Women in Pediatrics: Progress, Barriers, and Opportunities for Equity, Diversity, and Inclusion

There is much progress to report for US women physicians (Table 1). For example, in 2017, the number and proportion of women matriculating as first-year medical students exceeded that of men (50.7%).^1,2  At the same time, they comprised 45.6% of residents and fellows,³  35.2% of active physicians,⁷  and 41.1% of medical school faculty.⁴  In pediatrics in 2017, women comprised 72.3% of residents,³  63.3% of physicians in practice,⁷  and 57.4% of academicians.⁴  Concurrently, the National Institutes of Health (NIH), through the efforts of the Office of Research on Women’s Health and Working Group on Women in Biomedical Careers, launched a series of programs aimed at career reentry, mentoring, and development.⁵  Doximity reported that the gender compensation gap may be starting to close, with physician salaries for women increasing at the same time salaries for men remain constant.⁶ 

Despite advances, there are many reports demonstrating disparities, particularly at the highest levels of leadership in academic medicine. Although accounting for 44% of all dean-level administrators in US medical schools in 2016, higher proportions of women were found in positions focused on education and mentoring (49%) and institutional public image (57%) than leadership (15%) and corporate decision-making (39%).⁸  Moreover, in 2018, women accounted for only 16.8% of deans,⁹  18.0% of medical school department chairs, and 26.2% of pediatric chairs¹⁰  (Table 1). Inclusion of women among department chairs and deans has remained at 18% since 2016¹²  and between 16% and 18% since 2012,⁹  respectively, despite accounting for 25% of professors in 2018.¹¹  Investigation of leadership in physician-focused medical specialty societies also revealed less-than-equitable representation among presidents,¹³  with the American Academy of Pediatrics (AAP) being among those with the largest gaps. Similarly, calculation of gender-related representation within the Federation of Pediatric Organizations (FOPO) and its 7 associated pediatric societies revealed women comprised 55 (54.5%) of the 101 board positions yet 3 (37.5%) of the 8 president-equivalent positions (Table 2).^17–24  Therefore, data indicate insufficient progress in the promotion of women into the most senior levels of leadership.

It has been more than a decade since Carnes et al²⁵  published a report on progress in women’s leadership and advances in women’s health. The authors noted slow progress into leadership roles and systematically refuted 3 conventional disparity justifications (Fig 1): (1) there are not enough women to promote (pipeline), (2) they do not compete for leadership positions because of family and/or lifestyle reasons (family and/or lifestyle), and (3) they lack the necessary leadership skills (unqualified).

The pipeline (not enough women) justification may work well when there are no other impediments to advancement and there is simply an absence of women, an issue that is not applicable to pediatrics (Table 1, Fig 1). The family and/or lifestyle justification for there being too few women in top-level leadership positions is often cited alongside the pipeline issue because many women do make personal decisions that impact their individual career trajectory (eg, having children or acting as caregivers). However, research shows that family and/or lifestyle choices do not adequately account for gaps in the representation of women in leadership positions or other gender-related disparities. For example, Carr et al²⁶  found that women faculty with children faced greater obstacles than men faculty with children, including lower levels of institutional funding and secretarial support, fewer publications, slower career progress, and lower career satisfaction. Other reports reveal women in the workplace experience impediments to advancement that are different and more challenging to overcome than men.^27–29  Similarly, Dr Keith Lillemoe recognized during his 2017 presidential address to the American Surgical Association that traditional justifications simply do not fully account for today’s gaps when he stated, “The number of outstanding, qualified female candidates is more than adequate to fill every open surgical leadership position in America today. The problem is not the pipeline—it is the process.”³⁰ 

The AAP noted in a 2013 policy statement³¹  that supporting a diverse workforce is imperative to ensuring the best delivery of care, and creating and sustaining diversity would require leadership in recruitment, mentoring, and education. In 2015, the FOPO, an umbrella organization comprising 7 pediatric medical societies (including the AAP), stated “maintaining the status quo is not an option” while envisioning “a strengthened profession of pediatrics that has optimized its expertise, leadership, and diversity in a changing pediatric workforce.”³²  After examining gender, diversity, and generational-related data and differences in the pediatric workforce,³³  including how these differences influenced part-time and research careers, work-life balance, and competency training, the FOPO Gender and Generations and Diversity and Inclusion working groups stressed the need to (1) “acknowledge the impact that the increasing proportion of women has on the field of pediatrics,” (2) achieve greater diversity in the workforce, and (3) “ensure equity in paths to leadership positions.”³²  The AAP’s 2018 Diversity and Inclusion Statement went further in stating, “Maximizing the diversity of our members and leaders allows the AAP to benefit from the rich talents and different perspectives of these individuals.”³⁴  In 2018, it was a natural step for the AAP to join 5 other physician-focused societies in developing the Women’s Wellness through Equity and Leadership collaborative to foster workplace equity, networking, mentorship, and leadership training.³⁵ 

In addition to pediatric society-sponsored leadership training, thousands of women physicians, including pediatricians, have received formal education from other organizations. For example, the Association of American Medical Colleges (AAMC) Mid-Career Women Faculty Leadership Development Seminar³⁶  has trained nearly 5000 women from early to midcareer faculty ranks, including ∼650 women in pediatrics (Diana Lautenberger, Director, Diversity & Inclusion and Women in Medicine & Science, AAMC, personal communication, 2019). Similarly, the Drexel University College of Medicine’s The Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) program³⁷  has graduated nearly 1100 women who currently hold high-level leadership positions at 259 US and Canadian academic health centers (Nancy Spector, Executive Director of ELAM, personal communication, 2019).³⁷  Of the graduates, 130 (12.0%) are pediatricians, 42 of whom were at the associate professor level when they entered the training and 18 (42.3%) of whom have since achieved full professor ranking. Graduates have also realized higher administrative positions, including vice dean, dean, and vice president (Fig 2). These leadership training examples lend support to our conclusion that a lack of numbers (pipeline), qualifications (training), or interest (Fig 1) likely cannot account for low numbers or the absence of women in pediatric leadership positions.^37–39 

Although education and networking opportunities are benefits of leadership training, promotions generally cannot be attributed solely to training. Mentorship is usually considered to be positive for retention, productivity, and career advancement but also has challenging components (eg, investments of time and money by individuals and organizations). Nevertheless, formalized mentoring programs can be structured in a variety of ways,⁴⁰  such as traditional dyad mentoring, peer mentoring, and group mentoring, and mentoring programs in professional societies can provide opportunities for women as well.^41–43  However, women may be less likely than men to have mentors⁴⁴  and might benefit more from sponsorship: an intentional effort by a current leader to effectively advocate for a woman so that her career is advanced.⁴⁵  Indeed, despite the value in mentorship for those of all genders, including those who identify with underrepresented groups,⁴⁰  it may not be sufficient to equitably advance careers.^46,47  Sponsorship, an additive, may be “critical to career advancement.”⁴⁶ 

Single-institution studies of pay gaps for women in pediatrics report mixed results (Table 3). For example, the Vanderbilt University School of Medicine’s Department of Pediatrics found no significant gender-related compensation differences after accounting for years since first appointment, rank, clinical productivity, and track.⁴⁸  On the other hand, the University of Colorado's Department of Pediatrics found that, after adjustment, 72% of women and 51% of men doctor-of-medicine faculty received pay below the Association of Administrators in Academic Pediatrics national median salaries.⁴⁹ 

National studies and surveys, however, consistently report pay gaps for women in pediatrics even after adjusting for confounding variables.^{6,50,51,53–57}  For example, Medscape and Doximity ranked pediatrics among the lowest-compensated medical specialties, both noting 20% to 25% gaps for women.^56,57  Doximity’s survey went further, ranking pediatric pulmonology and general pediatrics among the 5 medical specialties with the highest gender-related wage gaps by percentage of annual income.⁵⁷  Notably, because both surveys used full-time salary equivalents, discrepancies cannot be explained by women pediatricians working part-time, making the case that pay gaps are not entirely due to women pediatricians’ personal work-related choices. Medscape, in particular, has refined its survey over time, and evidence suggests women physicians remain at risk for being unfairly compensated after adjustment for a variety of factors.⁵⁸  Importantly, the effects of unfair compensation are likely underestimated because analyses have not accounted for slow advancement of women, reduced 401(k) contributions, and slow debt repayment.^25,29,59 

To better understand the effects of pay disparities, we calculated the potential investment yield from the gaps found in 2 compensation studies demonstrating gender-related disparities in pediatrics even after accounting for confounding variables. Jena et al⁵¹  reported the annual gender-related pediatric compensation gap was ∼$24 500, whereas Frintner et al⁵⁴  more recently found the gap to be $8000. Respectively, over a 35-year career, a woman pediatrician could earn an additional $857 500 or $280 000, without accounting for inflation. Using publicly available financial modeling tools,^52,60–62  a relatively conservative estimate of the inflation-adjusted yield following annual investment of after-tax income could add >$700 000 and $200 000, respectively, to her income over the course of her career. Moreover, equity in pay could exact benefits beyond financial yield because this additional income could be used to relieve stress related to paying off educational debt or time spent on household and family responsibilities⁶³  (eg, allow for the hiring of a cleaning service or caregiver).

Over the last 2 decades, the number and proportion of women on the editorial boards of pediatric journals has increased.⁶⁴  In aggregate in 2001, <18% (average, 17.8%) of the editorial boards of 3 major pediatrics journals were women, although they represented 44% of pediatric faculty at that time.⁶⁴  In 2016, the editorial boards of these same journals consisted of almost 40% women (average, 39.8%).⁶⁴  However, the year before, they represented 55% of pediatric faculty^64,65  and 61.9% of pediatricians.⁶⁶  Therefore, despite the number and proportion of women on editorial boards in pediatrics increasing, and some publication organizations making more progress than others, a gap in the representation of women remains (Fig 3).^67–69 

The editorial gender-related gap cannot be explained by a lack of qualified candidates because there were >3200 women pediatric associate professors and professors working full-time in US medical schools in 2015.⁶⁵  A large body of research that documents publishing disparities for women at many levels; however,⁷⁰  relevantly, there are data that suggest gender diversity in reviewing teams, including editors, may improve equity in publication.⁷¹  Although concerning, this may not always be the case because a recent study of the relationship between an associate editor’s gender and the publication of original research articles in the Journal of Pediatrics showed no gender-related differences in outcomes.⁷²  Regardless of whether it affects other disparities (eg, publications for women), inequitable gender-related representation on editorial boards is itself a disparity that could be easily corrected.⁷³ 

In a large study of gender bias in medical publications that evaluated authorship in core specialties (pediatrics, internal medicine, obstetrics and gynecology, and surgery), researchers found that the proportions of women among first and last authors of original research increased between 1970 and 2004, with their percentages in the Journal of Pediatrics increasing from 15% to 39% among first authors and 4% to 38% among last authors.⁷⁴  However, women were represented at lower-than-expected levels as both first and last authors. More recent data in pediatrics similarly showed increasing proportions of women among authors of original research over time, with the percentages increasing from 40% to 57% among first authors and from 29% to 38% among last authors from 2001 to 2016.⁶⁴  Although these trends are promising, given that the majority of pediatric faculty (55%)^64,65  and pediatricians (61.9%)⁶⁶  were women in 2015 and the representation of women among pediatric faculty remains lower than among pediatricians in active practice, further work is needed to reach equity in representation (Fig 3). Moreover, a study of gender-related authorship of perspective-type articles in the 4 highest-impact pediatric journals revealed women, when compared with their proportions among pediatricians, were represented at lower-than-expected levels among physician first authors, last authors, and coauthors of articles written by men physician first authors.⁷⁵  This latter study highlights the importance of research in microinequities (more subtle forms of bias, such as being left out of medical society newsletters⁷⁶  or being introduced less formally as a speaker⁷⁷ ) because they likely contribute to macroinequities, such as those in pay or promotion.⁷⁸ 

One explanation for some of the underrepresentation of women in academic publishing could be lower research productivity, and so it is important to assess the role of gender bias in grant funding. Although men and women physicians were found to be equally likely to receive mentored K awards,⁷⁹  several studies have shown that critiques written for NIH Research Project R01 Grant applications from men and women appear to be written differently.^80–82  For example, critiques of women’s funded grant applications tended to have more references to competence or ability, whereas men’s tended to have more negative terminology,⁸¹  suggesting women’s grant applications might need to be of higher quality to receive a fundable score. Similarly, male investigators were more likely to be described as leaders and pioneers, whereas female investigators were more likely to have their success attributed to their environment.⁸²  Numerical scores assigned to women’s grants were also worse than those assigned to men’s.^80,82  Even when women had successful grant applications, they were awarded less money than men were.⁸³  However, when applications to the Canadian Institutes of Health Research were assessed by the quality of the science rather than characteristics of the investigator, the funding gap between men and women decreased.^84,85 

On its Web site, the AAP states the National Conference and Exhibition is the “premier venue for pediatric health care professionals to come together and share their passion for the health of all children,”⁸⁶  and undoubtedly, equity in the gender-related representation of speakers at this conference is an important metric to consider. We divided lists of plenary faculty⁸⁷  (AAP, personal communication, 2018) from meetings taking place from 2006 to 2018 into 3 categories according to information provided by the AAP (keynote, named lectureship, and other unnamed plenary session) and compared the data with benchmarks equivalent to the proportion of active women pediatricians reported by the AAMC near the beginning (55.4%; 2007)³⁸  and end (63.3%; 2017)⁷  of the 13-year study period (Fig 4). Our analysis demonstrated that women among all (Fig 4A), physician (Fig 4B), and nonphysician (Fig 4C) plenary faculty were represented at lower-than-benchmark levels in all session categories. Moreover, women physicians (Fig 4B) were represented at lower levels than women nonphysicians (Fig 4C) in all (30.8% vs 34.2%), keynote (0% vs 30%), and named lectureship (25% vs 50%) sessions, respectively.

Comparison of the yearly proportion of women physician plenary faculty during the 13-year study period to the proportion of women pediatricians as reported in each of 5 years by the AAMC^{7,38,66,88,89}  (Fig 5) revealed 3 important findings: (1) representation of women physicians at higher-than-benchmark levels 20% of the time (1 of 5 years; 2015); (2) representation of women physicians at lower-than-benchmark levels 80% of the time (4 of 5 years) with statistically significant underrepresentation occurring in 2013 and 2017; and (3) over the course of the entire study period, zero representation of women physicians 23% of the time (3 of 13 years: 2008, 2011, and 2013). Moreover, each year since 2015, the representation of women physicians among plenary faculty has remained <45%. Going forward, intentional effort will be needed to equitably represent women among physician speakers, particularly for keynote and named lectures.

The intersection of race and/or ethnicity and gender disparities has been studied in academic medicine, including pediatrics. Johnson et al⁹⁰  reported on unconscious racial bias among pediatric academic leaders, who may be influential in addressing workforce disparity through hiring decisions, such as training program directors, medical directors, or departmental or division leaders. Although underrepresentation of minorities in their pediatric departments was noted by 98% of participants, researchers found that when stratified by race or gender, non-Hispanic whites and men demonstrated more pro-white and/or anti-black preference, as evidenced by higher scores on the Implicit Association Test, a validated instrument that assesses unconscious bias.⁹¹  Moreover, 50% of these pediatric faculty leaders cited a lack of qualified minority candidates as a barrier to recruitment. This study did not evaluate outcomes pertaining to women of color. However, given disparities for women and the overrepresentation of men in leadership roles in pediatrics,^49,92  the bias described in this report deserves more study because it could influence the hiring, compensation, promotion, and retention of minority women pediatricians. For example, according to Ly et al,⁹³  47.8% of white male physicians earned >$200 000 annually. Even after adjusting for years in practice, practice type, specialty, and percentage revenue generated, only 14.3% of black women physicians earned the same amount.

The concern about potential bias influencing the pipeline of women of color in medicine is underscored by their low levels among academic faculty. The AAMC reported in 2016 that although 39% of full-time faculty were women, only 4% of them were underrepresented minorities.⁹⁴  Lett et al,⁹⁵  reporting on trends in faculty representation in 16 clinical specialties at US medical schools, found that black and Hispanic women physicians were underrepresented at the assistant professor level both overall and in pediatrics. Moreover, in pediatrics and 14 other clinical specialties, there were fewer black and Hispanic women physicians among associate or full professors in 2016 than in 1990.

Physician burnout was declared a public health crisis in the United States,⁹⁶  and despite some improvement,⁹⁷  it is associated with decreased job performance, disruptive behaviors, poor relationships with staff,⁹⁸  and large economic burden.⁹⁹  Workforce gender disparities in US physician burnout are multifaceted and emerging,¹⁰⁰  but some studies show that women experience more symptoms than men.^101–104  Rates vary considerably by specialty,¹⁰⁵  with pediatricians demonstrating relatively low levels.¹⁰⁶  Although studies in pediatricians have produced inconsistent results with regard to whether symptoms are more prevalent in women,^107–109  women reported spending more time on household responsibilities than men regardless of work intensity.⁶³ 

The prescription for gender equity in medicine should involve the basic scientific principles we use to tackle other difficult problems: (1) leadership accountability; (2) dedicated financial and human resources; and (3) an evidence-based, data-driven, and transparent approach to evaluation and reporting.¹¹⁰  For example, institutional hospital safety leaders, not patients (those most affected), are held responsible for identifying and prioritizing inadequacies, eliciting solutions, assigning institutional funds and resources, and collecting, analyzing, and compiling outcome data into reports distributed both internally and to regulatory agencies. In contrast, gender-equity initiatives have been largely driven from a grassroots level (with little or variable institutional recognition or support) by those most affected (women who are underpaid and underrecognized) with few resources (volunteering their spare time and often underwriting the initiatives themselves). Hospital safety initiatives rely on actionable metrics to ensure that interventions and the allocation of resources positively affect patient morbidity and mortality. In contrast to metrics, the creation of diversity structures, such as task forces, has been described as providing an illusion of fairness, and it has been suggested that they may actually make gender discrimination and inequities worse, particularly if the absence of data enables leaders to “legitimize the status quo.”¹¹¹  Like safety data, gender-equity data must also be collected, analyzed, and reported accurately to stakeholders on a regular basis, not just as part of a 1-time or irregular spot check. Crucially, organizational leaders must be actively engaged in creating and sustaining initiatives that advance progress because data collection is necessary but not sufficient to drive change.^111–113 

For more than a decade, pediatric professional organizations, including the FOPO and its 7 member organizations, have been focused on strategic initiatives to improve diversity and inclusion for women physicians (Table 4). Initiatives include the creation of leadership development programs for women, policy statements for diversity and inclusion, publications, committees or task forces, and special interest groups.^{31,32,34,114–122}  Similarly, pediatric subspecialty organizations have developed initiatives directed at women in pediatrics as well as diversity and inclusion broadly. For example, the American Society of Pediatric Hematology/Oncology has both a Diversity Special Interest Group and a Diversity Advisory Group, with the goal being to support members by increasing diversity (including gender diversity) and inclusiveness in membership and leadership.¹²³  The Society for Adolescent Health and Medicine Diversity Committee is constructing a workforce development plan that emphasizes the recruitment of providers from diverse backgrounds and improves the integration of ethnic, racial, and sexual diversity and inclusiveness into all Society for Adolescent Health and Medicine activities.¹²⁴  Other organizations, such as the Pediatric and Congenital Electrophysiology Society, have held networking receptions specifically for women.¹²⁵ 

Undoubtedly, pediatric professional organizations have contributed to progress; however, transparent metrics and reporting to stakeholders are lacking, making it difficult to assess efficacy. Because outcomes such as pay, promotion, publication, and recognition may be intertwined (especially in academia),¹²⁶  fair treatment of women pediatricians will require enhanced and simultaneous commitment from leaders in 4 key gatekeeper groups: (1) academic medical centers, hospitals, health care organizations, and practices; (2) medical societies; (3) journals; and (4) funding agencies.⁵²  By customizing metrics according to their unique structure and purpose,^110,126  each gatekeeper group can use the same strategic 6-step approach^52,110,126  (Fig 6): the equity, diversity, and inclusion cycle. The equity, diversity, and inclusion cycle provides a strategic methodology to examine equity, diversity, and inclusion data; share results with stakeholders; investigate causality; implement strategic interventions; track outcomes and adjust strategies; and disseminate results. Because the use of a cyclical data-driven approach to problem-solving is considered best practice, widespread adoption may accelerate progress toward workforce gender equity (Table 5).^{73,80–82,110,127–134} 

Although much work has been done and some progress has been made, numerous reports suggest medicine, including pediatrics, is not leading the way in gender equity, and attempts to close some gaps are slow, stalled, or even regressing. Beyond examining gender data and disparities, implementing strategic interventions, tracking metrics, and reporting outcomes, next steps must include enforcement of a climate of transparency and accountability, with leaders prioritizing financial and human resource support for workforce gender equity.

The authors thank Barbara Overholser (ELAM) for her review of the article, Diana Lautenberger (AAMC director of diversity and inclusion and the Group on Women in Medicine and Science) for providing training program data, and the pediatric professional societies listed in Table 3, all of whom responded to our request to verify their formal gender-equity initiatives. They include the AAP, the American Board of Pediatrics, Association of Medical School Pediatric Department Chairs, the Academic Pediatric Association, the Association of Pediatric Program Directors, the American Pediatric Society, the FOPO, and the Society for Pediatric Research.

AAMC

Association of American Medical Colleges

AAP

American Academy of Pediatrics

ELAM

Hedwig van Ameringen Executive Leadership in Academic Medicine

FOPO

Federation of Pediatric Organizations

NIH

National Institutes of Health