By: Victoria Cespedes
(Photo Credits: Molly Ferguson for Stat News)
This past July, an article was included in the Journal of Vascular Surgery, entitled, “Prevalence of unprofessional social media content among young vascular surgeons.” It quickly came under fire for its definition of inappropriate attire as “bikinis/swimwear,” which strongly echoes professional and academic dress codes that place restrictions primarily on women. Many female physicians took to social media with their own bikini pictures under the hashtag, #MedBikini, as a statement that their attire, especially during personal time, was no indication of their competence in medicine, nor should it have any bearing on their professional reputation. The article was quickly retracted due to bias and methodology issues, but its impact remains as a reminder that medicine, as well as the scientific field at large, holds women and minorities to a much different standard than their male or White counterparts. This holds true not only for salary compensation, but also specialty selection, patient interactions, and hiring. All of this compounds on the fact that these two populations are already underrepresented in medicine and this inequity is further exacerbated by the presence of skewed perceptions. Thus, despite the strides that have been made to diversify healthcare providers, the medical, scientific, and general communities still have much work to do to make this discipline more inclusive for all.
Underrepresented: Then and Now
Before addressing current perceptions and misconceptions, the history of underrepresentation in medicine must first be understood. Take, for example, Dr. Elizabeth Blackwell, the first women to earn an MD degree in the United States after graduating in 1849. Her admission to medical school was perceived as a joke to the male students, to whom the decision had been deferred to by the admissions committee after they had failed to make a decision themselves regarding the perfectly well-qualified candidate. Her degree conferral happened two years after that of Dr. David Jones Peck, the first African American man to earn an MD from an American medical school. Dr. Rebecca Lee Crumpler followed in 1864 as the first African American woman to receive an MD in the US. It would not be until more than 20 years later that Dr. Susan LaFlesche Picotte would become the first Native American woman to earn an MD. Despite their degrees, these physicians still faced substantial racism and misogyny in building their practices. Dr. Blackwell wrote of her experiences:
“I had not the slightest idea of the commotion created by my appearance as a medical student in the little town. Very slowly I perceived that a doctor's wife at the table avoided any communication with me, and that as I walked backwards and forwards to college the ladies stopped to stare at me, as at a curious animal. I afterwards found that I had so shocked Geneva propriety that the theory was fully established either that I was a bad woman, whose designs would gradually become evident, or that, being insane, an outbreak of insanity would soon be apparent."
Perhaps such blatant staring and assumptions of insanity might not be found in today’s medical schools and hospitals, but progress has still been slow. In 1980, women made up only 20% of all medical school applicants in the United States. That same year, the number of White applicants was more than double the number of Hispanic/Latino, Black, Native American/Alaska Native, and Asian applicants combined. In 2015, it was found that applicants were split between 53% male and 47% female, with a substantial increase in all minority populations, except the American Indian/Alaska Native group which declined instead. White applicants, however, still represent the largest single group in frequency. Moreover, even if these applicant numbers were perfectly distributed among gender and race/ethnicity (a metric that is still not taking gender identification or sexual orientation representation into consideration), the issue still remains of how these physicians are treated by their superiors, colleagues, and patients.
Persisting Perceptions of Underrepresented Physicians
The skewed attitudes and views towards women and racial minorities are what contribute to keeping them out of medicine, as well as impacting their choices, successes, and patient care once inside the field. From the examples discussed above, we have explored the proportional breakdown of medical applicants. Following matriculation and graduation, a subsequent step in a physician’s career is choosing a specialty. A 2016 study from Yale University School of Medicine found that sexual and gender minorities were more strongly influenced by their identity when selecting a specialty, opting for those they deemed more inclusive towards their identity, such as the fields of psychiatry, family medicine, pediatrics, preventative medicine, internal medicine, and pediatrics, rather than orthopedics, neurosurgery, thoracic surgery, general surgery, and rectal surgery. Sexual and gender minorities were also more likely to enter a “low prestige” specialty, as determined by competitiveness and income level of the specialty, suggesting that minority physicians are well aware of others’ perceptions and actively seek out more welcoming environments and opportunities. It is also worth noting that data such as this is important when considering false notions that point to the absence of a gender pay gap, as many have incorrectly concluded that minorities intentionally pick lower-paying specialties. Another unfortunate highlight from this study is that the specialties labeled as non-inclusive by the participants were the same ones labeled as such 20 years ago.
However, the gender pay gap is quite significant and was estimated to be about 28% in 2017, as per a Doximity report published in 2018. Dr. Theresa Rohr-Kirchgraber from Indiana University School of Medicine postulated a reason in an accompanying CNN article for potential justifications regarding this salary discrepancy: “Some people have said women doctors don't see as many patients as male doctors because they have other responsibilities at home with kids. That's why they make less... the assumption is that [male doctors] should make more because they are taking care of the family.” Dr. Fatima Stanford, a physician who teaches at Harvard Medical School, also concluded the article by describing her fear that low compensation combined with high stress could motivate many female physicians to leave the industry. The ongoing COVID-19 pandemic is a perfect reminder of why physician shortages should be avoided.
Such perceptions are not only just limited to this generation of healthcare providers; students are also affected. Missing Persons: Minorities in the Health Professions, a document released by the Sullivan Commission on Diversity in the Healthcare Workforce of Duke University, states that only 4.2% of medical school faculty members are underrepresented minorities (URM). Additionally, the aforementioned 2016 Yale study found that minority students found mentors who were also underrepresented to be instrumental in their success.
The Flip Side: Perceptions of Minority Patients
Fostering connections and trusting relationships are not just critical for students, but for patients, as well. A study from the American Economic Review in 2019 found that Black male patients were more likely to thoroughly discuss any health issues, undergo additional testing, and agree to more invasive necessary procedures with a Black physician versus a non-Black physician, thereby increasing the quality of their diagnostic care and treatment. Oluwaferanmi Okanlami, director of medical student success in the Office of Health Equity and Inclusion at Michigan Medicine, commented on this study in a Washington Post article, describing a “yearn[ing] for a sense of familiarity.” Physician diversity must increase to reflect a diverse patient population. However, it is not just a patient’s perception of their physician that matters, but vice versa as well.
Thus, recognition of empathetic identification is incredibly important in patient care, and including gender, sexual, and racial minorities might mitigate physician biases against patients. An article in the Journal of the National Medical Association found that race influenced how physicians evaluated their patient’s pain, with Black patients’ pain being underestimated twice as much as all other ethnicities combined. Another study in Academic Medicine describes the differences between “explicit attitudes” and “implicit biases” against LGBT individuals, with the latter being present in approximately 82% of the sampled heterosexual medical students. The study also found that frequent and positive contact with LGBT individuals was correlated with positive attitudes towards them. Furthermore, a commentary on the original study, also published in Academic Medicine, cites additional evidence that many physicians feel inadequately prepared and educated on how to mindfully treat this population.
Together, these data highlight not only a serious need for medical education to be more inclusive of minorities in its content, but also the worrying observation that physicians who represent minority individuals are also severely underrepresented in the field. This lack of knowledge and exposure, as well as the persistent presence of harmful stereotypes, continues to contribute to the discriminatory perceptions currently plaguing the medical community.
Burke, S., Dovidio, J., Przedworski, J., Hardeman, R., Perry, S., Phelan, S., Nelson, D., Burgess, D., Yeazel, M., & van Ryn, Mi. (2015). Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual Medical Students? A Report from Medical Student CHANGES. Academic Medicine, 90(5), 645–651.
Current Trends in Medical Education. (n.d.). AAMC. https://www.aamcdiversityfactsandfigures2016.org/report-section/section-3/
Elizabeth Blackwell, America’s First Women MD. (2000, March 20). History of Medicine. https://www.nlm.nih.gov/exhibition/blackwell/college_life.html
Fallin-Bennett, K. (2015). Implicit Bias Against Sexual Minorities in Medicine: Cycles of Professional Influence and the Role of the Hidden Curriculum. Academic Medicine, 90(5), 549–552.
Hardouin, S., Cheng, T., Mitchell, E., Raulli, S., Jones, D., Siracuse, J., & Farber, A. (2020). Prevalence of unprofessional social media content among young vascular surgeons. Journal of Vascular Surgery, 72(2), 667–671.
Johnson, L., & Ebrahimji, A. (2020, July 25). A medical journal apologized after an article prompted health professionals to post images of themselves in bikinis. CNN. https://www.cnn.com/2020/07/25/cnn10/medbikini-backlash-and-apologies-trnd/index.html
Kavilanz, P. (2018, March 14). The gender pay gap for women is big—And getting worse. CNN Business. https://money.cnn.com/2018/03/14/news/economy/gender-pay-gap-doctors/index.html
Marcella, A., Garrick, O., & Graziani, G. (n.d.). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111.
Missing Persons: Minorities in the Health Professions. (2004). Sullivan Commission.
Sitkin, N. A., & Pachankis, J. E. (2016). Specialty Choice Among Sexual and Gender Minorities in Medicine: The Role of Prestige, Perceived Inclusion, and Medical School Climate. LGBT Health, 3(6), 451–460.
Stanton, L., Panda, M., Genao, I., Kurz, J., Pasanen, M., Mechaber, A., Menon, M., O’Rorke, J., Wood, J., Rosenberg, E., Faeslis, C., Carey, T., Calleson, D., & Cykert, S. (2007). When
Race Matters: Disagreement in Pain Perception between Patients and their Physicians in Primary Care. Journal of the National Medical Association, 99(5).
Weiner, S. (2020, March 3). Celebrating 10 women medical pioneers. AAMC. https://www.aamc.org/news-insights/celebrating-10-women-medical-pioneers