Gender Equity and Diversity in Pediatric Critical Care Medicine: We Must Do Better

“Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease.” (Sir William Osler)

The COVID-19 pandemic is amplifying historic inequities worldwide. These inequities include not only gender disparities, but also systemic racism and an overall lack of diversity and representation in all areas of professional life.[1] At a time when the media has spotlighted science and medicine, women have been barely visible, with conspicuous underrepresentation in pandemic leadership and public policy.[2] With challenges of social isolation and closure of schools and childcare, women in health care and academia face inequalities in professional, childcare, and household responsibilities.

These deep-rooted inequities are pervasive in medicine and unacceptable in every arena. As female pediatric intensivists, we observed many examples in our own field that have not improved with time. A recent publication[3] examined gender distribution in Program in Cellular and Molecular Medicine (PCCM) randomized clinical trials, and found that the proportion of women authors increased from 28% in 1985 to 1989 to only 39% in 2015 to 2018. The authorship inequity in pediatric critical care[4] reflects other stark realities of underrepresentation in our field in leadership and senior positions[5] and as speakers at medical conferences.[6] As an example, in the Pediatric Sepsis Guidelines group, women comprised only 11 of 42 authors, and the presentation at the 2020 Society of Critical Care Medicine (SCCM) Congress Plenary included six men and no women.

We cannot ignore disparities in the workforce data worldwide, both in high- and low-middle income countries. The American Board of Pediatrics reported that in 2017 to 2018 women comprised >60% of first-year PCCM fellows in the United States and 40% of all PCCM board-certified physicians.[5] [7] We need to support and champion these rising intensivists by ensuring that they have advantages that have historically been denied to them and level the playing field for the next generation of leaders. Some recent examples include recent panel sessions at major conferences devoted to highlighting achievements in Women in Medicine and development of a list of interprofessional PCCM women speakers (bit.ly/picuwomenspeakers). This public list is open to any PCCM women worldwide that would like to join it with a goal to disseminate as widely as possible. We believe that this list in combination with increased remote conferences and grand rounds can give opportunities to women from different backgrounds and nationalities to speak and be heard in their areas of expertise.

The number of women entering medical schools annually now equals or surpasses that of men.[6] We need to break the cycle of the enduring systemic and organizational implicit bias reflected by fewer promotion and leadership opportunities and unequal pay that have long-term repercussions on women's academic career trajectories.[8] A recent study showed that even among specialties with higher numbers of women, such as pediatrics, women are disproportionally represented in leadership roles.[9] Gender inequity is clear among speakers at critical care conferences worldwide, with proportions of female physician speakers as low as 1%.[10] A lack of representation in the leadership and planning process may contribute to implicit bias in both conference planning and speaker invitations.

Higher burden of childcare and home responsibilities for women translate to fewer opportunities and publications, increased time to promotion, and lower pay.[11] On a broader level, studies have shown a negative impact during the pandemic on women's academic productivity and decreased rates of publication, especially as first author.[12] However, we must also acknowledge the role of discrimination in the underrepresentation of women. One in three physician moms have experienced discrimination because of pregnancy or breastfeeding.[13] Harassment, discrimination, and abuse have been described more frequently for women in subspecialty training.[14]

In addition to strategies described above to reduce gender disparities in our field, there is emerging literature in critical care medicine as a whole[11] including guidelines, practical initiatives, and education on gender bias and diversity benefits. These strategies must be widely promoted in PCCM, with broad support from medical and academic institutions, conference committees, journal editorial boards, and professional societies, where mentorship, women's group, leadership training sessions may not only support women but also identify potential leaders. Because the gender gap starts early and widens as women reach mid- or late-career, timing is especially important. If women experience burnout and feel undervalued in their roles, it further increases gaps in leadership opportunities and salary. Thus, mentorship/sponsorship relationships and leadership programs for women in training and in academic positions are also important.[15]

Other strategies and innovations to reduce the gender disparities include reform in grant funding agencies, increased human resources to support women in negotiations and arbitrations, and creative approaches to pediatric critical care staffing schedules to facilitate work-life integration. To encourage progress, transparency is crucial, including publicly available information on diversity metrics in pediatric critical care medicine departments/divisions. We cannot begin to fix what everyone cannot see.

Studies on gender disparities in medicine bring forth an urgent call for strategies to ensure greater diversity and inclusion. Medicine is overdue for an overhaul in the way we recognize and support providers. Diversity and inclusion in medicine, including gender, nationality, race, religion, and sexual orientation, needs to be celebrated. While we are primarily discussing gender inequity in this article, we strongly support the dismantling of systemic racism, the rights of LGBTQ+ individuals, and recognize the need to call out injustice in every form and continue to broaden our work in this field. Diversity in health care ensures better communication with patients of diverse backgrounds, more impactful research in diverse teams, and better outcomes[6] which is our ultimate aim as clinicians.

This is a call to action to encourage more diversity in those applying to medicine and be fearless in promoting our own work and that of other women and those in marginalized groups ([Fig. 1]). We need interventions at every step. We need to break into all specialties by recognizing our worth and supporting each other. There needs to be support, accountability, and transparency at every level up to the highest institutional tier. We are only now starting to see the tip of the iceberg concerning effects of gender inequities in pediatric critical care medicine and beyond. Now it is time to do something about it.

Fig. 1 Manuscript infographic.

Publication History

Article published online:
10 September 2021

• References

• 1 Ford CL. Commentary: addressing inequities in the era of COVID-19: the pandemic and the urgent need for critical race theory. Fam Community Health 2020; 43 (03) 184-186
• 2 Fletcher S, Joe MB, Hernandez S, Toman I, Harrison TG, Ruzycki SM. The gender of COVID-19 experts in newspaper articles: a descriptive cross-sectional study. J Gen Intern Med 2021; 36 (04) 1011-1016
• 3 Xu GM, Zavalkoff S, de Wildt SN, Duffett M. Gender and authorship in pediatric critical care randomized control trials. Pediatr Crit Care Med 2020; 21 (12) 1035-1041
• 4 Antkowiak MC, Parsons PE, Stapleton RD. Slow progress toward gender equality in critical care medicine. Am J Respir Crit Care Med 2020; 201 (07) 763-764
• 5 Maxwell AR, Riley CL, Stalets EL, Wheeler DS, Dewan M. State of the unit: physician gender diversity in pediatric critical care medicine leadership. Pediatr Crit Care Med 2019; 20 (07) e362-e365
• 6 Wheeler DS, Dewan M, Maxwell A, Riley CL, Stalets EL. Staffing and workforce issues in the pediatric intensive care unit. Transl Pediatr 2018; 7 (04) 275-283
• 7 American Board of Pediatrics. Pediatric Physicians Workforce Data Book, 2017–2018. Accessed 2021 at: https://www.abp.org/sites/abp/files/pdf/pediatricphysiciansworkforcedatabook2017-2018.pdf
• 8 Lewiss RE, Silver JK, Bernstein CA, Mills AM, Overholser B, Spector ND. Is academic medicine making mid-career women physicians invisible?. J Womens Health (Larchmt) 2020; 29 (02) 187-192
• 9 Davis T, Goldstein H, Hall D. et al; Don't Forget The Bubbles. Women and children first? Gender equity in paediatric medicine. Arch Dis Child 2021; 106 (02) 201-203
• 10 Chadwick AJ, Baruah R. Gender disparity and implicit gender bias amongst doctors in intensive care medicine: a 'disease' we need to recognise and treat. J Intensive Care Soc 2020; 21 (01) 12-17
• 11 Asgari MM, Carr PL, Bates CK. Closing the gender wage gap and achieving professional equity in medicine. JAMA 2019; 321 (17) 1665-1666
• 12 DeFilippis EM, Sinnenberg L, Mahmud N. et al. Gender differences in publication authorship during COVID-19: a bibliometric analysis of high-impact cardiology journals. J Am Heart Assoc 2021; 10 (05) e019005
• 13 Riano NS, Linos E, Accurso EC. et al. Paid family and childbearing leave policies at top US medical schools. JAMA 2018; 319 (06) 611-614
• 14 Hu YY, Ellis RJ, Hewitt DB. et al. Discrimination, abuse, harassment, and burnout in surgical residency training. N Engl J Med 2019; 381 (18) 1741-1752
• 15 Gottlieb AS, Travis EL. Rationale and models for career advancement sponsorship in academic medicine: the time is here; the time is now. Acad Med 2018; 93 (11) 1620-1623