Gender equity in medicine: come and take it

“My plea to the younger generation of doctors, men and women, is that you not be complicit by silence when you see inequity, harassment, abuse and discrimination at play. Do not be tempted to benefit from it, and be brave enough to call it when you see it. Power will not change of its own volition, we have to come and take it and mold it to a better use.”

AUSTRALIA’S gender equality scorecard published in February 2022 presented the following fairly sobering detail:

• 8% gender pay gap (with a gender pay gap in health care of 14.4%);
• women make up 50% of the workforce but less than 20% of chief executive officers (CEOs);
• women account for fewer than one in five CEOs or Board Chairs, and one in three board members;
• only 12% of people who took paid parental leave in 2021 were men;
• men are twice as likely to be earning above $120 000;
• over 85% of Australian employers still pay men more than women, on average;
• women were earning, on average, about 77% of men’s earnings.

We have seen recent high profile examples of the misogyny and inequity that runs rife in Australian society. Domestic violence, femicide, workplace harassment, and sexual assault (the latter two allegedly manifesting even in our national parliament). This is a national problem, and its roots go very deep.

Do these issues apply in medicine? The kneejerk response to this is to rationalise it out of relevance to medicine; for example, to ascribe the gender pay gap to part-time work, or to nursing versus medicine. I won’t go into detail here about the need to examine why women might be more likely to work part-time – it is in itself a reflection of a gender-biased society.

But even in medicine, and even in jobs that are not depending on ability to generate revenue, institutionalised pay gaps persist and career equality for women remains elusive.

I was once offered a salary where this was blatantly on view. I had done my research. I knew exactly how much my (male) predecessor had been paid. We had virtually identical qualifications and my experience was broader. I was offered a full 5% (7% with Consumer Price Index adjustment) below what my colleague had been paid. The offer was still a lot of money and it felt churlish to say that it was unacceptable. But when I considered the personal and institutional ramifications of accepting this, I simply could not.

Where paypoints are determined on anything other than years of service, women start to fall behind. In Queensland, levels 1 through 27 of the medical pay scales for the 2015 industrial award (still in force) are determined largely on years of service. Levels 28 and 29, the two highest paypoints for specialist doctors, are subject to a process where multiple other factors, such as international committees, conference plenaries, and “eminence” come into play.

It will surprise few women reading this to learn that the percentage of women appointed at level 28 and 29 under this scheme has historically been dramatically below the percentage of women overall employed in medical roles. It amplifies the gender bias expressed in the “manel” phenomenon (here, here and here), rewarding men with higher pay packets.

It is not just about the money – the pay symbolises the power imbalance. Women are increasingly leaders of learned colleges (the Royal Australian College of General Practitioners is a case in point), and I greatly admire my colleagues who have stepped into these roles. Professional leadership such as this is critical to advance equity, but wields only indirect levers to address workplace culture, remuneration decisions and career paths.

The Royal Australian College of Surgeons has been prominent in addressing equity and diversity, walking towards the problem when abuse of trainees was finally laid plain for all to see. Their Operating with Respect program has drawn international praise, and several of the other learned colleges have followed suit.

But it is not enough.

The Royal Australasian College of Medical Administrators is currently partnering with the Advancing Women in Healthcare Leadership project. Notably, this is a research-driven program, and the only governmental partner is the Victorian Department of Health. The program has no power to drive appointments, and without buy-in from health ministers and health departments to actually make decisions to appoint women, it will, like programs before it, shout into the void.

In 2019, Hempenstall and colleagues observed:

“Women have had gender parity in Australian medical schools for decades; however, they represent only 28% of medical deans and 12.5% of hospital [CEOs]”

In 2019, in Queensland, they represented just 16% of Level 29 appointments. In the history of Directors’ General of Health across the country, female doctors are virtually invisible, a recent appointment in South Australia being a standout exception. Doctors who are men hold the reins regularly, but when women are in charge of health departments, they are usually lawyers, nurses or administrative managers. Only one of the current members of the Health Chief Executives forum is a medically qualified woman. The other women are a former nurse (New South Wales), a career public servant (the Australian Capital Territory), and a former barrister (Tasmania).

By contrast, there are male doctors heading up the federal department, Western Australia, Victoria, the Northern Territory and, until a recent departure, Queensland (that position is yet to be permanently filled). Historically, the only woman to ever hold the Director General role in Queensland was a former social worker, The past three directors general of health in NSW have been women, all from administrative backgrounds, and the previous head of Health in Victoria was also a woman from administrative disciplines. I am not arguing that medical qualifications are necessary to be a health leader, but it does seem that medicine is doing very much worse than other disciplines at creating a female leadership pipeline.

Since the federal position of Chief Medical Officer (CMO) was established in 1983, there has been one female incumbent – Dr Judith Whitworth, 1997–1999. In the 40-year history of CMOs, there have been just 3 years of female leadership. There have been none this century. The career path to support medical women into leadership at the system level is sadly lacking.

Equity is not about treating everyone the same. It’s about recognising that some people start with barriers to overcome that the dominant group simply don’t have. Women surgeons have been shown to be affected by:

• workplace factors (such as climate and access to leave);
• epistemic injustices;
• role stereotypes; and
• experiences of objectification.

It is not fanciful to extend this analysis to non-surgeons. The physician leader, Dr Helena Teede wrote about the career barriers presented by unconscious bias from both men and women. She wrote of tokenism, and male stereotypes of what “good leadership” looked like. If we had effective gender equity policies and approaches in medicine, then women would make up 50% of the most senior and powerful positions. We are a very long way from that.

When I left Australia almost exactly 10 years ago to take up my post at the United Nations, I had never worked outside Australia before. My whole view of the world, of myself, of what work should be, and what I could expect in a workplace had been shaped by Australian norms and perspectives.

I had been working for the UN for about 6 months, and one day I realised that I was feeling lighter, less constrained, and more myself. After several weeks of reflection, I realised that for the first time in my career, my gender was not a barrier. For the first time, I did not need to be cautious when expressing an opinion, I didn’t need to seek preliminary approval or support from powerful men – I could just do my job without self-censorship. I didn’t even recognise that burden until it wasn’t there anymore. That freedom to be the fullest version of self is not yet experienced by the majority of women in Australian workplaces. There will be exceptions, but the proof will be proportionate representation in positions of power.

I have seen what happened at the UN, when Antonio Guterres simply decided to do it – to prioritise appointing women. In less than 12 months, he achieved gender parity at the top of the organisation and in leadership roles around the world. Finding qualified women candidates is actually not hard, you just have to be prepared to surrender the masculine stereotype and assumptions.

Last month I read these words from Rose Ailing Ellis, who is a deaf actor:

“Let me stop myself. Do you know what I am doing right now? I am doing what I always feel I have to do, making sure that I come across as happy, positive, and easy to work with. I am being careful, as I always am, to explain myself politely, because I have a constant underlying fear that if I dare to express my anger, I will be seen as difficult, too much like hard work, and that I will be replaced by someone who is not deaf. I am presenting the version of myself that I want you to see, the one where I am grateful for everything that has happened, and thankful for all the opportunities you have given me. But the reality is, it’s been a constant battle. I have to break through countless barriers to get to where I am. It’s been a lonely, upsetting journey, and whilst winning [Strictly Come Dancing] was an amazing experience, it shouldn’t be allowed to conceal the hardships I have been through to get here”.

Those words struck a chord. What woman in medicine (or for that matter, what person of colour, or with disability or with other aspects of diversity) has not experienced those emotions, that self-censorship, that need to be seen as not difficult, not demanding, and grateful for opportunities?

This is a constant cognitive load that women in medicine (and in other leadership roles) carry. It is reinforced by the casual misogyny that so many of our male colleagues express in front of us, describing other women as “batty”, “high maintenance”, “emotional”, “bonkers”, “hysterical”. While these casual comments carry a veneer of inclusion – “I can say this to you because you are not like them” – there is actually an implicit threat – don’t cause trouble, or I’ll talk about you the same way.

I have read with no surprise, but with some dismay, the dismissive comments about a recent article by Dr Aajuli Shukla. Commentators retreated to the same old arguments, and instead of listening to women, instead blamed them. Effectively saying “it’s your own fault if patients stereotype you”. Believe me, I have not ever publicised myself as a menopause expert, but it is assumed, because of my age and gender.

The argument about whether there is a problem is over. Does it matter? Gender bias does matter, and it is costing our patients. This situation should be worth fixing purely on its own merits, but if female doctors are disrespected and harmed in our health system, what does that mean for patients? Will disrespect and devaluation of women manifest also in therapeutic relationships?

Some aspects of gender-biased practice are well demonstrated. Women are less likely to receive best practice diagnosis and care for myocardial infarction. Women have been found to be less likely to receive appropriate pain relief and, horrifyingly, this even extends to female children. Time to presentation to diagnosis for endometriosis is 7–12 years. University College London found that women with dementia receive less medical attention than men, and a 2016 study showed that women with bladder cancer were less likely to receive systemic chemotherapy than men and had a lower chance of survival.

There is actually very little Australian research on this topic, most of the work has been done in the UK and the US. That in itself is noteworthy and is likely due to a lack of leadership in Australian STEM funding around the importance of gender perspectives in medical research. We have so much data, but so little of it is presented disaggregated by gender that it is extraordinarily difficult to monitor health systems for gender equity.

The UN Secretary General said:

“Gender inequality is a question of power. And something I’ve learned over time is that power is not given, it must be taken.”

The sentence is profound. It challenges us to stop waiting for change, but to demand it; to stop hoping that by playing the game by the rules written by those already in power, that we might one day share some of the crumbs.

The price for not playing by their rules can be high, but I have come to the view that we will not get to gender equity in medicine without some bravery, without some who are prepared to drive the agenda forward even if doing so compromises their personal interests. That is why women need men as allies, and there are many who are. The UN’s He For She program is widely supported across the world, and greater visibility of this in the Australian medical landscape would be invaluable.

My plea to the younger generation of doctors, men and women is that you not be complicit by silence when you see inequity, harassment, abuse and discrimination at play. Do not be tempted to benefit from it, and be brave enough to call it when you see it. Power will not change of its own volition, we have to come and take it and mold it to a better use.

Dr Jillann Farmer is a Brisbane-based GP and former Medical Director of the United Nations.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.

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