just a hemorrhaging of brilliant women physicians.

There are multiple reasons why it happens, right? One reason is this 'hustle culture' that Dr. Salles was talking about. If you have a uterus and you decide to get pregnant, that takes a toll on the body at some point, and you have to figure out how to adapt that into your work-life balance.

I have three kids. I have an eight-year-old and twins who are five. I will tell you, it is not easy. When I was in training and I got pregnant, nobody understood why I got pregnant, how I got pregnant, and how it was going to impact my career. When I found out I had twins, I had people tell me, "Oh, your career is over. You're going to stay home now, right? I'm not nominating you for any leadership positions." So there's this concept of a woman being able to be a parent and also be able to be a leader, that, again, feeds back into implicit bias.

Then there's a bullying culture that exists in a lot of healthcare, whether it's in surgery, as Dr. Salles mentioned, or throughout healthcare in general. We have a very hierarchical system that was set up before women were in the healthcare workforce. There's this idea that bullying is tolerated in healthcare, and not only is it tolerated, a lot of times the perpetrators fail up. They will do the bullying and then if they have somebody report them, instead of actually having any repercussions, it turns into he said, she said -- typically the woman is swept under the rug and oftentimes leaves the field altogether or doesn't feel like pursuing any other opportunities because who has time to deal with that -- and the man will end up failing up and getting a position at another institution. It's been reported over and over again.

A lot of times, bullying isn't even reported, or if it is reported, there's negative repercussions on the woman. I have been told numerous times not to report things specifically because it would be a career ender for me. They've said, "If you want to be a martyr, you should absolutely go forward and say something. But if you don't want to be a martyr and completely ruin your career -- is this one situation worth destroying your career over?"

I think that the concept of reporting structures and having a way to safely allow people to come forward when something like that is happening and then knowing that there'll be repercussions for the person who is a perpetrator, I think that is a huge culture shift that needs to happen in healthcare.

On top of that, there's so much data out there showing that women aren't nominated for leadership positions as much, women aren't given awards as much, women aren't provided the grant funding. You were asking about numbers earlier. There is data from the NIH that shows women get less money in grant funding and they get less grants than their male colleagues. It is documented by the NIH.

I think the good thing is that now we're talking more about it. We have an immense amount of data showing that this is a problem, but we are at a point in time where we need to focus on solutions and how to fix this system that is so broken, that is really causing this 'great resignation' everyone keeps talking about. Because if we don't, we're going to end up chasing more and more brilliant women away from medicine and from healthcare altogether.

We're seeing it. I mean, the Match just happened and we're seeing Match spots going unfilled in primary care, in ER, we're seeing places where we really need healthcare workers and we need leadership and we need women. They're not interested in doing those things because they know all of these barriers exist and things haven't changed as much as they really should by now.

A lot of these issues aren't just affecting women, right? The things that both Dr. Jain and I advocate for would really benefit everyone in the healthcare system: having humane working conditions, having work be recognized, having all work be recognized and valued.

To the point that Dr. Jain made earlier, by the way, about that McKinsey study, they specifically looked at DEI -- diversity, equity, and inclusion -- and wellbeing, and they shared what proportion of the companies they surveyed said they valued those things, which was a very high proportion. It was like 75%-80% that said they valued those things. What proportion actually financially remunerated people for doing that work? It was about a quarter.

So those are the issues that, again, may disproportionately benefit women because women are doing that work more, but they really help everybody to truly value the work that we say as organizations we value, and value it financially, value it when we're looking at promotions, value it when we're looking at opportunities for career development.

The other thing I wanted to say to go off what Dr. Jain was saying, often people say to me things like, "Well, women just leave the field, so we shouldn't even train women to be physicians." People have said this to me directly: "You've taken up a spot that should have gone to someone else."

I don't know if whoever will see this is aware, but I am not currently practicing. My relationship with clinical practice is a little hot and cold, mostly cold, and it's because of a lot of the things Dr. Jain was describing and my unwillingness to put up with the mistreatment that I was experiencing, which other people are experiencing too, and not just women.

I should note, by the way, [it affects] disproportionately women of color and people with multiple marginalized identities, But it's not just us.

Everyone is, in my opinion, being mistreated in some way or other in healthcare because of the way our current system is, and that's why we're seeing such large numbers of nurses leaving the profession and such large numbers of physicians intending to leave. The same pressures that force [women] to make these very difficult decisions and cut back our time or potentially leave clinical medicine are really impacting everyone.

So it's really going to benefit all of us to fix that. It's not that women are leaving because we can't handle it. I mean, I get that too: "Oh, you were just too weak." No, I'm just making a different choice. You can choose to be harassed all day long and still show up. I choose not to do that. That's not weakness, you know?

So I just want to reframe that a little bit for people who are sitting out there going, "Ugh, these women, all they want to do is complain." Really what we're saying is that we all deserve humane working conditions.

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