It’s Time to Break the Cycle: Gender Inequity in Pediatric Hospital Medicine Free

In this issue, Allan et al and Forster et al present compelling data on the gender-based differences that exist in postings on the AAP Section on Hospital Medicine Listserv and in salaries of practicing pediatric hospitalists, particularly for those that serve in leadership roles.^1,2  These findings are not surprising because we know gender inequity remains alive and well in medicine,^3–7  and pediatric hospital medicine (PHM) is no exception.^8–10  Occupational gender segregation^3,11  of women in pediatrics and in PHM has led to tremendous consequences in salary, advancement, and leadership inequity for women in our field.

In “Gender Communication Differences on a Pediatric Provider Listserv,” the authors share data from AAP Section on Hospital Medicine Listserv reviews that show that women, who represent 70% of the PHM community, contribute proportionally fewer listserv posts than men. They also found that, compared with women’s, men’s posts tend to have more words, are more likely to focus on health policy and research, include more statements than questions, and are more frequently coded as adversarial, authoritative, or self-amplifying. These findings are not surprising given societal pressures and socialization practices that encourage women to practice more communal behaviors compared with agentic traits more commonly encouraged in men.¹²  Furthermore, there is ample evidence that these communal behaviors are less likely to be rewarded when to comes to advancement to leadership, rising to “expert” status in the field, or salary negotiations.³ 

In “Association Between Gender and Salary Among Pediatric Hospital Medicine Physicians,” the authors share the results of a cross-sectional study of 559 pediatric hospitalists from major PHM listservs examining base and total salary values adjusted for hours worked, with subanalyses evaluating salary based on leadership positions and identified race. As would be expected given the salary findings in other specialties,^13,14  women have lower base and total salaries than men, with these differences most pronounced among those who hold leadership positions. That the demonstrated disparity gap widens as women and men move into leadership roles could suggest either that individuals of different genders may be differentially compensated for the same work or that the types of leadership roles commonly held by women are systematically undervalued compared with those commonly held by men. Evidence shows that men tend to hold more line-type leadership roles that are in a direct “line” to top leadership roles in an organization (eg, CEO, Dean, COO, CMO), whereas women hold more staff-type leadership roles that support and advise top leadership.¹⁵  We suspect that both are likely at play, but regardless of the primary driver, the impact is clear: Women in PHM are not equally compensated.

PHM is sadly holding a mirror to other specialties in and outside of pediatrics. Decades of research have demonstrated the pay gap that exists across various specialties, practice types, and ranks. Gender equity advocates have been banging on the pulpit for years about the need for continuous quality improvement efforts that focus on revisions to the components of the compensation calculus, improved transparency, standardization of salary negotiation practices, and decreased reliance on women physicians to execute “office housework” and tasks that do not lead to advancement. Despite these data and advocacy, we have yet to see meaningful changes in salary equity for women in medicine.³ 

In their designs, both studies acknowledge gender as a construct that is not binary; however, neither had sufficient nonbinary respondents or posters to comment on gender inequities beyond those between men and women. Whether this suggests the presence of few nonbinary physicians in PHM or few who are open about their identity professionally, it raises unanswered questions about inclusivity in PHM and in what way the gender inequities described extend to our nonbinary colleagues.

Although PHM is a field that prides itself on being innovative, inclusive, and progressive, the Allan and Forster articles are joining a growing body of literature that shows we are far from immune to gender inequity seen across medical subspecialties. Are we comfortable propagating the same well-intrenched inequities and biases? Is this who we want to be as a specialty?

Allan et al cite the evidence supporting social media platforms as a potential avenue to advancement, invited speaking and scholarship opportunities, and future citations through increased amplification.^16–18  Online platforms, including listservs and social media, have created more accessible avenues to make connections with colleagues across the country and have broken down barriers to accessing experts in the field. However, the demonstrated gender disparities in use suggest the presence of barriers that make this resource less accessible to some. Allan et al note that “under representation of women posters on the listserv may impact important components to career advancement” and provide some suggestions for how to achieve greater representation of women on the listserv such as deliberate amplification of work done by women and self-reflection by those who may use an abundance of declarative or adversarial language. Although potentially helpful, these suggestions depend heavily on changes in human behavior that must be self-regulated and therefore are not highly reliable for large-scale change. Although demanding these individual behaviors from ourselves and our community is necessary, it is not sufficient; we need also need to focus on advocating for and implementing systemic changes that are capable revolutionizing network cultivation for women.

As we imagine innovative systems changes, we need to aim to impact the online community and those that extend beyond it. Online platforms may have opened a new world for us to connect with others, but we believe it should not be relied on solely for network cultivation but should be coupled with other network-building strategies. There is no doubt that developing a strong network of colleagues is an important catalyst for success in medicine.¹⁹  It is our opinion that truly effective networks lead to deep, meaningful career relationships in which individuals develop respect, trust, and admiration for each other’s work. Having a strong network is not just about who you know, it’s also about how well they know you and your work. A strong network is built on the foundation of being one’s authentic self, giving and receiving of time and effort, and thoughtful cultivation.²⁰ 

As such, efforts for systemic change for gender equity should focus on all areas in which career-changing networking might occur, including online spaces. Initiatives such as creating networking and sponsorship programs within PHM, as well as having open calls participation or leadership for collaboratives, study groups, and interest groups and then ensuring diversity in these groups are examples of structured and sustainable ways to increase measurable networking opportunities for women.^19,21  Once women ascend into these communities or leadership roles, we must also focus on providing them the time and support for successful participation.

For the online space specifically, changing listserv and social media behavioral patterns presents a much tougher feat to conquer. Telling women to be more agentic and “post more” and men to be less adversarial and “post less” alone will not result in measurable change, even with effective implicit bias and gender equity training. Thoughtful initiatives that embrace a quality improvement lens and use high-reliability interventions could impact change. For example, if we want to increase amplification of women’s posts on a listserv or social media, we must have a structured mechanism that reliably highlights or responds to their posts. As the medical field becomes more comfortable with artificial intelligence, it could also serve as a useful tool in assisting with online mitigation and amplification efforts.

When it comes to the pay inequities highlighted by Forster et al, there are ample strategies provided in the literature that PHM leaders can implement to help close the salary gap between men and women. Strategies such as salary calculation transparency, setting a standard salary benchmark for new hires, eliminating salaries and bonuses based on seniority, leadership, and productivity (areas where women are at a disadvantage), conducting salary equity reviews and mitigating inequities discovered, sharing salary percentiles, and eliminating or being up front about the need for salary negotiation are effective steps to eliminate salary inequity.³  We also need to ensure our PHM leaders advocate for time and support for critical citizenship roles and that unfunded roles are being rotated through individuals of all genders. Last, leaders of PHM groups and institutions must be held accountable for achieving salary equity, even going so far to link the outcomes of these efforts to their own evaluations, salaries, and advancement opportunities.

PHM is at a critical crossroads of its history. We are still a young specialty capable of dynamic changes. Previous literature in addition to the thought-provoking articles by Allan et al and Forster et al show we are a specialty that is laden with inequities and challenges for women who make up roughly 70% of our workforce. We cannot be complacent and wait for things to change as our specialty grows and evolves. We must take strategic, deliberate action toward change. We challenge all PHM groups, leaders, and national organizations to incorporate improvement efforts that focus on highly reliable systemic changes that can be sustained and measured over time.

Earlier, we posed the question: Is this who we want to be as a specialty? We know our answer. We know we can do better. We must do better. It’s time to take action.