Sticky floors and glass ceilings in medicine
An investigation by McKinsey and LeanIn.Org revealed the immense amount of invisible work undertaken by women during the pandemic. In more than 400 companies and 65,000 employees at all levels of management, women have presented themselves as better leaders, championed DCI (diversity, equity and inclusion) work, and disproportionately led the essential work of supporting the well-being and promotion of employees. Companies have reaped great rewards from these efforts, but 75% of women said this extra work was not officially recognized, and nearly 40% considered downgrading their careers or leaving the workforce altogether. Over 50% of female leaders said in recent months that they often or almost always felt exhausted at work. The report concludes: “Women leaders do the job disproportionately to make their businesses better and do better. Their businesses should do better because of them.
Unfortunately, health care is not immune to invisible work, inequalities and the lack of recognition of women. Throughout this pandemic, women in medicine have outdone themselves, often taking on essential unpaid and unrecognized work that is vital to providing exceptional patient care and keeping health systems afloat. Despite (or more likely because of) this phenomenon, this pandemic has seen women leave the workforce in droves. This phenomenon is most pronounced for people with intersectional identities – women of color and LGBTQ + people have taken on much of the invisible work of the pandemic, such as tackling vaccine reluctance.
Our healthcare systems, our patients and our teams thrive on the incredible amount of extra work that women in medicine take on. Labor is necessary, but does not provide the currency – financial or otherwise – necessary for advancement. Women are more likely to participate in “citizenship tasks” that benefit the organization, but not the participating women. This mission-critical work, often done at night and on weekends, benefits others but exhausts women.
A 2021 report found that 51% of women in medicine said they felt exhausted, compared with 36% of men. Before the pandemic, we described the “third shift” – fairness work done during the non-working hours after the end of the first and second shift (regular work and family responsibilities). This third shift was already contributing to burnout before the pandemic. Similar to the McKinsey survey results, Julie Silver, MD, described an unpaid fourth COVID-19 shift that was disproportionately attributed to women. This work is often carried out outside working hours because it is essential, but at what cost?
Those same women in medicine who continue to perform unpaid and unrecognized necessary work are the same skilled women who continue to be overlooked for awards, grants, research, leadership, promotions, tenure and continue to do so. ‘be paid less than their male colleagues. A recent report from the Association of American Medical Colleges (AAMC) showed that the pay gap for women in medicine persists, a trend that mirrors the U.S. job market, and is worst for women of color. Amy Gottlieb, MD, said that “the traditional way of paying doctors and faculty inadvertently devalues the contributions of women and monetizes those of men.” When women are consistently undervalued, it’s no surprise that exceptional women continue to leave medicine. We know these disparities have been around for years, but they persist. And the pandemic has amplified them at all levels. Actions taken to close this gap have stagnated or declined, with these disparities more pronounced for people with intersectional identities.
The White House launched its first-ever national gender equality strategy to advance gender equity and equality. If we are strategic and intentional in how we change the system and come out of this pandemic, this could be a turning point in healthcare.
First, those who are not directly affected must be convinced that these inequalities affect everyone. Countless studies have shown that equity in leadership benefits patients. When leadership is diverse and representative of the communities served, health care outcomes improve – this includes reduced mortality, increased effectiveness in treating chronic diseases, and reduced hospital readmissions. Organizations with greater equity – such as equal pay – have improved overall performance and retention, and workers have greater confidence in leadership, better job satisfaction and increased productivity, and more innovation and creativity.
Second, there is no one-size-fits-all solution. The approach must be multi-pronged and requires intentional strategies that do not impose responsibility on those directly affected. It’s a recipe for burnout. The work must be supported by all. A comprehensive approach should include the following:
- Perform a cultural audit. Make sure all voices have a seat at the table. Be intentional in making sure there are individuals with intersectional identities, like women of color, whose ideas are heard.
- Equitably distribute the tasks of citizenship. Make sure that women are not the only ones assigned to citizen-type work that will not provide a return on investment. Do not rely solely on affected marginalized communities to do the necessary “invisible” work. Offer compensation for this type of work.
- Pay transparency. This is one of the most difficult, but the most necessary steps to move towards systemic equity. Hire an objective auditor, identify the cause, then implement a solution.
- Sponsorship and mentoring. Be intentional about who is sponsored and promoted to leadership positions. Think outside the normal social or professional circle. Equally skilled people are often overlooked because they do exceptional work at night and on weekends and not in plain sight. Look around and see who is not being offered opportunities and think critically and objectively about their attributes. The AAMC has a Women of Color initiative with a toolkit to advocate for their advancement.
- Be an accomplice. The majority of leaders continue to be men. Without male leaders helping to lead the change, the system will continue to function as usual. Provide leadership training to men interested in learning how to be more inclusive leaders. Men can also decline to participate in all-male or “manual” panel discussions as initiated by the NIH Director in 2019.
- Repair the system. Multiple barriers persist across care, perpetuated by a hierarchical structure that does not consider more than half of the health workforce to be female. Early morning or late evening meetings may not be achievable for everyone and should be adjusted to suit your team members.
We have a recipe for burnout when women: finish their work during the third and fourth shifts; assume responsibilities for the benefit of others but not for themselves; not being recognized fairly with rewards, opportunities and a fair wage; and work harder than their colleagues. We must stop the bleeding from our best and brightest women in medicine. Our health systems and our patients will suffer without them. Let this be our watershed moment and let’s change the system. We will all have to work together if we are to move forward.
Shikha Jain, MD, is an assistant professor of medicine in the division of hematology and oncology at the University of Illinois at Chicago. She is also CEO and President of the non-profit organization Women in Medicine and CEO of IMPACT. Monica Verduzco-Gutierrez, MD, is an accomplished academic physiatrist and professor and chair of the department of rehabilitative medicine at the Long School of Medicine at UT Health San Antonio. Vineet Arora MD, MAPP, is Herbert T. Abelson Professor of Medicine, Certified University Hospitalist and Dean of Medical Education at the University of Medicine of Chicago. She is co-founder of IMPACT.