NEW ORLEANS -- "Aren't you the princess of the ACP?"
Those words, related to her position as chair of the American College of Physicians board of governors, were tossed off in jest by a colleague of Susan Thompson Hingle, MD, the lead author of ACP's . But they caused her to re-think the value of her contributions inside and outside of medicine.
"For some reason, that impacted me on a personal level, despite my recognition that on an intellectual level I had been elected by my peers -- it took a hold of me and I started to question everything I did," Hingle said here at the annual meeting of the ACP. "If this guy thinks I'm a princess, who else thinks that?"
Susan Thompson Hingle, MD (photo credit: Joyce Frieden)
"Then I started to question decisions I was making at home which had no relation whatsoever to work I was doing," she continued. "It's a good example of how implicit bias can really negatively impact women physicians."
Hingle was eventually brought out of her funk by the residents she was training; they had been there when the colleague made the remark. They presented Hingle with a Wonder Woman sticker, which she still has on her computer 5 years later, and a card telling her that "We know you don't think you're Wonder Woman, but we do, and your strengths are your authenticity, your compassion, and your commitment to us."
Addressing Implicit Biases
Training to recognize one's own implicit biases, such as those expressed by Hingle's co-worker, is one of the ACP position paper's recommendations, along with investing in leadership development and improving parental and family leave policies for medical students, residents, and physicians. "As an organization, we're committed to acknowledging and addressing the unique challenges woman physicians must confront over the course of our careers," said Hingle.
There is no debate about the fact that a gap between men and women exists in physician compensation, said Sue Bornstein, MD, a member of the ACP board of regents. "In primary care, there can be as much as a 16% pay gap between males and females ... the gap is wider among subspecialists."
What's challenging is that the gaps exist "even after adjustment for factors such as specialty, place of employment, years of residency, and hours worked," she said. "We know there's something more going on here and we need to understand better what that is."
Hingle gave an example from her own experience. "In most places there are annual performance reviews; those are done on an individual level, and very rarely does the organization look at them in their entirety to see if there are inequities based on gender and race," she said. At one of the places Hingle worked, "I had been in practice for a long time and acquired a lot of educational responsibilities ... but I never looked at how I was paid.
"Someone got me to look at it, and I recognized that despite having the most responsibilities in the department, I was the lowest paid general internist," she said. Part of that had occurred because the institution had raised starting salaries over time to remain competitive for hiring newer physicians, "but it had never been corrected over a fairly long tenure."
Billing Also at Issue
Current billing structures can negatively impact women physicians, Bornstein noted. One ACP member who was on the committee that wrote the paper is a general internist in private practice. "She pointed out that as a rule, women physicians have more women patients, and to provide more comprehensive healthcare, many times the physical exam is indicated to include a Pap smear and perhaps a pelvic exam," as well as a discussion of the need for a mammogram and a human papillomavirus test.
"Because of this [need for] additional services, it results in longer visits -- up to 2 minutes longer per visit," said Bornstein. "So we're doing more work, but essentially for the same pay."
The position paper also addresses parental leave during residency training and practice. "The ACP is opposed to discrimination against medical students, resident fellows, and physicians on the basis of reproductive status," said Darilyn Moyer, MD, the college's CEO. "This is increasingly vital as more and more women enter the physician workforce -- at a time when the population is increasingly aging and increasingly medically complex. We need all hands on deck." For that reason, the ACP is calling for all training programs to offer parental leave to all residents and medical students, as well as private practices.
Jack Ende, MD, ACP president; Susan Thompson Hingle, MD, chair, ACP board of regents; Sue Bornstein, MD, member, ACP board of regents; Darilyn Moyer, MD, CEO of ACP discuss ACP's position paper on gender equity. (Photo credit: Joyce Frieden)
Such a policy is not without its difficulties, she continued. "It's a complex issue to balance training requirements with life requirements for trainees. This is meant to continue these very crucial conversations that need to go on at medical schools and institutions that sponsor [graduate medical education] programs. It's a call for everyone to look at the structural biases they might have in their own organizations ... and be able to implement changes."
The parental leave recommendations "will be among the more controversial and challenging aspects of the recommendations that we make," especially for small private practices, which will need to figure out coverage, said ACP president Jack Ende, MD. "It's a challenge, but it really is a challenge that we must meet." In fact, the U.S. is the only industrialized nation that doesn't mandate paid parental leave for all employees, he said.
Who's Choosing the Leaders?
Another way to attack the gender equity problem overall involves looking at who is choosing faculty members to run academic medical institutions, said Ende. "Promotion committees and selection committees, when recruiting a new chair or dean, should always include a diversity of members, and that certainly includes gender diversity."
In fact, Ohio State University, for its promotion and search committees, requires that faculty members being considered for the committees undergo implicit bias testing, "and they use those results to constitute the committees, where it really could have a significant impact," said Hingle. "They want to make sure not everyone on those committees has the same implicit biases."
Ende, who practices at the University of Pennsylvania, said his institution doesn't do that, "but once the committee is constituted, that committee then undergoes training in [how to recognize] implicit bias."