Effect of a Workshop to Break the Bias Habit for Internal Medicine Faculty: A Multisite Cluster Randomized Controlled Study.

PURPOSE: Recognition that cultural stereotypes can unintentionally perpetuate inequities throughout academic medicine has led to calls for "implicit bias training" without strong evidence to support these recommendations and some evidence of potential harm. The authors sought to determine the effectiveness of a single 3-hour workshop in helping department of medicine faculty overcome implicit stereotype-based bias and in improving the climate in the working environment. METHOD: A multisite cluster randomized controlled study (October 2017 to April 2021) with clustering at the level of divisions within departments and participant-level analysis of survey responses involved 8,657 faculty in 204 divisions in 19 departments of medicine: 4,424 in the intervention group (1,526 attended a workshop) and 4,233 in the control group. Online surveys at baseline (3,764/8,657 = 43.48% response rate) and 3 months after the workshop (2,962/7,715 = 38.39% response rate) assessed bias awareness, bias-reducing intentional behavioral change, and perceptions of division climate. RESULTS: At 3 months, faculty in the intervention vs control divisions showed greater increases in awareness of personal bias vulnerability ( b = 0.190 [95% CI, 0.031 to 0.349], P = .02), bias reduction self-efficacy ( b = 0.097 [95% CI, 0.010 to 0.184], P = .03), and taking action to reduce bias ( b = 0.113 [95% CI, 0.007 to 0.219], P = .04). The workshop had no effect on climate or burnout, but slightly increased perceptions of respectful division meetings ( b = 0.072 [95% CI, 0.0003 to 0.143], P = .049). CONCLUSIONS: Results of this study should give confidence to those designing prodiversity interventions for faculty in academic medical centers that a single workshop which promotes awareness of stereotype-based implicit bias, explains and labels common bias concepts, and provides evidence-based strategies for participants to practice appears to have no harms and may have significant benefits in empowering faculty to break the bias habit.

A novel approach for assessing bias during team-based clinical decision-making.

Many clinical processes include multidisciplinary group decision-making, yet few methods exist to evaluate the presence of implicit bias during this collective process. Implicit bias negatively impacts the equitable delivery of evidence-based interventions and ultimately patient outcomes. Since implicit bias can be difficult to assess, novel approaches are required to detect and analyze this elusive phenomenon. In this paper, we describe how the de Groot Critically Reflective Diagnoses Protocol (DCRDP) can be used as a data analysis tool to evaluate group dynamics as an essential foundation for exploring how interactions can bias collective clinical decision-making. The DCRDP includes 6 distinct criteria: challenging groupthink, critical opinion sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation. Based on the strength and frequency of codes in the form of exemplar quotes, each criterion was given a numerical score of 1-4 with 1 representing teams that are interactive, reflective, higher functioning, and more equitable. When applied as a coding scheme to transcripts of recorded decision-making meetings, the DCRDP was revealed as a practical tool for examining group decision-making bias. It can be adapted to a variety of clinical, educational, and other professional settings as an impetus for recognizing the presence of team-based bias, engaging in reflexivity, informing the design and testing of implementation strategies, and monitoring long-term outcomes to promote more equitable decision-making processes in healthcare.

Pilot test of a multicomponent implementation strategy for equity in advanced heart failure allocation.

Advanced heart failure (AHF) therapy allocation is vulnerable to bias related to subjective assessments and poor group dynamics. Our objective was to determine whether an implementation strategy for AHF team members could feasibly contribute to organizational and culture change supporting equity in AHF allocation. Using a pretest-posttest design, the strategy included an 8-week multicomponent training on bias reduction, standardized numerical social assessments, and enhanced group dynamics at an AHF center. Evaluations of organizational and cultural changes included pretest-posttest AHF team member surveys, transcripts of AHF meetings to assess group dynamics using a standardized scoring system, and posttest interviews guided by a framework for implementing a complex strategy. Results were analyzed with qualitative descriptive methods and Brunner-Munzel tests for relative effect (RE, RE >0.5 signals posttest improvement). The majority of survey metrics revealed potential benefit with RE >0.5. REs were >0.5 for 5 of 6 group dynamics metrics. Themes for implementation included (1) promoting equitable distribution of scarce resources, (2) requiring a change in team members' time investment to correct bias and change the meeting structure, (3) slowing and then accelerating the allocation process, and (4) adaptable beyond AHF and reinforceable with semi-annual trainings. An implementation strategy for AHF equity demonstrated the feasibility for organizational and culture changes.

Group Dynamics and Allocation of Advanced Heart Failure Therapies-Heart Transplants and Ventricular Assist Devices-By Gender, Racial, and Ethnic Group.

Background US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. Methods and Results We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. Conclusions Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation.

Mini-Residencies to Improve Care for Women Veterans: A Decade of Re-Educating Veterans Health Administration Primary Care Providers.

Background: Many primary care providers (PCPs) in the Veterans Health Administration need updated clinical training in women's health. The objective was to design, implement, and evaluate a training program to increase participants' comfort with and provision of care to women Veterans, and foster practice changes in women's health care at their local institutions. Methods: The Women's Health Mini-Residency was developed as a multi-day training program, based on principles of adult learning, wherein knowledge gleaned through didactic presentations was solidified during small-group case study discussions and further enhanced by hands-on training and creation of a facility-specific action plan to improve women Veterans' care. Pre, post, and 6-month surveys assessed attendees' comfort with and provision of care to women. The 6-month survey also queried changes in practice, promulgation of program content, and action plan progress. Results: From 2008 to 2019, 2912 PCPs attended 26 programs. A total of 2423 (83.2%) completed pretraining and 2324 (79.3%) completed post-training surveys. The 6-month survey was sent to the 645 attendees from the first 14 programs; 297 (46.1%) responded. Comparison of pre-post responses indicated significant gains in comfort managing all 19 content areas. Six-month data showed some degradation, but comfort remained significantly improved from baseline. At 6 months, participants also reported increases in providing care to women, including performing more breast and pelvic examinations, dissemination of program content to colleagues, and progress on action plans. Conclusions: This interactive program appears to have been successful in improving PCPs' comfort in providing care for women Veterans and empowering them to implement institutional change.

The Influence of Messaging on Perceptions of Careers in Veterinary Medicine: Do Gender Stereotypes Matter?

The veterinary medical workforce is increasingly female; occupational feminization often transfers stereotypes associated with the predominant gender onto the profession. It is unknown whether within veterinary medicine a feminized public image is a possible contributor to the reduction in male applicants to training programs. The influence of stereotypically gendered messaging on how male and female undergraduate students perceive veterinary medicine was investigated in 482 undergraduate students enrolled in five introductory or second-level biology courses. Two short videos introducing the field of veterinary medicine were developed with imagery and language selected to emphasize either stereotypic feminine (communal) or masculine (agentic) aspects of the field. Participant groups were randomly assigned one of the two videos (feminine/communal or masculine/agentic) or no video (no exposure). An outcome survey elicited impressions of the field of veterinary medicine and gathered demographic data. There was a significant linear trend of condition on perception of the profession as feminine or masculine and on perception of the activities of a veterinarian as feminine/communal or masculine/agentic. Female participants were significantly more likely to agree that someone of their gender would be valued in the profession. Male participants reported significantly higher self-efficacy scores for performing the tasks of a veterinarian when they viewed the feminine stereotype video. These results demonstrate that gendered perceptions of the field can be manipulated. Intentional gendered messaging should be further explored as one strategy to broaden the talent pool in the workforce by attracting men back to the field.

Next Steps: Advocating for Women in Orthopaedic Surgery.

Orthopaedic surgery is the least diverse of all medical specialties, by both sex and race. Diversity among orthopaedic trainees is the lowest in medicine, and growth in percentage representation is the lowest of all surgical subspecialties. Women comprise only 6% of orthopaedic surgeons and 16% of orthopaedic surgery trainees. This extreme lack of diversity in orthopaedics limits creative problem-solving and the potential of our profession. Women in orthopaedics encounter sexual harassment, overt discrimination, and implicit bias, which create barriers to training, career satisfaction, and success. Women are underrepresented in leadership positions, perpetuating the lack of diversity through poor visibility to potential candidates, which impedes recruitment. Correction will require a concerted effort, as acknowledged by the American Academy of Orthopaedic Surgeons leadership who included a goal and plan to increase diversity in the 2019 to 2023 Strategic Plan. Recommended initiatives include support for pipeline programs that increase diversity of the candidate pool; sexual harassment and implicit bias acknowledgement, education, and corrective action; and the active sponsorship of qualified, capable women by organizational leaders. To follow, women will lend insight from their diverse viewpoints to research questions, practice problems, and clinical conundrums of our specialty, augmenting the profession and improving patient outcomes.

Women Oncologists' Perceptions and Factors Associated With Decisions to Pursue Academic vs Nonacademic Careers in Oncology.

Importance: Women outnumber men in US medical school enrollment, but they represent less than 40% of academic oncology faculty. Objective: To identify the key factors associated with female oncologists' decision to pursue academic or nonacademic oncology practice and to characterize their perceptions about their current career. Design, Setting, and Participants: This cross-sectional survey study was distributed through email and social media to female physicians in academic and nonacademic oncology practice in the United States. The survey was open for 3 months, from August 1 to October 31, 2020. Main Outcomes and Measures: No single primary study outcome was established because of the cross-sectional nature of the survey. Data were collected anonymously and analyzed using t tests for continuous variables and χ2 tests for categorical variables. Results: Among the 667 female respondents, 422 (63.2%) identified as academic oncologists and 245 (36.8%) identified as nonacademic oncologists. Approximately 25% of respondents reported that their spouse or partner (156 [23.5%]) and/or family (176 [26.4%]) extremely or moderately affected their decision to pursue academic practice. Academic oncologists perceived the biggest sacrifice of pursuing academics to be time with loved ones (181 [42.9%]). Nonacademic oncologists perceived the biggest sacrifice of pursuing academics to be pressure for academic promotion (102 [41.6%]). Respondents had different perceptions of how their gender affected their ability to obtain a chosen job, with 116 academic oncologists (27.6%) and 101 nonacademic oncologists (41.2%) reporting a positive or somewhat positive impact (P = .001). More than half of the women surveyed (54.6% academic oncologists [230]; 50.6% nonacademic oncologists [123]; P = .61) believed they were less likely to be promoted compared with male colleagues. Academic and nonacademic oncologists reported rarely or never having a sense of belonging in their work environment (33 [7.9%] and 5 [2.0%]; P < .001). Most respondents reported that they would choose the same career path again (301 academic oncologists [71.3%]; 168 nonacademic oncologists [68.6%]); however, 92 academic oncologists (21.9%) reported they were likely to pursue a career outside of academic oncology in the next 5 years. Conclusions and Relevance: This survey study found that a spouse or partner and/or family were factors in the career choice of both academic and nonacademic oncologists and that female gender was largely perceived to adversely affect job promotion. Given that more than 20% of female academic oncologists were considering leaving academia, gender inequality is at high risk of continuing if the culture is not addressed.

Sex Disparities in Organ Donation: Finding an Equitable Donor Pool.

Background The majority of living organ donors are women, but few are deceased organ donors, which increases risks associated with sex mismatched organs. We sought to identify reasons for sex disparities in organ donation and strategies for equity. Methods and Results Using Amazon's Mechanical Turk, we examined US adults' perceptions regarding donation in a mixed-methods survey study. Results were compared by sex with Fisher's exact test and T-tests for quantitative results and qualitative descriptive analyses for write-in responses. Among 667 participants (55% women), the majority of men (64.8%) and women (63.4%) self-identified as registered donors. Women's willingness to donate their own organs to family members (P=0.03) or strangers (P=0.03) was significantly higher than men. Donors from both sexes were guided by: desire to help, personal experience, and believing organs would be useless to deceased donors. Non-donors from both sexes were guided by: no reason, medical mistrust, contemplating donation. When considering whether to donate organs of a deceased family member, women were equally guided by a family member's wishes and believing the family member had no further use for organs. Men had similar themes but valued the family member's wishes more. Among non-donors, both sexes would consider donation if more information was provided. Conclusions In a national survey, both sexes had similar reasons for becoming and not becoming an organ donor. However, compared with men, women were more willing to donate their organs to family members and strangers. Improving education and communicating wishes regarding organ donation with direct relatives may increase sex equity in deceased organ donation.

Engaging faculty in a workshop intervention on overcoming the influence of implicit bias.

INTRODUCTION: To study the effectiveness of any educational intervention for faculty requires first that they attend the training. Using attendance as a measure of faculty engagement, this study examined factors associated with the percentage of faculty in divisions of departments of medicine who attended a workshop as part of a multisite study. METHODS: Between October 2018 and March 2020, 1675 of 4767 faculty in 120 divisions of 14 departments of medicine attended a 3-hour in-person workshop as part of the Bias Reduction in Internal Medicine (BRIM) initiative. This paper describes the workshop development and study design. The number of faculty per division ranged from 5 to 296. Attendance rates varied from 2.7% to 90.1%. Taking a quality improvement approach, the study team brainstormed factors potentially related to variations in workshop attendance, constructed several division- and institution-level variables, and assessed the significance of factors on workshop attendance with hierarchical linear models. RESULTS: The following were positively associated with workshop attendance rate: the division head attended the workshop, the BRIM principal investigator gave Medical Grand Rounds, and the percentage of local workshop presenters who completed training. Workshop attendance rates fell when departments identified more than five on-site study leaders. CONCLUSIONS: Factors associated with higher workshop attendance may have increased the perceived status and value of attending the workshop, leading faculty to choose the workshop over other competing demands. For future investigators studying educational interventions that require participation of faculty in clinical departments at multiple sites, this work offers several valuable lessons.

Improving Department Climate Through Bias Literacy: One College's Experience.

Many institutions of higher education are investing in "implicit bias training" as a mechanism to improve diversity and inclusion on their campuses. In this study, we describe an effort to implement this training in the form of a 3-hour workshop delivered to faculty members in the College of Engineering at the University of Wisconsin-Madison. Evaluation form data collected immediately post-workshop, and in-person interviews and survey data collected 6-12 months post-workshop, were used to measure the effectiveness of the intervention. These data show that faculty awareness of implicit bias in their workplace environments increased significantly, although individual motivation and self-efficacy to act without bias, and self-reported bias-reduction actions, did not increase. At the same time, we found evidence of improved department climates and bias-reduction actions at the department level, which increase our confidence that the workshops were having a positive impact. Importantly, women and faculty of color in the College did not report increases in negative behavior after the workshop, and reported that their departments were engaging in explicit discussions of potential biases in departmental processes more often. These findings support the continued implementation of the "Breaking the Bias Habit®" workshops along with measurement of their success.

Videoconferencing Etiquette: Promoting Gender Equity During Virtual Meetings.

Considerable evidence has demonstrated that gender influences interactions during in-person meetings, most commonly, negatively impacting women and persons of color. Pervasive gender stereotypes about roles that were (and are) occupied by men and women lead to implicit assumptions about competency in said roles. For example, women may receive more negative verbal interruptions or nonverbal cues that undermine their authority as a leader, a stereotypically male-typed role. The coronavirus pandemic has led to the rapid rise in videoconferencing in professional interactions; however, little is known about videoconferencing etiquette and how gender bias permeates to this new setting. Although there are many benefits to the use of this technology, it has the potential to reinforce gender bias rooted in cultural and societal norms, gender stereotypes, and traditional gender roles. The well-documented implicit biases that have been shown to favor men over women during in-person meetings may translate to further gender gaps in leadership during virtual meetings. It is also possible that videoconferencing could be used to reduce gender bias, but until we have research to shine a light on this topic, this article provides 10 tips for promoting gender equity during virtual meetings.

"This happens all the time": a Qualitative Study of General Internists' Experiences with Discriminatory Patients.

BACKGROUND: Workplace discrimination negatively affects physicians of color personally and professionally. Although the occurrence of discrimination from patients has been visible in social media, popular press, and personal essays, scant research exists on patients as a source of discrimination directed at physicians of color. OBJECTIVE: To explore practicing general internists' experiences observing or interacting with patients exhibiting discriminatory behavior directed at physicians of color. DESIGN: A qualitative study with in-depth, semi-structured, one-on-one telephone interviews conducted and recorded between May and September 2019. PARTICIPANTS: A purposive sample of 24 general internists practicing at 12 academic health centers in the USA: 14 self-identified as White and 10 as a physician of color, which included Asian, Black, Native American, and self-identified other race. APPROACH: Four coders analyzed the transcribed and verified interview text; thematic analysis was used to inductively identify cohesive themes and subthemes. KEY RESULTS: Analyses revealed four major themes: (1) assumption that a legitimate doctor is White, male, and able-bodied; (2) legacy of the Black experience; (3) working through the struggle of discrimination; and (4) ethical dilemma of providing care to discriminatory patients. In addition to discrimination from patients based on a physician's race or ethnicity, participants described experiencing or observing discrimination based on a physician's gender and disability status. Participants generally expressed a need for greater support from colleagues and more guidance from institutional policies. CONCLUSIONS: General internists practicing in academic settings reported observing or experiencing discrimination from patients based on the physician's race, ethnicity, gender (or their intersection), and disability status and the ethical dilemma of providing care to such patients. These results contribute to growing evidence of the need for institutions to better support an increasingly diverse physician workforce with policies and specific guidance to help physicians respond to discrimination from patients while still providing quality care.

Research Conducted in Women Was Deemed More Impactful but Less Publishable than the Same Research Conducted in Men.

Background: Female scientists, who are more likely than their male counterparts to study women and report findings by sex/gender, fare worse in the article peer review process. It is unknown whether the gender of research participants influences the recommendation to publish an article describing the study. Materials and Methods: Reviewers were randomly assigned to evaluate one of three versions of an article abstract describing a clinical study conducted in men, women, or individuals. Reviewers assessed the study's scientific rigor, its level of contribution to medical science, and whether they would recommend publishing the full article. Responses were analyzed with logistic regression controlling for reviewer background variables, including sex and experience level. Results: There was no significant difference in perceived research rigor by abstract condition; contribution to medical science was perceived to be greater for research conducted in women than men (odds ratio = 1.7; p = 0.030). Nevertheless, reviewers were almost twice as likely to recommend publication for research conducted in men than the same research conducted in women (predicted probability 0.606 vs. 0.322; p = 0.000). Conclusions: These results are consistent with abundant data from multiple sources showing a lower societal value placed on women than men. Because female investigators are more likely than male investigators to study women, our findings suggest a previously unrecognized bias that could contribute to gender asymmetries in the publication outcomes of peer review. This pro-male publication bias could be an additional barrier to leadership attainment for women in academic medicine and the advancement of women's health.

Gender Can Influence Student Experiences in MD-PhD Training.

Background: Female physician-scientists have led major advances in medicine broadly and particularly in women's health. Women remain underrepresented in dual MD-PhD degree programs that train many physician-scientists despite gender parity among medical and biomedical research students. Materials and Methods: To explore how the training environment might be experienced differently for male and female students in one MD-PhD program, the authors analyzed gender differences in annual symposium speakers with exact binomial tests, student participation as question-askers at a weekly seminar with logistic regression, and number of publications with quasi-Poisson generalized linear models. They compared male and female students' perceptions of gender-based discrimination using a survey, including qualitative analysis of free text responses. The program consisted of 71 total students in the 2017-2018 and 2018-2019 academic years. Female students comprised 42.0% (81/191) of program matriculants from 1997 to 2019. Results: Male and female students were equally likely to present at the annual program symposium, but faculty (p = 0.001) and keynote (p = 0.012) presenters were more likely to be male. Compared with male counterparts, female students asked fewer seminar questions (p < 0.005) and female speakers received more questions (p = 0.03). Female students perceived less support and differed from men in reasons for asking or not asking seminar questions. Free text responses described repeated small acts of discrimination toward women with cumulative impact. Positive program changes followed presentation of findings to program leaders and students. Conclusions: The authors identified several aspects of one MD-PhD program that could discourage career or training persistence of female students. Increasing awareness of these issues was temporally related to positive programmatic changes.

Race and Gender-Based Perceptions of Older Adults: Will the Youth Lead the Way?

BACKGROUND: Older individuals encounter the greatest racial/gender biases. It is unknown whether younger generations, who often lead culture shifts, have racial and gender biases against older populations. METHODS: Using Amazon's Mechanical Turk's crowdsourcing, we identified how an individual's race and gender are associated with perceptions of individuals aged mid-60s. Participants were asked to rate photograph appearances on Likert Scale (1-10). Interactions between participant and photograph race and gender were assessed with mixed effects models. Delta represents rating differences (positive value higher rating for Whites or women, negative value higher rating for African-Americans or men). RESULTS: Among 1563 participants (mean 35 years ± 12), both non-Hispanic White (WP) and all Other race/ethnicity (OP) participants perceived African-American photos as more trustworthy [Delta WP -0.60(95%CI-0.83, - 0.37); Delta OP - 0.51(- 0.74,-0.28), interaction p = 0.06], more attractive [Delta non-Hispanic White participants - 0.63(- 0.97, - 0.29); Delta Other race/ethnicity participants - 0.40 (- 0.74, - 0.28), interaction p < 0.001], healthier [Delta WP -0.31(- 0.53, - 0.08); Delta OP -0.24(- 0.45, -0.03), interaction p = 1.00], and less threatening than White photos [Delta WP 0.79(0.36,1.22); Delta OP 0.60(0.17,1.03), interaction p < 0.001]. Compared with OP, WP perceived African-American photos more favorably for intelligence (interaction p < 0.001). Both genders perceived photos of women as more trustworthy [Delta Women Participants (WmP) 0.50(0.27,0.73); Delta Men Participants(MnP) 0.31(0.08,0.54); interaction p < 0.001] and men as more threatening [Delta WmP -0.84(-1.27, -0.41), Delta MnP - 0.77(- 1.20, - 0.34), interaction p = 0.93]. Compared with MnP, WmP perceived photos of women as happier and more attractive than men (interaction p < 0.001). Compared with WmP, MnP perceived men as healthier than women (interaction p < 0.001). CONCLUSIONS: Among a young generation, older African-Americans were perceived more favorably than Whites. Gender perceptions followed gender norms. This suggests a decline in implicit bias against older minorities, but gender biases persist. Future work should investigate whether similar patterns are observed in healthcare.

Will Losing Black Physicians Be a Consequence of the COVID-19 Pandemic?

A compelling case exists that increasing the number of Black physicians trained and practicing in the United States is one effective intervention to promote health equity and reduce the persistent health disparities that have become glaringly evident during the COVID-19 pandemic. However, the U.S. physician workforce has relatively few Black physicians. Blacks comprise approximately 13% of the U.S. population but only 5% of practicing physicians. In this Invited Commentary, the authors caution that the COVID-19 pandemic may erode the meager progress that has been made in increasing the number of Black physicians. This loss of Black physicians may happen because Black patients are overrepresented among cases of COVID-19, Black physicians care for relatively more Black patients often in settings with less access to SARS-CoV-2 testing and personal protective equipment, and Black physicians have more comorbid chronic conditions that increase their own susceptibility to mortality from COVID-19. All organizations in which physicians train and practice must redouble their efforts to recruit, train, and retain Black physicians. If nothing else, the COVID-19 pandemic must make academic health centers and health care systems recognize Black physicians as the precious resource they are and protect and reward them accordingly.

When a Specialty Becomes "Women's Work": Trends in and Implications of Specialty Gender Segregation in Medicine.

The gender composition of physician specialties varies dramatically with some becoming increasingly female predominant while others remain overwhelmingly male. In their analysis of physician workforce data, the authors demonstrate that despite large increases in the number of female physicians over 4 decades, the degree of gender segregation between specialties has not declined. The authors describe lessons from the highly gender-segregated U.S. workforce as a whole to understand these demographic patterns in the physician workforce. Echoing U.S. workforce findings, women physicians are becoming overrepresented in certain specialties, and this appears to be associated with a relative decline in earnings for physicians in these specialties over time. The authors found a strong negative relationship between the proportion of female physicians in a specialty and its mean salary, with gender composition explaining 64% of the variation in salaries among the medical specialties.Female physicians face biases in the workplace and fall behind male peers in leadership attainment, academic advancement, and earnings. Tenacious gender stereotypes and the conflation of gender and status contribute to these biases and reinforce occupational gender segregation. The clustering of women in certain specialties means these specialties will be disproportionately affected by gender bias. Recognizing the consequences of gender demographics within physician specialties is important to maintain the strong and diverse physician workforce needed to support the health care needs of the populations who depend on these specialties for care.