State of Women in Medicine: History, Challenges, and the Benefits of a Diverse Workforce

Women seem to have always been healers. In Ancient Egypt, Isis was universally worshipped as the goddess of medicine, and her priestesses were accepted as physician-healers.¹  In Ancient Greece, Hygeia and Panacea, the daughters of Aesculapius, were “sainted mortals” and likely practiced as independent physicians.¹  In both Ancient Egypt and Ancient Greece, women appeared to be widely accepted as physicians and surgeons.¹  From the Middle Ages to Colonial America, women bore the responsibility for most medical care in the home.^1,2  This included women in their traditional domestic roles and women as lay practitioners, but they were not typically recognized as professionals.²  However, this role started to change in the midnineteenth century with 1 major milestone, the admittance of Elizabeth Blackwell to medical school at Geneva College in New York. Her admittance, however, had been intended as a practical joke,³  but she persevered and became the first women to receive a medical degree in the United States in 1849. She graduated first in her class and then worked in children’s hospitals in London and Scotland,⁴  later opening the New York Infirmary for Women and Children in 1857.

In the late 1800s, there was a surge in the number of medical schools. These included schools in established colleges and universities like Johns Hopkins, which opened its medical school in 1893, but also included many proprietary and commercial medical schools.²  This increased access to medical education opened the door for women to take on the professional role of physician, and, by the end of the nineteenth century, there were 17 medical colleges for women in the United States.²  In the 1890s, women made up as many as 30% of graduates from some medical schools.⁵  Traditionally male-only medical schools also started to accept women, lauded by some as a step toward gender equity in medicine, but this shift also resulted in many women’s medical schools closing or merging with existing medical schools.² 

Around the turn of the century, the American Medical Association’s priority to reform medical schools, standardize, and set minimum requirements for medical education ultimately led to the Flexner report being published in 1910. This report was an independent critique of US medical schools and medical education, supported by the Carnegie Foundation for the Advancement of Teaching and authored by Abraham Flexner.²  Although the number of medical schools had already started to decline in the years leading up to the Flexner report, this trend was accelerated by requirements for longer training periods and higher tuitions resulting from the higher costs to medical schools to provide adequate medical education.²  Although Flexner himself had stated that “privileges must be granted to women…on the same terms as men,”¹  the consequences of the more stringent educational standards included a morphing of the profession into one that was more socially uniform, with declining access of women to medical education.²  As a result, women accounted for only 6% of US physicians in 1910, which remained the same for 50 years.⁵ 

The aftermath of the Flexner report in creating a more socially homogeneous profession also created barriers for immigrants, lower and working class Americans, Jewish Americans, and Black Americans, who, along with women, were discriminated against in their efforts to access medical education, or were “priced out” with rising tuitions and increasing opportunity costs.²  The 7 Black medical schools running before the Flexner report were whittled down to only 2, and graduates commonly struggled to get internships or hospital privileges.² 

As the feminist movement burgeoned in the United States in the 1970s, there was renewed attention to the role of women in medicine and particular attention to the paternalistic culture of American medicine, in which women who were patients and nurses were routinely denied the right to participate in medical decisions.²  The proportion of women medical students increased substantially during the 1970s, representing >25% of US medical students by the end of the decade.² 

Acknowledging the state of women in medicine is key to understanding existing systems and structures that may influence the trajectory of women’s progress in medicine, in both academic and nonacademic settings. In addition to educational initiatives for women, data collection and analysis are needed to implement systemic and institution-level interventions to achieve gender equity and inclusion in medicine. Because of the variability of practice settings in the United States, it remains difficult to obtain data from nonacademic settings; therefore, much of the data presented here are from academic environments. However, many of the challenges faced by women in medicine are universal and not unique to their practice setting, so the concepts presented are broadly applicable to academic and nonacademic environments.

Since 1983, the Association of American Medical Colleges has reported data on women’s representation in all facets of medicine using a variety of survey data to illustrate women’s representation as learners, faculty, and leaders in medicine. In September 2020, the Association of American Medical Colleges published its 2018–2019 report on the “State of Women in Academic Medicine.” This report reveals that although women represent just >50% of medical school applicants and matriculates, they represent only 47.9% of medical school graduates, and, in fact, women have never represented ≥50% of medical school graduates.⁶  Although racial and ethnic diversity have been slow to increase, women do represent a slightly more diverse group of medical school graduates than men do.⁶  Although only a small attrition from medical school graduation, women represent only 45.6% of total US medical residents⁶  (Fig 1).

The proportion of women in all faculty ranks has increased since 2009, but women continue to represent a majority only at the instructor level (58%).⁶  Women faculty from an underrepresented-in-medicine race or ethnicity increased only from 12% in 2009% to 13% in 2018, and women at the full professor rank are 74.6% white.⁶  Overall, 49% of medical schools reported having a formal position dedicated to women and/or gender equity beyond Title IX and/or compliance roles, and this position was allocated an average of only 0.38 full-time equivalents.⁶  The proportion of women as division and section chiefs has increased from 16% in 2003% to 29% in 2018, an increase of only ∼1% per year.⁶  Women as department chairs have grown from 13% in 2009% to 18% in 2018, similar to the increase in women as deans rising from 12% to 18% across the same period.⁶  Of importance, among women department chairs, the vast majority were white, and only 8% and 5% of all women in these positions were Black or African American or Hispanic, respectively.⁶  This reveals a significant shortage of women of color in departmental leadership positions. Beyond the numbers, women faculty in leadership positions were more commonly in offices that are perceived to be communal and less influential, such as offices for diversity, equity, and inclusion; faculty affairs and/or development; and student affairs and/or admissions. On the other hand, the smallest proportions of women leaders were in offices for research and clinical and/or health affairs.⁶  This highlights that woman leaders are not in roles that exhibit final decision-making and budgetary power.

In a recent Journal of the American Medical Association study, men had more National Institutes of Health (NIH) awards overall and, therefore, more total funding.⁷  Across all NIH funding mechanisms, women received 23% of awards in 1998, slowly increasing to 35% by 2020.⁷  A major factor in funding disparity by gender is the low number of grant applications submitted by women relative to men, a disparity relatively proportional to that of women in faculty positions making up the NIH research grant applicant pool. Disparities in funding are even greater for women who are also underrepresented in medicine.⁸  On the other hand, when women apply for NIH funding, award amounts were larger for R01s (R01 awards being the NIH gold standard for independent research awards) associated with women program directors and principal investigators. In addition, once women are funded, their funding longevity is similar to that of men.^9–10 

Lack of support for women participating in research contributes to their slower progress through the academic ranks and into leadership positions. To close the gaps in NIH funding gender disparities, it is critical not only to train women in grant writing and the grant review process but also to address challenges faced by women in transitioning to independent research, career development, and advancement. It is also important to take steps to mitigate gender stereotypes in the research community and promote inclusive environments, in which all scientists can achieve their maximal potential to advance science.

There are several factors that may prevent women from pursuing an academic career, including a lack of adequate mentoring and suitable role models, work–life balance, and financial concerns, but the impact of such factors is not clearly understood.¹⁰  Because the greatest attrition in commitment to research seems to occur during residency, it is imperative that medical schools and teaching hospitals work in partnership to improve gender climate and culture at the interface between the medical school and teaching hospitals (Table 1).¹¹ 

In both academic medicine and the private industry, researchers have found that organizational strategies, decision-making processes, and outcomes are strengthened by including and engaging diverse perspectives, including gender, racial, ethnic, and other elements of diversity. As noted above, women have made strides in terms of entry into medicine, although the success of those from historically marginalized and excluded groups has been much more limited and challenging. It is also critical to note that women representation in medicine is uneven among medical specialties. Among residents, women continue to enter fields such as obstetrics and gynecology, pediatrics, and dermatology at high rates (83%, 71%, and 60%, respectively); however, little progress has been made in terms of increasing their representation in surgical specialties and other fields, such as radiology, that have traditionally had few women.⁵  Mentorship, sponsorship and salary equity are among some of the factors that create biases or structural barriers hindering women’s representation across all medical fields.

There are several studies in which researchers suggest differences in practice patterns and measures of quality between women and men physicians. For example, women physicians may be more likely to adhere to clinical guidelines,^12–14  provide preventive care more often, including cancer-specific prevention services,^15,16  and provide more psychosocial counseling to their patients than their male peers do.^17,18  In quality metrics, women physicians tend to use more patient-centered communication, when compared with male physicians.^19–21  In other research, it was indicated that women physicians are likely to spend more time with their patients than male physicians are and adopt a more partnership-building style with patients.²² 

In addition, the differences noted in practice patterns between men and women physicians may have important clinical implications for patient outcomes. This importance was revealed in a cross-sectional study in which researchers examined nationally representative data of hospitalized Medicare beneficiaries, comparing mortality and readmission rates of patients cared for by men and women physicians. Results revealed that patients treated by women physicians had significantly lower mortality rates and readmission rates compared with those cared for by male physicians within the same hospital.²³  In other aspects of patient care, such as procedures and postsurgical care, studies have revealed that the patients of women physicians tend to experience better outcomes.^24,24  In a study of >100 000 patients who underwent surgical procedures, the authors found that fewer patients treated by female surgeons died, were readmitted to the hospital, or experienced complications in the 30 days after a surgery than those treated by male surgeons. These results were concluded after patients were matched on the basis of age, gender, the presence of other diseases or medical conditions, hospital, and surgeon age and number of surgeries they had performed.²⁵ 

More broadly, there is a growing awareness that patients from a variety of groups that have historically been marginalized and excluded are not being adequately served by the current medical profession and that patient needs may be better met by having physicians who reflect the diversity of patient characteristics and experiences. For example, the ability to provide linguistically and culturally competent care may emanate from a more diverse workforce. Racial and ethnic or linguistic concordance have been identified as key to improving communication and trust in mental health, essential in the development of a therapeutic alliance for those needing access to care.²⁶  In addition, research has revealed that physicians from historically marginalized and excluded groups are more likely to provide care to those living in underserved areas.^27–29  Similarly, Americans with disabilities are less likely to receive routine medical care, including cancer screening, flu vaccines, and vision and dental examinations, and have higher rates of unaddressed risk factors such as obesity, smoking, and hypertension.²⁹  Increasing physicians and learners with lived experiences of disability into the workforce can help address health disparities in patients with disabilities. This is due to the ability of physicians with such experiences to demonstrate empathy to these patients and be a role model to other physicians in the care of patients with disabilities.³⁰  Recruitment, retention, and promotion of women physicians from a variety of groups may help better represent the diversity of the US patient population and better meet their needs.

In many of these studies, researchers present correlations between physician gender and other demographics and patient outcomes. Even where causation was not demonstrated, it is important to note that, in these studies, researchers did document observable trends in patient outcomes and might inform future research on the delivery of medical care.

With increasing numbers of women entering medical school, there has been more focus placed on providing opportunities for women students and early-career physicians to succeed. This much-needed support is intended to fill gaps in areas of mentorship as well as address issues such as maternity leave and child care. Although much has been accomplished, there is still much to be done in these areas as well as in addressing career development for early-career women physicians, gender bias in promotion and attainment of leadership positions, salary inequity, and professional isolation. However, with a few notable exceptions, these efforts tend not to be directed toward women physicians in middle or late career, with the presumption that the challenges and biases faced by early-career women will no longer remain significant issues or impediments with increased seniority and experience. Unfortunately, that is not the case, and the continuation of these issues into middle and late career may be relatively invisible to colleagues, institutions, researchers, and commentators.

Seniority and accomplishments in medicine alone do not protect women from the myriad forms of gender-based bias and discrimination. Formal recognition of professional accomplishments, such as awards from medical societies³¹  and invitations to speak at conferences and grand rounds,³²  are less likely to be conferred on women than men. In addition, when speaking at grand rounds, women are less likely to be introduced by their professional titles.³³  One-third of women physicians over the age of 60 noted, in a recent study, that they still experience gender-based discrimination.³⁴  The slower advancement of women’s careers in medicine lasts throughout the career continuum, as evidenced by the low number of women tenured professors, department chairs, and deans of medical schools as well as leadership positions in hospitals and medical practices.

Bullying and sexual harassment, in all their forms, are also not only a concern for early-career women physicians. Because these behaviors are typically attempts to maintain the status quo, successful middle and late career women physicians continue to be at risk for becoming victims. In a recent study of more senior women physicians,³⁴  researchers found that although episodes of sexual harassment declined with physician age, 10% of women physicians over the age of 60 were still at least at least occasionally victims of sexual harassment, with a slighter higher percentage noting verbal abuse or bullying on the basis of age. Women from racial groups that are underrepresented in medicine often face additional challenges because this discrimination is compounded by race-based harassment and bias.

Although more prevalent and consistent policies regarding parental leave and child care are needed, the challenges facing women are broader than those at the policy-level. It is important to remember that societal gendered expectations assume that women, regardless of age or profession, will continue to be the primary caretakers for their families. Women physicians in middle age and older are often caretakers for grandchildren, elderly parents and/or partners, and other family members. These family responsibilities and issues with work–home interference for women are career-long, yet, again, policies and resources are focused almost exclusively on issues for early-career physicians.

Gender bias, sexual harassment, lack of recognition, slower career advancement, salary inequities, and lack of career-long family leave policies can lead women to feel a lack of connection and sense of belonging in the workplace. These outcomes are major drivers in the development of burnout³⁵  and may lead to women becoming disillusioned and potentially leaving medicine. The higher rates of burnout noted among women physicians as compared with men might be attributed to differences in presentation and reporting. However, even if the prevalence is similar, risk factors and institution-based efforts to address this differ.

In parallel with the sharpened focus on women medical students and early-career physicians, there has been increased attention on the lack of women in senior leadership positions in medicine. However, advancement of women into leadership roles in medicine cannot occur, regardless of investments in the initial pipeline and early-career development, if women lack support during the entirety of their careers. By midcareer, the time at which physicians are typically applying or being considered for leadership positions, women may become disillusioned and give up aspirations to achieve leadership positions or leave the profession entirely. The solution to the issues being faced by women physicians is not to wait to have more women in leadership positions. Although that will be a major step forward, it will not occur unless the issues that women face at all stages of their careers, especially middle and late career are addressed, including eliminating sexual harassment and gender- and age-based biases, developing career-long family leave policies, and making women feel welcome in medicine. This requires the engagement and investment of all physicians, especially men currently in leadership positions. The mental image of the “pipeline” of women in medicine must change from one of getting women into the pipeline to start this career to one in which women become successful while advancing throughout their rewarding career.

To ensure that students of all genders have equal opportunities to become the next generation of leaders and innovators in medicine, health care organizations, medical schools, and teaching hospitals might consider conducting regular and recurring environmental assessments and equity trainings, such as implicit bias training. However, implicit bias training tends to be a passive activity, and having faculty, especially those on search or promotion committees, and leadership identify their own biases through such assessments such as the Implicit Association Test or similar individual testing may help to inform their decisions. In addition, there should be mandated gender and race diversity within search and hiring and promotion committees, to continue to bring in new perspectives. We would also recommend limits on terms of leadership within academia, so that women interested in leadership are recognized and allowed to fulfill their potential. These actions can help organizations retain and promote women in their careers by systematically addressing biases, microaggressions, and stereotype threats and promoting a more inclusive and supportive culture (Table 2).^36,37 

Although women have made great progress in terms of entering medicine, they continue to face many challenges that can hinder them from entering residency, achieving leadership positions that exhibit final decision-making and budgetary power, and, in academic medicine, being promoted. Women from historically marginalized and excluded groups experience additional barriers, including bias and discrimination. In addition to educational initiatives for women, data collection and analysis are needed to implement systemic and institution-level interventions to achieve gender equity and inclusion in medicine. Attention to engagement and promotion of women in science and medicine at all stages of the career continuum is critical to ongoing progress.

NIH

National Institutes of Health