Gender Diversity and Inclusion in Medicine: Lessons from Management
by Sonia Kang and Sarah Kaplan
Despite increasing representation, five myths are still leading to discrimination against women in medicine — and across industries.
WOMEN’S REPRESENTATION IN MEDICINE has slowly increased over the past few decades. However, this rise in numbers of women — gender diversity
— has not been matched by a rise in gender inclusion
. Despite increasing representation, women still encounter bias and discrimination when compared with men in these fields across a variety of outcomes, including treatment at school and work, hiring, compensation, evaluation and promotion.
This disconnect between diversity and inclusion is not unique to medicine. In this article we will identify five myths that perpetuate gender bias and five strategies for improving not only the number of women in medicine — and other industries — but also their lived experiences, capacity to aspire, and opportunity to succeed.
Myths About Diversity and Inclusion
The year 2017 marked the first time in history when the number of women enrolling in U.S. medical schools exceeded the number of men. When this historic cohort of female students enters the workforce, what kind of work environment will they encounter?
Despite the record numbers of women entering fields across STEM and medicine, women continue to experience disadvantage and discrimination — a reality that is too often amplified for women of colour, of low socio-economic status and social class, and of advanced age, and women who do not identify as heterosexual, are disabled, or belong to other traditionally devalued groups.
In medicine, these inequities manifest for women as everyday experiences of sexism, which includes exposure to sexist jokes in class; sexual harassment by clinicians, faculty or patients; weaker reference letters than men for medical school applications; lower income than men; channelling into lower paid areas of medicine such as family practice; and a decreased likelihood of being addressed by one’s professional title than men. While we may be making progress on the numbers, true progress on improving women’s sense of belonging and inclusion is critically lagging.
Diversity and inclusion policies and practice are becoming nearly ubiquitous in organizational settings. Finding an organization without a written statement outlining their commitment to diversity is now rare, and billions of dollars each year are spent on efforts to increase the representation of women and minorities.
To create lasting change and to prevent the current focus on diversity and inclusion from becoming another passing trend in management, it is important to ensure that efforts are evidence-based and do not rely on common myths that might be perpetuating the very problems they are trying to solve. Following are five key myths for leaders to be aware of.
The most promising solutions are likely behavioural and systemic changes.
MYTH 1: OTHER PEOPLE ARE BIASED, NOT ME.
The first myth that should be debunked is the idea that bias is a problem unique to the racists, sexists and bigots among us. Research on the human brain and how it makes sense of the world suggests not only that all of us are biased, but that we must be biased to survive. Cognitive biases and heuristics are shortcuts that allow us to interact meaningfully with people, objects and tasks without having to exhaust our insufficient attentional resources to decipher every sensory signal.
Whenever you encounter a person, your brain rapidly engages in a series of calculations to interpret that person’s relevance to you by placing them within a social category. The first automatic calculations regard age, race and gender. Because of this perceptual primacy, gender has come to frame the way we see the world; it is an implicit or unconscious bias that serves as a foundation upon which stereotypes, expectations and norms have been created.
Social categorization is an inevitable part of our perceptual experience. The stereotypes we hold about different social groups alter our perceptions of, and reactions to, individual group members. Rejecting the idea that only some people are biased is a crucial first step to personally engaging with the problem of discrimination so as to bring about change.
MYTH 2: THE KEY TO CONTROLLING BIAS IS TO CONTROL HOW PEOPLE THINK.
Most efforts to minimize bias in organizations have focused on controlling or eradicating the biases that exist in our minds. Implicit bias training is an example of such efforts. Testing for implicit bias via the Implicit Association Test (IAT) has become commonplace. Despite the millions of dollars spent on administering the IAT and training people to act without bias, the evidence that this kind of training actually changes organizational outcomes is scarce.
Moreover, diversity training has produced a host of unintended consequences: It has been shown to be associated with reduced diversity, worsened behaviour towards minority co-workers, and the creation of the illusion of fairness, such that those who claim to have experienced discrimination are less likely to be believed. Instructing people to avoid the use of stereotypes can paradoxically lead to increased activation of those stereotypes, and attempts to increase the awareness of stereotype prevalence can inadvertently normalize stereotyping and discrimination (such as ‘If everyone uses stereotypes, it must be okay’).
Although educating people about these biases and teaching them how to recognise biases is an important first step, we must go further to create systems and environments in which bias and stereotyping are either less likely to become initiated, or are prevented from resulting in discrimination even when they are active.
MYTH 3: UNDER-REPRESENTATION OF WOMEN IS A PIPELINE PROBLEM.
The representation of women across STEM fields has been slowly increasing, albeit at different rates within these fields and across nations. If we look to the research on child development and psychology, girls perform to an equal or better standard than boys in STEM topics, and report high interest in pursuing careers in STEM. Therefore, the pipeline of female trainees and candidates itself is healthy. The real problem is brought about by the pressures that push women out of the pipeline.
Research shows that discrimination exists against women at each stage of professional life, from recruitment and selection, to recommendation, evaluation, promotion, training and compensation. These effects are often exacerbated for women of colour or for those who possess other devalued intersectional identities. Women are conferred less respect and status, experience greater workplace hostility and harassment, are disproportionately punished for errors, and experience higher amounts of invisible and uncompensated labour, particularly in terms of emotional labour, than men.
It is often argued that women choose to opt out of certain careers or opt in when lower status roles are available due to motherhood. However, research suggests that the effects of this so-called motherhood penalty are structured by discriminatory dynamics. Further, if motherhood fully explains women’s under-representation in STEM and medicine, then we would not also observe under-representation of men of colour, but we do. Therefore, it is not the case that women are entering the pipeline in too few numbers, but rather that a confluence of factors is pushing them out.
MYTH 4: PROMOTING DIVERSITY VIOLATES MERITOCRACY.
One of the most commonly cited explanations for rejecting diversity initiatives is that organizations are meritocratic — that people are selected for roles according to merit. The arguments are that if women were equally qualified, they would be hired and promoted, and that any diversity initiatives aimed at righting the imbalance would compromise quality. However, an abundance of research evidence shows our so-called meritocracies are not so meritocratic.
Studies that control for underlying quality show that a signal of female gender by itself leads to devaluation: For equal curriculum vitae in which only the name is different, ‘Brian’ is more likely than ‘Karen’ to be seen as hireable; with equal business cases for a start-up company in which only the video narration voice differs, the male narration is deemed twice as investable as the female narration; female postdoctoral applicants have to be 2.5 times more productive than the average male applicant to be hired; and computers named ‘James’ are valued nearly 25 per cent more than computers named ‘Julie’. So, if anything, underlying biases appear to be causing the current meritocratic systems to bypass many highly capable women and members of other minority groups. We are drawing heterosexual, white men from much further down the distribution of talent than we are for other social categories.
MYTH 5: WE HAVE TO ‘FIX’ THE WOMEN.
Most programs attempting to address gender inequality focus on ‘fixing the women’ by teaching them such skills as how to lean in, negotiate better, stand up straight, adopt powerful postures, talk more in meetings, and be more assertive, to name a few. Many of these solutions are themselves highly biased, in that they train women to act more like men because the actions of men are perceived as the correct way to succeed.
What is neglected in this approach is the backlash women often experience when engaging in these behaviours: Competent women with agency have been shown to experience backlash for violating expectations of warmth and so-called feminine niceness. Research also shows that women are punished more severely than men for mistakes or failures, and that these negative effects can negatively affect perceptions of other female coworkers. Thus, attempts to ‘fix the women’ will continue to be counterproductive within a system that is rigged against them.
Achieving Gender Equality
We will now present some suggestions based on management research for improving the experience of women in medicine. We believe that medicine is particularly well suited to interventions that target organizational change by designing for equality. Following are five potential solutions in this context.
SOLUTION 1: TREAT GENDER EQUALITY AS AN INNOVATION CHALLENGE.
Justifications for gender equality are often discussed in terms of the so-called business case, focusing on how equity, diversity and inclusion are economically productive, rather than focusing on them as the right thing to do. To make progress in achieving gender equality, we must declare the discussion on whether and why we should pursue equality to be over. From this point, within contexts where this is possible, we can switch our focus to experimentation and innovation.
As with any organizational initiative, gender equality should be approached with a willingness to experiment and measure outcomes. Because the challenge of achieving equality is complex and multifaceted, openness to failure and the willingness to change tactics is a must, as is transparency via measurement and reporting, so that momentum and accountability for change remain high. The most promising solutions are likely behavioural and systemic changes that focus on creating a climate for change, an approach widely supported by the so-called nudge theory, rather than those focusing only on changing individual attitudes or values.
If everyone else appears to value diversity, we are more likely to act like we value diversity ourselves.
Gender-inclusive workplace cultures are those that create a positive social climate for people of all gender identities, and can be cultivated through such practices as increasing the representation of women and gender non-binary people in leadership, by use of gender-inclusive photos and pronouns in organizational communications, and adopting anonymous evaluation practices that minimize the potential for bias by eliminating gender cues such as names and pronouns.
That said, no quick fix solution is available to offer, and actual change will only follow from the repeated application of commitment, courage, and many iterations of innovative experimentation.
SOLUTION 2: CHANGE INSTITUTIONAL NORMS. Norms are the conventional patterns of behaviour that are considered acceptable by a particular social group. For example, people of all gender identities are under pressure to conform to gender norms (e.g. women are expected to be kind and nurturing; men are expected to be competent and strong). Such norms have a powerful influence on our behaviour, and result in women being socialized into more communal medical specialties (e.g. family medicine) and men being socialized into more agentic specialties (e.g. surgery). Over time, these norms have strong effects on other measurable outcomes beyond behaviour. For example, as family medicine has become more feminized over time, the pay gap between it and other specialties has widened considerably.
Fortunately, because we are a fundamentally social species, changing perceptions of norms also changes behaviour. Theories on the social influence of norms predict that if everyone else in an organization appears to value diversity, we are more likely to act like we value diversity ourselves. Conversely, if expression of prejudicial attitudes or engagement in discriminatory behaviour is considered normative, these practices will become embedded
within a social environment.
The most important source of normative change involves a group’s leaders. The behaviour of those at the head of a group have a powerful influence on the people further down, and therefore the communication and behaviour of hospital administration and senior staff, for example, must show a commitment to diversity for others to follow suit.
SOLUTION 3: CREATE A CULTURE IN WHICH PEOPLE FEEL PERSONALLY RESPONSIBLE FOR CHANGE. One of the reasons diversity training programs can be so spectacularly unsuccessful is that they challenge people’s sense of autonomy, self-determination and control. Just as humans are inherently prone to bias, so too do we have an inherent drive towards autonomy, which can lead us to resist initiatives that we feel are forced upon us. People react negatively to perceived coercion, and overbearing diversity programs can therefore go wrong and actually make organizations less inclusive.
Better results are seen with programs that increase contact between diverse groups and include all members of the organization rather than only those who are part of the group targeted for intervention. Examples of successful diversity programs are mentoring programs, which effectively increase representation among minority women in particular, and the establishment of diversity task forces. Even more effective are sponsorship programs in which sponsors become personally invested in their protégé’s career success, take risks to champion them for recognition and advancement, and actively embed them in powerful networks.
SOLUTION 4: IMPLEMENT BEHAVIOURAL GUIDELINES AND ACTION PLANS. People often encounter difficulty translating their goals into action. This issue can be remedied through a type of planning known as ‘implementation intentions’, which links anticipated acute situations to goal-directed responses (e.g. ‘whenever situation x happens, I will initiate the goal-directed response y’). These kinds of systems are already very common in medical workplaces, as seen with the code systems used to clearly link specific situations to a prescribed set of responses. To advance towards the goal of gender equality, one suggestion is to put more emphasis on behavioural rather than attitudinal guidelines for promoting diversity and inclusion.
For example, consider what might happen if a hospital decides to combat gender bias during the search for new attending physicians. A typical first step would be clearly outlining the goal (e.g. ‘to eliminate gender bias within the search committees’) and the rationale (e.g. ‘eliminating gender bias will benefit our team, patients, organization, and other various stakeholders’). This step is where most plans for improving diversity end. People are left with an abstract set of values and goals, but no distinct action plan for achieving them and no indication of how progress will be measured and success identified — which research shows to be an essential part of effective goal-setting.
Worse still, in some cases abstract or attitudinal diversity goals or statements have been unsuccessful and end up doing more harm than good. To move from abstract plans to actions and avoid unintended consequences, organizations must clearly lay out the specific steps that will be taken to enact their values and goals, and specify the indicators that will be used to measure success, while also taking into consideration the many barriers that stand in the way of individual behavioural change.
In the attending physician example, some of these guidelines might include ‘ensuring that at least a third of hiring committee members are women’, with success being identified as ‘a steady state of 50:50 men and women on committees within three years’, and using a statistically significant increase in the number of women hired over a three-year period as an indicator of success.
SOLUTION 5: CREATE ACCOUNTABILITY FOR CHANGE. Methods for holding individuals, teams, and the organization as a whole accountable for change can help by measuring and keeping progress on track towards essential milestones, and by signalling the importance of the initiative. The common maxim ‘What gets measured gets done’ applies just as well to diversity initiatives as it does to any other type of initiative an organization might wish to set up. Without ongoing data collection and transparency, whether time and resources are being expended effectively or just wasted is impossible to tell. However, to avoid backlash associated with threats to autonomy, organizational accountability must be designed empathetically and with room for failure.
As with any innovative endeavour, failure is part of the experimental process, and learning from mistakes allows us to refine, redesign and retest. Organizational initiatives embedded within accountability frameworks such as affirmative action plans and work processes adhered to and promoted by diversity committees and task forces and diversity managers or departments have shown great promise in increasing and sustaining diversity. Again, the most promising approach is comprehensive, in which individual, structural, and organizational initiatives are combined in the push for progress.
The available evidence is clear: decades of policies and billions of dollars aimed at changing individuals have not been successful in bringing about gender equality in medicine or any other industry. We have made progress in the number of women entering and working in medicine, but true progress on inclusion remains elusive. By understanding more about how bias works and dismissing the myths that have held us back for so long, we can turn our attention and resources towards structural and systemic interventions that have more promise for success — in medicine and every other industry.
is an Associate Professor of Organizational Behaviour and HR Management at the University of Toronto Mississauga, Chief Scientist at the Behavioural Economics in Action Research Centre (BEAR) and a Faculty Research Fellow at the Institute for Gender and the Economy (GATE) at the Rotman School of Management. Sarah Kaplan
is Director of GATE, Distinguished Professor of Gender & the Economy and Professor of Strategic Management at the Rotman School. She is the author of The 360° Corporation: From Stakeholder Trade-offs to Transformation
(Stanford Business Books, 2019). This article was published in The Lancet
, a weekly peer-reviewed general medical journal.
This article appeared in the Spring 2020 issue. Published by the University of Toronto’s Rotman School of Management, Rotman Management explores themes of interest to leaders, innovators and entrepreneurs.
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