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Commentary
Commentaire
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, 1894
1
A
lthough there are more medical women today in
academia as students, residents and faculty than
Osler could ever have imagined, a certain si-
lence reigns over the challenges they face in balancing ca-
reer demands with family life. Nor are gender bias and ha-
rassment 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 exclu-
sive 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 edu-
cation 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 re-
sponsibilities that women have traditionally carried as their
children’s primary caregivers.
5
This can lead to dissatisfac-
tion 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 acad-
emic responsibilities (such as working part-time) as benefi-
cial.
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 em-
barked on an academic career also face numerous impedi-
ments. A national survey conducted in the US found that,
compared with male colleagues with children, female med-
ical-school faculty with children published less, perceived
their careers as progressing more slowly and were less satis-
fied 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 profes-
sionals, they may be seen as lacking seriousness; as mothers,
they may be seen as lacking selflessness. Institutional insen-
sitivity to the balancing act executed by women as they try
to demonstrate commitment to their profession while ful-
filling their commitment to family has not been the excep-
tion, 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 acade-
mic 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. Unfortu-
nately, 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 pe-
Medical women in academia: the silences we keep
Anita Palepu, Carol P. Herbert
CMAJ • OCT. 15, 2002; 167 (8) 877
© 2002 Canadian Medical Association or its licensors
riphery of a group; few of us want to be the one to com-
plain (which calls attention to this disadvantage) or to be
seen as overreacting (an interpretation that trivializes
women’s experience.) Often, we think that defensive ac-
tion will compromise the position we have. It requires
courage as well as mental and moral energy to deal effec-
tively with sexual harassment, which, unfortunately, re-
mains prevalent in medical schools
11–13
as well as in acade-
mic medicine. A national survey conducted in the United
States found that 77% of women faculty experienced gen-
der-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 depart-
ment 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 distribu-
tion 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 pro-
fessors eligible for the award.
16
For women with children or other familial responsibili-
ties, 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 avail-
ability of high-quality child care, the career path and sup-
portiveness 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 earn-
ings 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 re-
flects 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. Ulti-
mately, 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 im-
prove 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. Sup-
portive 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 sys-
tem and to help address gender bias when it arises. This
assistance with career development and psychosocial sup-
port is crucial to the success of junior faculty.
17
Establish-
ing support networks, including some outside of medicine
or that extend beyond one’s own institution or city, to al-
low for an objective perspective, is also important. In addi-
tion 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 acade-
mia, and so some of us might decide on dual roles as prac-
titioner and mother, rather than taking on an academic
role as well; but this will have clear implications for med-
ical schools facing a competitive marketplace as they re-
place an aging professoriate.
Medical schools can take the initiative to create more
welcoming environments for both women students and fac-
ulty members.
18–21
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 ha-
rassment 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 posi-
tions 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 vigor-
ously once the children are older. The most important con-
tribution that an academic institution can make to the suc-
cess of medical women is to explicitly invite flexible and
creative solutions for individuals.
If we truly aim to create hospitable learning environ-
ments 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 individ-
ual women, the onus is on the academic system to address
these issues of gender equity if we are to foster real change.
Commentaire
878 JAMC • 15 OCT. 2002; 167 (8)
In doing so, we can create an environment that is hos-
pitable to both the men and women of our profession.
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Commentary
CMAJ • OCT. 15, 2002; 167 (8) 879
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 As-
sociate Editor of CMAJ. Dr. Herbert is Dean of the Faculty of Medicine and Den-
tistry and Professor of Family Medicine at the University of Western Ontario,
London, Ont. She is also a member of CMAJ’s editorial board.
Competing interests
: None declared.
Contributors
: Drs. Palepu and Herbert each wrote sections of the article. Both
edited drafts and agreed upon the final version to be published.
Correspondence to: Dr. Anita Palepu, St. Paul's Hospital 620B-
1081 Burrard St., Vancouver BC V6Z 1Y6 fax 604 631-8005;
anita@hivnet.ubc.ca
CLINICAL PRACTICE GUIDELINES
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In February 1998
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REVISED:
Guideline 3: Mastectomy or lumpectomy? The
choice of operation for clinical stages I and II
breast cancer [July 23, 2002]
Guideline 5: The management of ductal carcinoma
in situ [Oct. 2, 2001]
Guideline 7: Adjuvant systemic therapy for women
with node-negative breast cancer [Jan. 23, 2001]
Guideline 8: Adjuvant systemic therapy for women
with node-positive breast cancer [Mar. 6, 2001]
Guideline 10: The management of chronic pain in
patients with breast cancer [Oct. 30, 2001]
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Guideline 11: Lymphedema [Jan. 23, 2001]
Guideline 12: Chemoprevention [June 12, 2001]
Guideline 13: Sentinel node biopsy [July 24, 2001]
Guideline 14: The role of hormone replacement
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