Intensive Care Medicine: Reflections on the Gender Gap

The NHS Future Forum has acknowledged the under-representation of women in senior leadership positions and the need for appropriate development opportunities (Dacre 2008). Despite women making up over three quarters of all NHS staff, in 2018, 37% of all senior roles were held by women compared with 31% in 2009, and 36% of consultants were women compared with 30% in 2009. This is less than 10% improvement in nearly a decade (Dacre 2008). Perceptions of gender composition in critical care medicine, including perceived drivers i.e. influencing factors of gender inequity, observed implications i.e. associated consequences and related strategies to encourage and retain women in the specialty, have not yet been comprehensively explained (Parson et al. 2019). Harvard researchers used sensors on employers to study how women interact at work and “no perceptible differences were observed in the behavior of men and women, yet women weren’t advancing and men were” (Gavet 2017).

ICM is a discipline where technology is increasingly represented and progressively developed. Unfortunately, there is a significant mismatch between the number of engineers developing medical devices (Kanze et al. 2017; Malmstrom et al. 2017; Devlin and Hern 2017) and the bedside users, which are mostly women (nurses and doctors) (Canadian Medical Association 2018). We cannot quantify such gap in healthcare and in particular in ICM; however, in general, women are a minority in tech companies and engineering. The Guardian recently reported the case of an engineer working at Google, who lost his job because he suggested that “male domination of Silicon Valley is down to biological differences between the sexes” (Devlin and Hern 2017). There are currently 20% of Google engineers that are women, a statistic that is matched roughly across big tech companies.

There are countless scientific studies that claim to identify differences between male and female cognitive aptitudes and in the UK, far fewer girls choose to study computer science in secondary schools (20% of the total number of students), at degree level (16%) and beyond. However, while 16% of computer science undergraduates in the UK and in the USA are female, the balance is different in India, Malaysia and Nigeria where 50% are women (Devlin and Hern 2017). Prof Dame Wendy Hall, a director of the Web Science Institute at the University of Southampton suggested that the gender gap and the “male stereotype” is dated back to the advent of the home computer in the early 80s. As a matter of fact, home computers were marketed as gaming systems for men (Devlin and Hern 2017). Jane Margolls is a psychologist at the University of California, Los Angeles, who interviewed computer science students in the 90s at Carnegie Mellon University, which had one of the top programmes in the country at the time. “Many of the women at Carnegie Mellon talked about computers being in their brother’s bedroom and there were a lot of father-son internships around the computer that were not happening with the daughters.”

The setting and structure of ICM is “gender unfriendly” by design. Authors could assume that women working at the bedside in ICM have an environment designed by male engineers. Furthermore, they have to use guidelines created by male task force members or authors. Interestingly women have no representation in leadership or academic scale to express their difficulties. This is a system that is designed to fail as soon as the number of women in medicine increases.

To change this culture, our critical care community must acknowledge that gender inequity exists and is problematic. Mehta et al. (2017) advocate for diversity and propose 5 proactive strategies to ensure gender parity, which we have listed in Table 2.

Barriers to Career Progression for Women in ICM

The question is: how could it be possible to address system barriers for women’s progression in the field of ICM? Table 3 contains some suggestions:

Change the myth that less than full time work/training equals being lazy or not ambitious

Frequently, trainees or specialists working outside the full-time scheme are seen as an exception to the ‘norm’ and sadly affiliate to lack of ambition and enthusiasm. The concept of part time or less than full time (LTFT) employments is crucial and relates very closely to parental responsibilities. It is evident that caring responsibilities continue to have a more substantial impact on women’s careers, despite the findings that there is little difference in male and female doctors’ personal values and their orientation towards family, children and work. Central to this issue is the need to address the bias that working or training part time or less than full time (LTFT) is a deviation from the ‘normal’ pathway.

In 2019, The College of ICM of Australia and New Zealand published that it “is committed to providing an inclusive environment that welcomes contributions from the broad diversity of the intensive care community” (cicm.org.au). This is the first formal document suggesting “The College will support accredited ICUs to offer high quality part-time training positions and part-time specialist positions“ (cicm.org.au). Nevertheless, public perception of LTFT work is unchanged, identifying individuals in this category as less productive or valued. Younger members of the British Medical Association (BMA) in the UK report that “there are often significant administrative and practical hurdles to gaining LTFT status and concerning reports of bullying and undermining behaviour from managers and colleagues” (Mehta et al. 2017). The Australian and New Zealand documents one of few examples of training institution, college or hospital, which formally addresses this issue. All Royal Colleges and specialist societies should be required to publish the proportion working LTFT in their specialty and at each grade. This would help highlight where it is currently more restricted and encourage action on identifying and removing barriers in those specialities in the future.

Moreover, according to BMA junior doctors’ surveys, “traditional career pathway of full-time, uninterrupted training to consultant or attending is not as appealing to younger generations of doctors and medical students, whether male or female. Widening access to LTFT training and working will help retain more staff, improve wellbeing and reduce burnout in women and men. Employers or trainees who take extended periods of leave, including maternity/parental leave are not guaranteed a return to the rotations that they had previously been allocated. This can have a significant impact on career progression and increase the existing gap.” Return to work or training is mostly unsupported. This has a major impact on self-confidence. People returning to work or training in a stressful environment do not feel supported in advancing their career or asking for more responsibility for several months or years. Making senior jobs more accessible and attractive to women include and moving away from the full-time default for senior posts.

Enhance transparency

Recruiting managers and academics is challenging and the interview panel is hardly trained in how to carry out these processes to minimise bias influencing decisions. Job advertisements and role descriptions should be reviewed for gendered language. There is no global regulation and frequently there is no transparency in the way those jobs are offered. There are no specific global requirements for academics to become Professors; as a matter of fact, leading roles in academia could be given without a PhD if “someone” is the right candidate. This is highlighted also in the UK gender gap enquiry by the fact that high level degrees have more value when owned by men compared to women. Transparency must be offered for:

-advertising

-recruiting

-contracting (mangers and academics)

Transparency in advertising and recruiting is likely to increase gender parity by shining a light on areas and processes that need to be improved and making individuals more aware of their rights. The UK government is currently consulting on requiring large employers to be transparent about their work-life policies and flexible work opportunities on job advertisements, which we would support.

Challenge negative behaviours

ICM organisations and societies should produce a set of recommendations on what is needed to effectively challenge behaviour and create a more positive workplace culture. Culture provides the context within which employees judge the appropriateness of their behaviour. Health and safety used to be all about policies, procedures and policing, and the focus on people was not on the agenda. Currently a safe workplace is about changing behaviour and influencing engagement. Safety is more about people, human factor and not policies. ICM specialists need to move away from the command and control mindset, and focus on daily habits, changing attitudes and recalibrating the way people think about safety. Proactive, preventative behaviour needs to be enhanced and in this context challenging negative behaviour should be part of the hospital culture. Women will benefit from this change and might find support in male colleagues. Harvard researchers showed that gender parity efforts are most effective when men believe they have a role to play, that their partnership is valued and that transformation of the workplace is something they can share in (Johnson and Smith 2018).

Promote sponsorship vs mentoring

Providing access to senior level sponsors and advocates could make a significant impact on successfully developing, retaining and progressing women. The General Medical Council in the UK states in its “Duties of a Doctor” guidance that doctors should be willing to take on a mentoring role for more junior doctors and healthcare professionals (gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/duties-of-a-doctor).Those specialties which currently have the widest gender pay gaps, are male dominated, and should be prioritised and additional government funding also provided to support an enhanced mentoring and sponsorship programmes.

Increase the number of grants, awards and clinical excellence awards applications done by women.

The process and application to grants and awards should be open and transparent. Women are not empowered when applying to research grants as well as excellence awards. To address the gender imbalance in submissions all possible steps should be taken to train and encourage women to apply. Success rate following application is not different for excellence awards and might increase for research grants in future.

Reduce gender pay gaps within grades and specialties. Changes to mandatory gender pay gap reporting. Reduce gender pension gap.

Laine et al. (2004) reported evidence from the US Census Bureau that “female physicians’ wages averaged 63% for each dollar earned by their male colleagues.” The College of Medicine in the US female academics earned 89% of the average male salary (Connolly and Holdcroft 2007). In April 2018, Department of Health & Social Care (DHSC) commissioned a review, chaired by Professor Dame Jane Dacre, to identify the causes of the gender pay gap in the medical sector. Data are not published, but still a significant pay gap is being recorder in the UK. Additionally, some analysis has been done on the intersection between gender and other protected characteristics such as disability, ethnicity and sexual orientation using the Oaxaca-Blinder decomposition (Elder et al. 2010).

The Gender pension gaps also needs consideration given its impact on gender long term pay inequalities. As women earn less than men on average they accrue less pension, and they are also more likely to take pension holidays to cover family costs such as childcare. Older women may also work less to provide care for others (e.g. care of adults with illnesses and disabilities) meaning they are more likely to give up work or reduce their working hours. Women working LTFT are additionally disadvantaged because pension contributions are frequently calculated on the basis of full-time equivalent earnings rather than actual earnings.