Improving the lot of women in medicine

Gail D’Onofrio, M.D., M.S., wanted to be a physician for as long as she can remember, but after graduating from Duke with a degree in nursing, she was sidetracked. “I started in nursing because there weren’t people anywhere along the road who said medical school is an option,” she said.

D’Onofrio spent eight years working in general and thoracic surgery, earning a master’s degree in nursing along the way. Then, in her early 30s, she returned to her original goal and entered medical school at Boston University (BU). When it came time to apply for a residency in 1987, she was advised to conceal her age and to deny any interest in having children. After securing a position at BU, she disregarded this advice and gave birth to triplets. She joined the faculty there and juggled her responsibilities by working nights, taking one fewer clinical shift per week (along with a large pay cut), and completing her academic work while her children slept.

In 1996 D’Onofrio arrived at Yale and helped to build the emergency medicine section, becoming chief in 2005 after a nationwide search. When the section became a full department in 2009, she was chosen to lead it. “You’re not going to become a department chair by having a lot of outside interests,” she said. “My hobbies were and are my children.” She found time to be a classroom mother and a soccer coach while advancing in her career. Besides heading a department, she is chief of adult emergency services for Yale-New Haven Hospital and is recognized as a national leader in emergency medicine.

As did other women in medicine, D’Onofrio ignored the discouraging words and pursued her goal of becoming a physician. But the medical establishment has not always welcomed women into the fold. Women now make up about half the student body in medical schools around the country; their representation on med school faculties has increased as well. But at Yale and other institutions, some of the forces arrayed against D’Onofrio and others of her generation—lack of mentors and role models as well as the need to juggle family and career—still present a challenge to women, despite great strides in addressing issues of gender equality since the 1970s.

“A waste of effort and funds”

The presence of women in medicine is not a new phenomenon. Ancient Egyptian medical schools accepted women as both students and teachers, and until the 19th century most health care providers were midwives. This tradition persisted despite both the medieval practice of accusing midwives of witchcraft and a petition to England’s King Henry V in 1421 to banish them from practicing medicine. But when the University of Pennsylvania’s medical school and Columbia University’s College of Physicians and Surgeons opened their doors to colonial American students in 1765 and 1767, respectively, all their first entrants were men.

It was not until 1849 that Elizabeth Blackwell became the first woman to receive a medical degree in the United States, from what was then the Geneva Medical College in Geneva, New York. When Louise Farnam and two other women set their sights on the Yale School of Medicine in 1916, one impediment to their acceptance was a lack of bathroom facilities. Farnam’s father, a Yale alumnus and professor of economics, paid for the construction of a women’s lavatory. (Susan J. Baserga, M.D. ’88, Ph.D. ’88, recounted the history of women at the medical school in “The Early Years of Coeducation at the Yale University School of Medicine,” published in The Yale Journal of Biology and Medicine in 1980.)

The next year the School of Medicine accepted only one woman, Ella Clay Wakeman Calhoun, M.D. ’21. “My partner was courteous and distant with me; it was probably a trial for him to have a woman for a partner,” she wrote, reflecting on her first-year anatomy class. Her second-year pathology professor “was known to consider women medical students (certain, one day, to become housewives) a waste of effort and funds!” Calhoun went on to serve for 23 years as health officer for the Connecticut town of Bethany.

More than 40 years later, when Carolyn W. Slayman, Ph.D., arrived at Yale in 1967 as a young assistant professor of physiology and microbiology, there were still few female students or role models. Dorothy M. Horstmann, M.D., FW ’43, had been the first woman promoted to full professor in 1961. Slayman, Sterling Professor of Genetics and deputy dean for academic and scientific affairs, remembers the late Phyllis T. Bodel, M.D., questioning why there were only about seven women in every class of 100. The admission committee’s response? “Because that’s the right number.”

Bodel chaired the Committee on the Status of Professional Women at Yale Medical School, which in 1974 recommended increasing the number of female faculty members and identifying areas of the curriculum in which gender discrimination was affecting learning. The Office for Women in Medicine—the first such office in an American medical school—was established in 1975 in response to these recommendations, with Bodel serving as its first director. The timing was right. It occurred at the height of the women’s movement and three years after the passage in 1972 of Title IX, which required educational institutions that receive federal funding to offer equal opportunities to all students regardless of sex.

Women continued to make headway at Yale—more women were entering medical school and more women on the faculty were winning promotions—but progress was slow. In 1978 women occupied only 4 percent of professorships, and there were no female department heads until 1984, when Slayman was appointed chair of the Department of Human Genetics.

Fifteen years later a report from the Massachusetts Institute of Technology drew attention across the country. The 1999 report found inequities among tenured women at MIT in salary, access to space, resources, and inclusion in positions of power and administrative responsibility. Although Yale had been addressing these issues for more than 20 years, the report rekindled the debate. After the medical school’s Commission on Women Faculty found in 2003 that women earned on average about 4.9 percent less than men, then-Dean David A. Kessler, M.D., set about bringing salaries of women into line with those of men. Since that time, there has been a commitment to reexamine this issue on a yearly basis.

“It’s not just an issue of today and this year, but if you amortize the amount of money you’re losing over a 20- or 30-year career, it’s an extraordinary amount,” said Carolyn M. Mazure, Ph.D., professor of psychiatry and psychology and associate dean for faculty affairs. Mazure is also a member of the Status of Women in Medicine (SWIM) committee, which was formed in 1974 as the Committee on the Status of Women and reinvigorated after the commission’s 2003 report. “In many ways Yale is a leader, and we don’t see any reason why we shouldn’t be a leader in this regard, too.”

Compared to other medical schools, Yale fares as well or better in terms of the numbers of women on its faculty: According to the Association of American Medical Colleges, female professors comprise 18 percent of medical school faculty at Yale and in the United States. The percentage of female associate professors at Yale is 36, above the national average of 30. Yale also tops the national average for female assistant professors—46 percent as opposed to 41 percent nationally. At Yale, three department chairs out of 28 during the past academic year were female, slightly lower than the national average; however, the recent departure of Margaret K. Hostetter, M.D., from pediatrics has reduced the number of female chairs by a third.

“There have been huge changes in the number of women over the last 40 years, and that has changed the whole community here,” said Slayman. “But we need to figure out why it’s taking so long for more women to become full professors.”

“It is unacceptable that while 50 percent of our students are female, when they look at the professors, they don’t see many women,” said Robert J. Alpern, M.D., dean and Ensign Professor of Medicine.

There’s no easy answer to why it’s harder for women to advance in medicine. The notion that women haven’t been around long enough in large enough numbers—the “pipeline” argument—doesn’t explain the data. Even in pediatrics or psychiatry, where women have accounted for half the field for more than 25 years, they have accounted for only about 10 percent of department chairs during the past decade. Such other explanations as the notion that women don’t compete due to family issues highlight cultural issues that undermine women yet remain pervasive in work environments. “Some women feel there are subtle barriers to their advancement beyond family issues,” said SWIM co-chair Jennifer M. McNiff, M.D., professor of dermatology and pathology.

“Paid less, promoted more slowly”

In 2007, a report from the National Academies of Science titled “Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering,” found that women faculty members “are paid less, are promoted more slowly, receive fewer honors, and hold fewer leadership positions than men.” These discrepancies, the report continued, did not appear to be based on productivity, significance of work, or other performance measures. Changes in institutional culture would be needed to recruit, retain, and promote more women. “We have these climate issues that are part of the American culture, and they’re manifest here the way they would be anywhere else,” said Mazure.

Those issues are “microinequities,” ostensibly small matters that interfere with a faculty member’s efforts to advance or work effectively. In a SWIM-sponsored presentation at the medical school in April, “The Fallacy of Fairness,” one of the contributors to the “Beyond Bias” report, Jo Handelsman, Ph.D., professor of molecular, cellular, and developmental biology, cited research showing that even though they intend to be fair, both men and women can hold implicit biases. They may rate a job performance lower if told it involved a woman. They may be more likely to hire a candidate if a male name appears on the CV, and in letters of recommendation they may refer to men as “researchers” and “colleagues” and to women as “teachers” and “students.” Collectively, these inequities take their toll, creating an environment with unnecessary barriers to women.

“Both men and women have unconscious biases,” said Merle Waxman, M.A., associate dean and director of the Office for Women in Medicine. “It’s a matter of making people conscious of them, and we’re trying to do that through diversity training.”

That training began in 2009, and the medical school revamped its recruitment procedures in the process. Search committees now include a diversity representative to minimize the influence of biases. Diversity training strives to make faculty aware of biases and assumptions that can influence the search, such as undervaluing or unfairly attributing the work of women or minorities. Committee chairs are also advised on how to run a fair and proactive search process, and they are encouraged to brainstorm strategies for increasing diversity. Such strategies include inviting women and other underrepresented minorities to participate in department-sponsored symposia and visiting appointments.

“There clearly is a bias,” said Alpern. “We’ve had a number of sociologists come visit, and the more we can educate the search committees about these biases, the more it will help. … All of these things help, but we have a long way to go.”

The importance of role models

For many women, mentoring has played a pivotal role in their careers. Hostetter, the former chair of pediatrics, was discouraged from going into medicine by her mother, herself a physician. D’Onofrio started out as a nurse rather than a doctor because there were few mentors to guide her. Last year an ad hoc committee at the medical school reviewed existing mentoring programs to develop a template that would define requirements and procedures for evaluation and promotion and provide structured mentoring for new hires and for faculty at critical junctions in their careers. “We have to find women in every department—and they’re there—and give them the skills and opportunities to mentor,” said D’Onofrio.

The impetus to move forward is not just internal. The Liaison Committee on Medical Education, which accredits all U.S. and Canadian schools that confer the M.D. degree, has taken an interest in how faculty are mentored, said Linda K. Bockenstedt, M.D., HS ’85, the Harold W. Jockers Professor of Medicine and director of professional development and equity. Her position was created to examine mentoring systems and to focus on issues related to gender and underrepresented minorities.

One of the major challenges for women today—just as it was for D’Onofrio—is balancing careers and personal lives. “For me, having kids and family and this career has meant that by and large I don’t do anything else,” said Laura E. Niklason, Ph.D., M.D., professor of anesthesiology and biomedical engineering. Fourth-year medical student Lara E. Rosenbaum said that she and her classmates—men and women alike—wonder how they’ll balance a family and career. “I’m working hard on this with my faculty, because if people don’t have that balance, they won’t be successful in their careers,” said Roberta L. Hines, M.D., HS ’83, FW ’84, chair and the Nicholas M. Greene Professor of Anesthesiology.

Among the steps Yale is taking to address these issues is the Faculty Advancement Series sponsored by the Office for Faculty Affairs, a series of lectures on wide-ranging topics that include demystifying the promotion process, mentoring, and developing child care options for faculty. “We’re trying to help clarify the process of promotion and what one has to achieve to make associate professor and professor in different tracks,” said Bockenstedt.

Yale has also re-examined the promotion clock and the length of child rearing leave. Faculty can now delay the promotion process for one year without being penalized if they wish to have or adopt a child, and paid childrearing leave has been extended to eight weeks. Space has also been allocated for lactation rooms. A SWIM survey highlighted the need for additional child care facilities, a key issue when recruiting both male and female faculty. “It’s a family issue, not just a women’s issue,” said SWIM co-chair Paula B. Kavathas, Ph.D., professor of laboratory medicine, genetics, and immunobiology.

While most young women today choose medicine without facing the resistance that D’Onofrio and others encountered, many realize the road that their mentors have traveled. “I’m grateful to the generations of physicians who overcame gender barriers that existed,” said Katriina Hopper, M.D., HS ’10, a fellow in geriatrics. “It’s a great time to be a woman in medicine.” But those further along in their careers remember the battles and recognize the challenges ahead. “There have been a lot of positive changes, but it does require constant vigilance, and we have a lot more to do,” said Mazure. “It’s a matter of continuing to foster change so all faculty members, women and men, can receive the full recognition they deserve and feel gratified by what they do.” YM