“It feels like we are constantly treading water to just stay afloat and get by.” (Female, Parent, Faculty, 6–10 years in practice)1
Gender disparities are well-documented in academic medicine, including the representation of women in authorship, speaking opportunities, and other measures of academic productivity.2,3 Unfortunately, the coronavirus disease 2019 (COVID-19) pandemic has further exacerbated this gender divide,4 which threatens women’s career advancement and risks accelerating the attrition of women from academic medicine.5 Women faculty with children are particularly vulnerable and more likely than faculty without children to consider departing academic medicine.6 Although the societal view of women as caregivers is not new, the increased demands placed on caregivers during the COVID-19 pandemic have been unprecedented. In this month’s issue of Hospital Pediatrics, Sharp et al describe a survey study revealing that women pediatricians who were parents were significantly more likely to report decreased academic productivity during the COVID-19 pandemic compared with men with children.1 The authors’ qualitative thematic analysis of free text responses provides additional insight into key stress points for women physicians during the pandemic. Although the focus of Sharp et al’s survey was on childcare, the highlighted points of stress likely also apply to women in other caregiving roles, such as caring for elderly parents. The authors call for intentional change from institutions, grant funding agencies, medical societies, journals, and leaders to support all women in medicine. We review key strategies that each of these stakeholders can take to promote meaningful and sustainable change.
What Can Institutions Do?
Institutions play a key role in recognizing, supporting, and rewarding the role women play in scholarly projects and initiatives. Institutions must ensure that resource allocation, including dedicated nonclinical time, is transparent and tracked over time. Because the COVID-19 pandemic has disproportionately impacted women as first authors,7 institutions should pay particular attention to supporting early career faculty, who may have missed out on foundational scholarly opportunities while simultaneously facing the highest work-life stress.6 Institutions can support academic productivity through programs that provide guidance from project development through publication. Additionally, institutions should offer structured mentorship programs that go beyond individualized guidance to create valuable networks as well as sponsorship opportunities. Providing the infrastructure for mentorship networks, including peer mentorship, can maximize limited resources, cultivate new collaborations, and increase the diversity of mentee–mentor relationships.8
Institutions should also pay particular attention to midcareer faculty women, who face unique challenges at their career stage.9,10 Because of the pandemic, midcareer women may have missed a period of high academic productivity and national recognition because of a plethora of professional and personal demands. Institutions need to recognize the unique needs of women at this stage and provide support for the transition to senior authorship, recognize scholarly activities that were postponed or canceled because of the pandemic, and adjust promotion structures to account for disruptions or delays in academic productivity.
Although women in senior academic positions may be somewhat protected from the loss of productivity during the pandemic, they are often expected to do the extensive work of ushering more junior colleagues of all genders through the promotion process. With the disproportionately low number of women in senior positions compared with women entering academic medicine, the load of serving as a mentor for so many younger women falls on a small number of shoulders. Institutions must recognize and reward senior faculty of all genders and backgrounds who mentor junior faculty with diverse backgrounds, recognizing that effective mentorship does not require a demographic match.11
Institutions must also acknowledge and adapt to the ways that the pandemic has increased demands on health care workers’ time, both at home and within the workplace. Sharp et al found that 60% of physician parents reported unreliable childcare during the pandemic.1 Unstable childcare was a significant contributor to the gender disparity in perceived academic productivity, further supporting the need for medical institutions to provide on-site, reliable, and affordable childcare. In addition, institutions should offer reasonable leave policies and permit the use of federally permissible funds for dependent care.12 Innovative programs, like the Doris Duke Charitable Foundation’s Fund to Retain Clinical Scientists, provide institutions with support to retain physician researchers, especially during times of increased caregiving responsibilities.13 Additional support and funding during these critical years not only allows continued productivity but also validates, rather than stigmatizes, individuals as both caregivers and researchers.14
Finally, institutions should specifically reward service activities that are often undertaken by women, to avoid an uncompensated “citizenship tax” that takes time away from scholarly activities.15 This step is particularly important for women with multiple marginalized identities who face the challenges of intersectionality16 and an increased burden of tasks, including mentorship, due to underrepresentation of women of color in senior positions.
What Can Grant Funding Agencies Do?
Grant funding agencies have particular power stemming from their control over resource allocation. Studies reveal that women receive less overall grant funding17 and bias is present during the grant peer review process.18 To combat bias, grant funding agencies can embrace practices such as increasing the representation of women on review committees and requiring recurring implicit bias training for all members on review committees.19 Grant funding agencies should provide applications and reviews with objective, nongendered language and encourage best practices to promote the diversity of applicants.20 Agencies should expand the topics of research funded beyond what has conventionally been viewed as the center of biomedical research, including diversity, equity, and inclusion work both focused on the workforce and to address disparities among patients in health outcomes, work which is largely done by women and underrepresented groups without any external funding. Finally, grant awards should have increased flexibility for extended funding time periods during times of increased caregiving demands and processes for support.21
What Can Medical Societies Do?
Medical societies are in a critical position to support women in academic medicine. Society-sponsored conferences offer valuable opportunities for members to present scholarly work and gain national recognition. The underrepresentation of women as invited and plenary speakers has been well described, even in fields of medicine that are now predominantly constituted by women, such as pediatrics.3 Strategies to promote the representation of women as speakers include establishing and publishing a clear commitment to speaker diversity, transparently tracking speaker demographics, and ensuring diverse members on conference program selection committees.22 Support for lactation at conferences should become the expectation, rather than the exception. Lastly, conferences should establish codes of conduct that not only specify unacceptable overt misbehavior but also highlight more subtle ways that women are systematically devalued. For example, societies can explicitly instruct moderators to introduce all speakers by their professional titles in light of evidence that absent such instructions, women are less likely to be treated respectfully than men.23
What Can Journals Do?
Medical journals must make a commitment to diversity throughout the publication process, from invited authorship to reviewer selection to editorial board composition. The underrepresentation of women as editors-in-chief is pervasive across medical specialties and, unfortunately, shows minimal improvement over time.24 Because editors-in-chief are frequently selected from editorial boards, increasing the representation of women on editorial boards must be a priority. Journals should also track author demographics and target increasing the representation of women as solicited authors.
What Can Leaders Do?
Commitment to change must also occur at the individual level. Although the transition to a virtual world has allowed some increased flexibility, there has also been a blurring of work–life boundaries as described by several comments in Sharp et al, Leaders have a responsibility to create and promote a work culture that is inclusive of all members and acknowledge that early morning and evening meetings are unlikely to be family-friendly. Leaders should also look for and encourage diverse perspectives and ideas, which have been shown to promote innovation.25 Because men hold the vast majority of senior leadership positions in medicine and constitute the majority of senior authors,2 men need to be intentional when selecting protégés and inclusively sponsor women as well as men for project involvement and leadership.26
The importance of allyship is not limited to leaders; all individuals, including other women, can amplify women’s ideas, sponsor women for positions, and nominate women for speaking opportunities and awards. Similar to public declarations of refusing to participate on a panel of all men, individuals need to closely consider their participation in projects with all men. The actions of individuals have the potential for positive compounded change and serve as important role modeling for others. Lastly, and perhaps most importantly, are men’s contributions at home. Prioritizing shared household responsibilities, especially tasks with significant cognitive load, is key to supporting women’s success in academic medicine.27
The COVID-19 pandemic has exacerbated inequities for women, particularly around academic productivity. The responsibility to promote change cannot fall on the shoulders of women. Institutions, grant funding agencies, medical societies, journals, and leaders must make intentional and ongoing commitments to promote gender equity in medicine. As the evidence for worsening pandemic-related gender disparities continues to grow, the medical community must transition from awareness to action. It is time to implement strategies in all areas of medicine to achieve the retention and advancement of women.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: Dr Jagsi has stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health care companies; she has received personal fees from the National Institutes of Health as a special government employee (in her role as a member of the Advisory Committee for Research on Women's Health and the Board of Scientific Counselors), the Greenwall Foundation, and the Doris Duke Charitable Foundation. She has received grants for unrelated work from the National Institutes of Health, the Doris Duke Foundation, the Greenwall Foundation, the American Cancer Society, the Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium. She had a contract to conduct an investigator-initiated study with Genentech. She has served as an expert witness for Sherinian and Hasso, Dressman Benzinger LaVelle, and Kleinbard LLC.
Drs Allan, Jain, Jagsi, and Shaughnessy wrote, reviewed, and revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.hosppeds.org/cgi/doi/10.1542/hpeds.2022-006650.