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Dr. Palepu is Assistant Professor of the Division of General Internal Medicine, St. Paul's Hospital, University of British Columbia, Vancouver, BC. She is also an Associate Editor of CMAJ. Dr. Herbert is Dean of the Faculty of Medicine and Dentistry and Professor of Family Medicine at the University of Western Ontario, London, Ont. She is also a member of CMAJ's editorial board.
Correspondence to: Dr. Anita Palepu, St. Paul's Hospital 620B-1081 Burrard St., Vancouver BC V6Z 1Y6 fax 604 631-8005; anita{at}hivnet.ubc.ca
I come here today ... to tell you that coeducation has proved an absolute failure, from our standpoint. When I tell you that 33.3 per cent of the ladies, students, admitted to Johns Hopkins Hospital at the end of our short session are to be married, then I tell you that coeducation is a failure. — William Osler, 18941
Although there are more medical women today in academia as students, residents and faculty than Osler could ever have imagined, a certain silence reigns over the challenges they face in balancing career demands with family life. Nor are gender bias and harassment freely discussed. This silence serves to perpetuate a culture that is inhospitable to the retention of women in academic medicine. The experiences we describe and the suggestions we put forth in this commentary are not exclusive to women in academic medical environments; nor do all academic women have partners or children. But we raise these issues in the context of academic medicine in the hope of fostering open dialogue that will support women in all areas of our profession.
The hard-won acceptance of women into medical education has been far from the failure decried by Osler. The majority (59%) of medical students in Canada are women,2 as are almost 30% of practising physicians.3 For the women of Osler's day, family attachments were expected to spell the end of a professional career; in our time, many medical women balance the demands of both. But that balance is often precarious. Like women in other professions, female physicians experience fatigue, stress, guilt and "role strain," which has been described as:
a divided or uncertain sense of identity experienced [by women] many times at all stages of their professional career. It is not only that a professional woman is impelled to divide her time and energy to cover both home and work but also that, unlike the male professional, she is constantly beset by divided loyalties and a sense of guilt.4
Female physicians are by no means exempt from the responsibilities that women have traditionally carried as their children's primary caregivers.5 This can lead to dissatisfaction not only with their professional circumstances but also with their achievements on the home front. A recent study at a Canadian medical school found that at all career stages (medical school, residency, practice and teaching) women were less likely than men to recommend parenting to their peers, were more dissatisfied than their male colleagues with the amount of time they spent with their children and were more likely to consider flexibility with regard to academic responsibilities (such as working part-time) as beneficial.6 Although the respondents thought that the optimal time to start a family was upon completion of medical training, more women are having children during medical training than previously, thereby increasing the need for maternity leaves, greater flexibility in training programs and improved options for child care.7,8
Women who delay having children until they have embarked on an academic career also face numerous impediments. A national survey conducted in the US found that, compared with male colleagues with children, female medical-school faculty with children published less, perceived their careers as progressing more slowly and were less satisfied with their careers.9 When the same comparisons were made between male and female faculty without children, the differences between the groups were less marked. In addition, women faculty with children had less research funding and secretarial support from their institutions than men with children. It appears that family responsibilities consume more time for women faculty, who are therefore less able than men to increase their working hours.9 Women who try to fulfill a double role as professional and as parent incur social penalties on both fronts. As professionals, they may be seen as lacking seriousness; as mothers, they may be seen as lacking selflessness. Institutional insensitivity to the balancing act executed by women as they try to demonstrate commitment to their profession while fulfilling their commitment to family has not been the exception, but the norm. Women are constrained by traditional assumptions about gender roles; these assumptions reflect broader societal values by which parenting and children are undervalued.10 The time women need to spend on their family life conflicts with the expectations of typical academic routines and promotion processes.10 One of us (C.P.H.) recalls that, as a single parent, she had to leave her young children to get themselves off to school so that she could get to a 7:30 a.m. departmental meeting on one occasion. If she declined to attend the meeting, she felt that she would be seen as uncommitted to her work. Nor did she feel it was "safe" to ask that the meeting be rescheduled. Unfortunately, similar stories are told today.
Experiences of gender bias and sexual harassment are also downplayed, for a number of reasons. Harassment and discrimination emphasize one's position on the periphery of a group; few of us want to be the one to complain (which calls attention to this disadvantage) or to be seen as overreacting (an interpretation that trivializes women's experience.) Often, we think that defensive action will compromise the position we have. It requires courage as well as mental and moral energy to deal effectively with sexual harassment, which, unfortunately, remains prevalent in medical schools11,12,13 as well as in academic medicine. A national survey conducted in the United States found that 77% of women faculty experienced gender-based discrimination and harassment during their professional careers.14 These included behaviours, actions and policies that adversely affected work by resulting in disparate treatment according to gender or by creating an intimidating environment. As described by Till,15 sexual harassment included a spectrum of behaviours ranging from generalized sexist remarks and behaviour to threats to engage in sexual behaviour and coercive advances. Such experiences have been most notable in surgical specialties.11,14 One qualitative study involving 34 department chairs in academic medicine found that barriers to women's advancement included manifestations of sexism in the professional environment and a lack of effective mentors.10 The situation is not different in Canada where a recent report examining the gender gap in the distribution of Canada Research Chairs found that only 21% of the Tier 2 posts went to women despite the fact that women comprise 33% of the assistant and associate professors eligible for the award. 16
For women with children or other familial responsibilities, pursuing a demanding professional career will always be a balancing act that is affected by many things, such as whether a pregnancy is difficult or relatively easy, whether one's children are healthy or have special needs, the availability of high-quality child care, the career path and supportiveness of one's spouse, and the presence of extended family or friends who can lend a hand in a crisis. It is wise to avoid the impulse to be a superwoman and "do it all;" pragmatic choices have to be made, such as spending earnings to purchase domestic help and necessary childcare. Taking a maternity leave can be difficult for many women physicians in view of concerns about finances or academic productivity. In addition, some women physicians may have colleagues who are unwilling to cover their on-call responsibilities during a maternity leave. This often reflects an overextended system that has not evolved to allow for a proportion of physicians who may want or need parental leaves. Unfortunately, the time one does not spend with growing children can never be regained. Ultimately, we are more likely to regret the time that we did not have for our families rather than the time that we did not have for work. One of us (C.P.H.) still regrets missing her son's first steps because she was on call that weekend in the hospital as a first-year resident.
It can smooth the way to choose schools or workplaces where there is a "critical mass" of women, assuming that the women who have "made it" have also worked to improve the environment for others to be follow in their footsteps. We need more women leaders in medicine who explicitly encourage and support women medical students. The truth is that many specialties have few women, which means that much of the ground has yet to be broken. Supportive male colleagues in positions of authority do exist and can serve as advocates to help foster a healthy working environment. Individual women should seek out mentors to help them navigate through the academic medical system and to help address gender bias when it arises. This assistance with career development and psychosocial support is crucial to the success of junior faculty.17 Establishing support networks, including some outside of medicine or that extend beyond one's own institution or city, to allow for an objective perspective, is also important. In addition to a mentor, a supportive superior such as a division or department head or dean, is invaluable. In recent years it has become possible to stop the tenure clock, a policy that has been helpful to women faculty who are having children. However, clinical practice is busier than ever and patients frequently seek women physicians. There can be more immediate rewards in clinical practice than in academia, and so some of us might decide on dual roles as practitioner and mother, rather than taking on an academic role as well; but this will have clear implications for medical schools facing a competitive marketplace as they replace an aging professoriate.
Medical schools can take the initiative to create more welcoming environments for both women students and faculty members.18,19,20,21 Having a dean or director position for equity and gender issues within a faculty of medicine sends a clear message that equity is a defined expectation. The climate must be one in which there is zero tolerance for harassment and where equal work is rewarded with equal pay and recognition. Moreover, it should also be ensured that women faculty are appointed to major faculty and selection committees, and that qualified women are encouraged to apply for faculty positions. Leaders at academic institutions can help women to take up faculty roles or leadership positions by recognizing that their career trajectory may differ from that of their male counterparts; women may take time out to have children, returning to pursue their career vigorously once the children are older. The most important contribution that an academic institution can make to the success of medical women is to explicitly invite flexible and creative solutions for individuals.
If we truly aim to create hospitable learning environments for women students and residents in our medical schools, we must ensure that leaders in our universities and faculties of medicine support the career development and leadership potential of women faculty at all career stages. This will improve both recruitment and retention in the academy. Although we can provide suggestions to individual women, the onus is on the academic system to address these issues of gender equity if we are to foster real change. In doing so, we can create an environment that is hospitable to both the men and women of our profession.
Footnotes
Contributors: Drs. Palepu and Herbert each wrote sections of the article. Both edited drafts and agreed upon the final version to be published.
Competing interests: None declared.
References
This article has been cited by other articles:
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  A. L. Seritan, R. Bhangoo, S. Garma, J. DuBe, J. H. Park, and R. Hales Society for Women in Academic Psychiatry: A Peer Mentoring Approach Acad Psychiatry, October 1, 2007; 31(5): 363 - 366. [Abstract] [Full Text] [PDF]
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 R. Hatala Medical women in academia: silenced by the system Can. Med. Assoc. J., March 4, 2003; 168(5): 542 - 542. [Full Text] [PDF]
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A. Palepu and C. Herbert Medical women in academia: silenced by the system Can. Med. Assoc. J., March 4, 2003; 168(5): 544 - 544. [Full Text] [PDF]
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S. Epstein Medical women in academia: silenced by the system Can. Med. Assoc. J., March 4, 2003; 168(5): 542 - 542. [Full Text] [PDF]
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S. R. Pendharkar Medical women in academia: silenced by the system Can. Med. Assoc. J., March 4, 2003; 168(5): 542 - 544. [Full Text] [PDF]
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