Institutional imperatives for the advancement of women in medicine and science through the COVID-19 pandemic
Authors: Arghavan Salles, Reshma Jagsi
Journal: The Lancet (2021)

The multiple roles women have in societies, including in medicine and science, mean that many women have faced unique challenges personally and professionally since the start of the COVID-19 pandemic. Worldwide, women undertook 75% of unpaid care work before the pandemic.1Madgavkar A Krishnan M White O Mahajan D Azcue X COVID-19 and gender equality: countering the regressive effects. McKinsey & Company, July 15, 2020https://www.mckinsey.com/featured-insights/future-of-work/covid-19-and-gender-equality-countering-the-regressive-effectsDate accessed: August 2, 2021Google Scholar According to the UN, "the world's formal economies and the maintenance of our daily lives are built on the invisible and unpaid labour of women and girls".2UNPolicy brief: the impact of COVID-19 on women.https://www.un.org/sexualviolenceinconflict/wp-content/uploads/2020/06/report/policy-brief-the-impact-of-covid-19-on-women/policy-brief-the-impact-of-covid-19-on-women-en-1.pdfDate: April 9, 2020Date accessed: August 2, 2021Google Scholar As external caregiving resources reduced substantially during the pandemic, the burden of caring for children, older adults, and others fell disproportionately on women. There have also been considerable negative impacts on the labour force. Millions of people lost their jobs, with women, and particularly women from marginalised groups, being most vulnerable.3International Labour OrganizationFewer women than men will regain employment during the COVID-19 recovery says ILO.https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_813449/lang--en/index.htmDate: July 19, 2021Date accessed: August 11, 2021Google Scholar For example, a disproportionate number of job losses in the USA were among Black, Latina, and disabled women.4Ewing-Nelson C All of the jobs lost in December were women's jobs. National Women's Law Center, January, 2021https://nwlc.org/wp-content/uploads/2021/01/December-Jobs-Day.pdfDate accessed: August 13, 2021Google Scholar The cost of doing nothing to counteract the impact of the pandemic on women's employment is estimated to result in a loss of US$13 trillion for the global economy by 2030.5Jablonska J Seven charts that show COVID-19's impact on women's employment. McKinsey & Company, March 8, 2021https://www.mckinsey.com/featured-insights/diversity-and-inclusion/seven-charts-that-show-covid-19s-impact-on-womens-employmentDate accessed: August 2, 2021Google Scholar The pandemic has also had negative impacts on women's health—eg, intimate partner violence has worsened in many settings,6Gosangi B Park H Thomas R et al.Exacerbation of physical intimate partner violence during COVID-19 lockdown.Radiology. 2020; 298: e38-e45Crossref PubMed Google Scholar and there has been a mental health toll, particularly for women engaged in direct patient care and other essential services during the COVID-19 response.7National Academies of Sciences, Engineering, and MedicineThe impact of COVID-19 on the careers of women in academic sciences, engineering, and medicine. The National Academies Press, Washington, DC2021Google Scholar Here we highlight how to combat longer-term negative impacts of the pandemic on women's career trajectories. Data from North America have shown women physicians are more likely than men to follow clinical guidelines and may have better patient care outcomes.8Salles A Battle of the sexes: who gives better medical care?. Medscape, March 1, 2021https://www.medscape.com/viewarticle/946412Date accessed: August 2, 2021Google Scholar Despite providing excellent care, women are more likely than men to want to work part time, partly due to competing responsibilities outside of work. In 2016 almost three-quarters of women physicians who participated in a US survey reported working part time or considering it within 6 years of having completed training.9Frank E Zhao Z Sen S Guille C Gender disparities in work and parental status among early career physicians.JAMA Network Open. 2019; 2e198340Crossref PubMed Scopus (87) Google Scholar In Japan, women physicians often leave the workforce after childbirth and do not return to work, even years later.10Ramakrishnan A Sambuco D Jagsi R Women's participation in the medical profession: insights from experiences in Japan, Scandinavia, Russia, and Eastern Europe.J Women's Health. 2014; 23: 927-934Crossref PubMed Scopus (82) Google Scholar With women constituting substantial proportions of the physician workforce worldwide, innovative approaches are needed to ensure their retention, wellbeing, and advancement in medicine.11Kang SK Kaplan S Working toward gender diversity and inclusion in medicine: myths and solutions.Lancet. 2019; 393: 579-586Summary Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 12Jagsi R Fuentes-Afflick E Higginbothom E Promoting equity for women in medicine.N Engl J Med. 2021; 384: 2265-2267Crossref PubMed Scopus (25) Google Scholar The COVID-19 pandemic has amplified the importance of ensuring that such innovations embrace an intersectional approach.13Crenshaw K Demarginalizing the intersection of race and sex: a Black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics.Univ Chic Leg Forum. 1989; 1: 139-167Google Scholar Those with more than one marginalised identity, such as Black, Latina, LGBTQIA+, or disabled women, are impacted more by the challenges of gendered expectations, bias, and harassment than are others. What can institutions do to hire, retain, and promote women in medicine in the pandemic context and for the long term? Mariam Mousa and colleagues' metasynthesis of organisational interventions to promote gender equity in health-care leadership showed that effective strategies include policy changes such as family leave and flexible schedules, increasing the awareness of the challenges faced by women, formal mentoring networks, targeted leadership development, and measurements of cultural support.14Mousa M Boyle J Skouteris H et al.Advancing women in healthcare leadership: a systematic review and meta-synthesis of multi-sector evidence on organizational interventions.EClinicalMedicine. 2021; 39101084Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar Mousa and colleagues concluded that successful efforts require committed leadership alongside monitoring and evaluation over time.14Mousa M Boyle J Skouteris H et al.Advancing women in healthcare leadership: a systematic review and meta-synthesis of multi-sector evidence on organizational interventions.EClinicalMedicine. 2021; 39101084Summary Full Text Full Text PDF PubMed Scopus (79) Google Scholar Building on these findings and evidence of the impacts of the COVID-19 pandemic on women, we propose four strategies institutions that employ women physicians and medical scientists should pursue. First, institutions must intentionally implement best practices to recruit, select, retain, and promote women to help them regain career footing lost during the COVID-19 pandemic and improve diversity in leadership positions.15University of Michigan Advance ProgramWhat can we do? Top 10 best practices. STRIDE faculty recruitment workshop.https://advance.umich.edu/wp-content/uploads/2019/09/STRIDE-Ten-Best-Practices072119.pdfDate: 2019Date accessed: August 14, 2021Google Scholar Such practices include criterion-based evaluations that set performance priorities and metrics a priori and transparency of role requirements and compensation. Unfortunately, the necessarily rapid decisions made during the pandemic might have amplified unconscious bias regarding women's competence or belonging in professional roles and compromised gains towards equity, particularly for minoritised women. Leaders and institutions can create more advancement opportunities for women by dedicating financial and human resources so organisation-wide policies are sustained in the long term, ensuring leaders are committed, incorporating accountability, collecting data, and adopting an intersectional lens.16National Academies of Sciences, Engineering, and MedicinePromising practices for addressing the underrepresentation of women in science, engineering, and medicine: opening doors. The National Academies Press, Washington, DC2020Google Scholar Second, institutions should ensure they provide paid parental leave and resources to support caregiving. Flexible options for work location and timing can be helpful if they are part of a broader approach that recognises the existence of family responsibilities for all employees. The pandemic has illustrated that employment flexibility initiatives can succeed if accompanied by the provision of adequate resources to allow workers to establish necessary boundaries and protect the time and space required for active work participation.7National Academies of Sciences, Engineering, and MedicineThe impact of COVID-19 on the careers of women in academic sciences, engineering, and medicine. The National Academies Press, Washington, DC2021Google Scholar Ready availability of professional caregiving services, generous paid leave policies to allow men and women to participate in family caregiving when necessary, and conscious efforts to destigmatise their use are crucial to facilitate the work participation of women. Third, academic institutions should ensure that women researchers receive adequate funding to mitigate any longer-term impacts of the COVID-19 pandemic on their contributions to medical science. This support is needed because women have borne a disproportionate share of the burdens imposed by the pandemic, including losses in scholarly productivity17Andersen JP Neilsen MW Simone NL Lewiss RE Jagsi R COVID-19 medical papers have fewer women first authors than expected.eLife. 2020; 9e58807Crossref PubMed Scopus (279) Google Scholar and time for research.18Myers KR Tham WY Yin Y et al.Unequal effects of the COVID-19 pandemic on scientists.Nat Hum Behav. 2020; 4: 880-883Crossref PubMed Scopus (481) Google Scholar In addition to offering bridge funding to support researchers whose work was disrupted, institutions can target intramural support for topics more commonly studied by women, such as research on sex-related and gender-related differences in health. Institutions could also develop programmes to fund research support for employees with family caregiving responsibilities.19Doris Duke Charitable FoundationCOVID-19 fund to retain clinical scientists request for applications.https://www.ddcf.org/siteassets/funding-areas/medical-research/documents/covid-19-frcs-rfa.pdfDate: 2021Date accessed: August 2, 2021Google Scholar Finally, institutions should more proactively address workplace gender bias and sexual harassment, which have worsened and taken on new forms with virtual work, particularly for non-white women.20Fessler L Workplace harassment in the age of remote work.The New York Times. June 8, 2021; Google Scholar, 21Project IncludeRemote work since Covid-19 is exacerbating harm.https://projectinclude.org/assets/pdf/Project_Include_Harassment_Report_0321_R8.pdfDate: 2021Date accessed: August 20, 2021Google Scholar Institutions need to adopt approaches that go beyond mandatory training. Institutional leaders must explicitly embrace equity and inclusion and back up verbal commitments with aligned and adequately resourced organisation-wide actions such as those listed above to create an environment in which bias and harassment are at the very least suppressed, if not eliminated. To be effective these efforts will require an intersectional lens. Cultural transformation requires not only allyship from the ground up but also from the top down. Institutions should incorporate equity, diversity, and inclusion metrics into the compensation of leaders to provide further motivation and accountability. For both patient care and research, teams are stronger when they include women.22Greenwood BN Carnahan S Huang L Patient-physician gender concordance and increased mortality among female heart attack patients.Proc Natl Acad Sci USA. 2018; 115: 8569-8574Crossref PubMed Scopus (318) Google Scholar, 23Nielsen MW Alegria S Börjeson L et al.Opinion: gender diversity leads to better science.Proc Natl Acad Sci USA. 2017; 114: 1740-1742Crossref PubMed Scopus (331) Google Scholar The leading institutions of the future will be the ones who make the choice now, in this moment of uncertainty, to reverse the pandemic-induced backsliding of women's careers. AS declares no competing interests. RJ has stock options as compensation for her advisory board role in Equity Quotient, a company that evaluates culture in health-care companies; has received personal fees from the National Institutes of Health as a special government employee (in her role as a member of the Advisory Committee for Research on Women's Health), the Greenwall Foundation, and the Doris Duke Charitable Foundation; has received grants for unrelated work from the National Institutes of Health, the Doris Duke Foundation, the Greenwall Foundation, the Komen Foundation, and Blue Cross Blue Shield of Michigan for the Michigan Radiation Oncology Quality Consortium; has a contract to conduct an investigator initiated study with Genentech; and has served as an expert witness for Sherinian and Hasso, Dressman Benzinger LaVelle, and Kleinbard LLC.