Journal Club - Gender Bias and Discrimination in emergency medicine training

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https://www.timeshighereducation.com/news/gender-bias-rife-in-history-departments-says-report/2018937.article

https://www.timeshighereducation.com/news/gender-bias-rife-in-history-departments-says-report/2018937.article

Background

On January 23rd, 1849 Elizabeth Blackwell became the first female graduate of a US medical school, graduating from Geneva College in New York as the Valedictorian of her class.  Despite the passage of 172 years from that remarkable moment, female physicians continue to face both implicit and explicit gender bias within the medical profession and culture.  Until recently the impact of this differential treatment has not been widely acknowledged, examined or addressed.  While gender parity was finally achieved in students entering medical school in 2018, large gender discrepancies still exist within many specialties.  Within emergency medicine (EM), male physicians still outnumber female physicians nearly 3 to 1.  Unsurprisingly, gender bias has demonstrated a negative impact on the educational environment, as recent studies have shown that female trainees receive inconsistent feedback on their performances as compared to their male colleagues, and by the end of residency, an achievement gap exists between female and male EM residency graduates despite starting training with equal skill sets.[1,2] This month’s journal club examines the impact of gender bias on female emergency medicine trainees.

 

Articles reviewed

1. Lu DW, et al. #MeToo in EM: A Multicenter Survey of Academic Emergency Medicine Faculty on Their Experiences with Gender Discrimination and Sexual Harassment. West J Emerg Med. 2020;21(2):252-260. Published 2020 Feb 21. doi:10.5811/westjem.2019.11.44592 [Pdf]

2. Dayal A, et al. Comparison of Male vs Female Resident Milestone Evaluations by Faculty During Emergency Medicine Residency Training. JAMA Intern Med. 2017 May 1;177(5):651-657. doi: 10.1001/jamainternmed.2016.9616. Erratum in: JAMA Intern Med. 2017 May 1;177(5):747. PMID: 28264090; PMCID: PMC5818781.[Full Text]

3. Brucker K, et al. Exploring Gender Bias in Nursing Evaluations of Emergency Medicine Residents. Acad Emerg Med. 2019 Nov;26(11):1266-1272. doi: 10.1111/acem.13843. Epub 2019 Sep 23. PMID: 31373086.[Pdf]

Additional reading

4. Deluca, et al. Opinion: How Does Gender Bias Affect the ED, and How Do We Address It? ACEP Now.

5. Jamieson, et al. Gender equality in emergency medicine: Ignorance isn’t bliss. Emergency Medicine Australasis: EMA (2016) 28, 341-343.[Pdf]

6. The good, the bad, and the ugly of implicit bias. The Lancet, Vol 393, February 9, 2019. [Pdf]


LU ET AL

Lu Table 2 and 3.jpg

This study reviewed academic Emergency physician’s experiences with workplace related gender discrimination and sexual harassment.  It was a cross-sectional survey of EM faculty from six different residency programs.  The survey consisted of the Overt Gender Discrimination at Work Scale (OGDW Scale), the frequency and source of experienced and observed discrimination, and also assessed whether study subjects had experienced unwanted sexual behaviors in their careers.  Study subjects were also asked to assess whether these unwanted behaviors had a negative impact on their self-confidence and career advancement.  Study completion was 40% and women reported higher mean OGDW scores than men (15.4% vs 10.2%).  Female subjects reported  higher rates of gender-based discriminatory treatment than male subjects (62.7% vs 12.5%). The most frequent sources of observed or experienced gender-based discriminatory treatment were patients, admitting staff and nurses.  Women also reported higher rates of experiencing unwanted sexual behaviors than men (52.9% vs 26.2%).  Women reported higher rates of negative effects on their self-confidence and career advancement (22.9% vs 12.5%). 

Bottom Line: This study concluded that female EM faculty perceived more gender-based discrimination and unwanted sexual behaviors in their workplaces than their male colleagues. 



DAYAL ET AL

This study utilized the EM milestones (a standardized framework for longitudinal resident assessment across all years and programs) to compare faculty observed training milestone achievement in male and female emergency medicine residency trainees.  This was a retrospective cohort study at 8 academic and community residency training programs in the United States during a two year time period.  More than 33,000 milestone evaluations were included from 359 EM residents (66% male, 34% female) as assessed by 285 faculty members (68.1% male, 31.9% female).  Achievement of milestones was similar during the first year of EM residency training, but diverged after that with men achieving EM milestones at a rate of almost 13% higher than women throughout residency.  By graduation, this gap had increased to be equivalent to 3-4 months of additional training opportunities for male EM graduates.  No statistically significant difference in milestone achievement scores was noted based on gender of the evaluator. 

Bottom line: The authors concluded that the rate of milestone achievement was higher for male than female EM residents across all EM subcompentencies, creating a gender gap in evaluations that persisted until graduation. 


BRUCKER ET AL

This study explored the presence of gender bias in nursing evaluations of emergency medicine resident trainees. Nursing evaluations were examined for comments that fit within four potential categories; standout, ability, grindstone and interpersonal. Residents’ ABEM in-training examination scores and milestone evaluations were used to assess whether there were measurable differences in the ability of male and female residents. The study determined that 51% of ability comments about female residents were negative compared to 20% of male resident ability comments.  Furthermore, 57% of grindstone comments were negative for females versus 24% of grindstone comments for males.  Review of ABEM in-service training exams and milestone achievements did not demonstrate any measurable gender based difference in this cohort. 

Bottom Line: The study concluded that despite the lack of objective differences in male and female residents, nurses evaluated female residents lower in both ability and work ethic as compared to their male colleagues.

 
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  • Female EM faculty experience significantly higher rates of gender-based discrimination and unwanted sexual behaviors in the workplace than their male colleagues.

  • The rate of EM milestone achievement is higher for male than female EM residents across all EM subcompentencies, creating a gender gap in evaluations that persists until graduation and could be due to a gender bias when evaluating medical trainees. 

  • Despite the lack of objective differences in male and female EM residents’ competence, nursing evaluations’ comments on both ability and work ethic were lower in female EM residents as compared to male EM residents.

 

Download article summaries

 
lu et al.

lu et al.

dAYAL et al.

dAYAL et al.

BRUCKER ET AL

BRUCKER ET AL

 

Looking for more? Check out Dr. Sam Wood Giving an Evidence-Based talk on Gender in Medicine

 

References

1. Mueller AS, Jenkins TM, Osborne M, et al. Gender differences in attending physicians’ feedback to residents: a qualitative analysis. J Grad Med Educ. 2017;9(5):577-585. [Pdf]

2. Dayal A, O’Connor DM, Qadri BA, et al. Comparison of male vs female resident milestone evaluations by faculty during emergency medicine residency training. JAMA Intern Med. 2017;177(5):651-657. [Pdf]

Authored by Christine Hein, MD

Edited and Posted by Jeffrey A. Holmes, MD