Applying the Theory of Gendered Organizations to the Lived Experience of Women with Established Careers in Academic Medicine.

Phenomenon: The number of women who enter medical school has been on par with the number of men for almost 20 years, but parity in training has not translated to equity in professional life. To capitalize on the perspective of women faculty with established careers in academic medicine and to bring theory to the largely descriptive research on gender inequity in academic medicine, the authors used the Theory of Gendered Organizations to demonstrate how academic medical centers function as inherently gendered organizations. Approach: The authors recruited women faculty with established careers at one academic medical center based on purposeful and snowball sampling and interviewed 30 participants in Summer/Fall 2018. They coded and analyzed data inductively. In later stages of analysis they used sensitizing concepts from the Theory of Gendered Organizations to guide our focus on formal expectations of, and informal interactions in, the academic medical center. Findings: The disjuncture, i.e., "lip service", between formal expectations intended to be gender-neutral and informal interactions that advantaged men demonstrated how the academic medical center functioned as a gendered organization. Participants experienced these interactions as being treated differently than men and/or being stereotyped. As their careers progressed, participants recognized gender inequity as embedded in the organization, or as they said, "the way things were stacked". Subsequent to this recognition, they navigated this gendered organization by advocating for themselves and younger women faculty. Insights: Women with established careers in academic medicine experienced gender inequity as embedded in the organization but navigate gendered interactions by advocating for themselves and for younger women. Using the Theory of Gendered Organizations as an analytic lens demonstrates how academic medical centers function as gendered organizations; these findings can inform both theory-based research and pragmatic change strategies.

Gender Differences in Emergency Medicine Attending Physician Comments to Residents: A Qualitative Analysis.

Importance: Prior studies have revealed gender differences in the milestone and clinical competency committee assessment of emergency medicine (EM) residents. Objective: To explore gender disparities and the reasons for such disparities in the narrative comments from EM attending physicians to EM residents. Design, Setting, and Participants: This multicenter qualitative analysis examined 10 488 narrative comments among EM faculty and EM residents between 2015 to 2018 in 5 EM training programs in the US. Data were analyzed from 2019 to 2021. Main Outcomes and Measures: Differences in narrative comments by gender and study site. Qualitative analysis included deidentification and iterative coding of the data set using an axial coding approach, with double coding of 20% of the comments at random to assess intercoder reliability (κ, 0.84). The authors reviewed the unmasked coded data set to identify emerging themes. Summary statistics were calculated for the number of narrative comments and their coded themes by gender and study site. χ2 tests were used to determine differences in the proportion of narrative comments by gender of faculty and resident. Results: In this study of 283 EM residents, of whom 113 (40%) identified as women, and 277 EM attending physicians, of whom 95 (34%) identified as women, there were notable gender differences in the content of the narrative comments from faculty to residents. Men faculty, compared with women faculty, were more likely to provide either nonspecific comments (115 of 182 [63.2%] vs 40 of 95 [42.1%]), or no comments (3387 of 10 496 [32.3%] vs 1169 of 4548 [25.7%]; P < .001) to men and women residents. Compared with men residents, more women residents were told that they were performing below level by men and women faculty (36 of 113 [31.9%] vs 43 of 170 [25.3%]), with the most common theme including lack of confidence with procedural skills. Conclusions and Relevance: In this qualitative study of narrative comments provided by EM attending physicians to residents, multiple modifiable contributors to gender disparities in assessment were identified, including the presence, content, and specificity of comments. Among women residents, procedural competency was associated with being conflated with procedural confidence. These findings can inform interventions to improve parity in assessment across graduate medical education.

Racial disparity in analgesic treatment for ED patients with abdominal or back pain.

OBJECTIVE: Research on how race affects access to analgesia in the emergency department (ED) has yielded conflicting results. We assessed whether patient race affects analgesia administration for patients presenting with back or abdominal pain. METHODS: This is a retrospective cohort study of adults who presented to 2 urban EDs with back or abdominal pain for a 4-year period. To assess differences in analgesia administration and time to analgesia between races, Fisher exact and Wilcoxon rank sum test were used, respectively. Relative risk regression was used to adjust for potential confounders. RESULTS: Of 20,125 patients included (mean age, 42 years; 64% female; 75% black; mean pain score, 7.5), 6218 (31%) had back pain and 13,907 (69%) abdominal pain. Overall, 12,109 patients (60%) received any analgesia and 8475 (42%) received opiates. Comparing nonwhite (77 %) to white patients (23%), nonwhites were more likely to report severe pain (pain score, 9-10) (42% vs 36%; P < .0001) yet less likely to receive any analgesia (59% vs 66%; P < .0001) and less likely to receive an opiate (39% vs 51%; P < .0001). After controlling for age, sex, presenting complaint, triage class, admission, and severe pain, white patients were still 10% more likely to receive opiates (relative risk, 1.10; 95% confidence interval, 1.06-1.13). Of patients who received analgesia, nonwhites waited longer for opiate analgesia (median time, 98 vs 90 minutes; P = .004). CONCLUSIONS: After controlling for potential confounders, nonwhite patients who presented to the ED for abdominal or back pain were less likely than whites to receive analgesia and waited longer for their opiate medication.

Examining faculty awards for gender equity and evolving values.

BACKGROUND: Awards given to medical school faculty are one important mechanism for recognizing what is valued in academic medicine. There have been concerns expressed about the gender distribution of awards, and there is also a growing appreciation for the evolving accomplishments and talents that define academic excellence in the 21st century and that should be considered worthy of award recognition. OBJECTIVE: Examine faculty awards at our institution for gender equity and evolving values. METHODS: Recipient data were collected on awards from 1996 to 2007 inclusively at the University of Pennsylvania School of Medicine (SOM). Descriptions of each award also were collected. The female-to-male ratio of award recipients over the time span was reviewed for changes and trends. The title and text of each award announcement were reviewed to determine if the award represented a traditional or a newer concept of excellence in academic medicine. MAIN RESULTS: There were 21 annual awards given to a total of 59 clinical award recipients, 60 research award recipients, and 154 teaching award recipients. Women received 28% of research awards, 29% of teaching awards and 10% of clinical awards. Gender distribution of total awards was similar to that of SOM full-time faculty except in the clinical awards category. Only one award reflected a shift in the culture of individual achievement to one of collaboration and team performance. CONCLUSION: Examining both the recipients and content of awards is important to assure they reflect the current composition of diverse faculty and the evolving ideals of leadership and excellence in academic medicine.

The brief CV review session: one component of a mosaic of mentorship for women in academic medicine.

BACKGROUND: In the current climate of increasing demands on a disproportionately small number of senior female faculty, we implemented a brief curriculum vitae (CV) review session as an opportunity to expand the professional network of junior women faculty and provide them with additional formal career advice. METHODS: For 3 years, junior (mentees) and senior (mentors) faculty from different departments were paired in half-hour CV review sessions, as part of an annual conference focused on professional development for faculty women. Participating faculty received questionnaires to assess their experience with the sessions, and their feedback was combined over all 3 years and compared using chi2 and Fisher's tests. RESULTS: During the 3 years, there were 93 CV review sessions. Although 84% of the mentees reported having a mentor, only 62% of mentees reported that any previous mentoring experience was helpful. Most (90%) participated in the CV review to determine if their career was "on track." The mentees reported that the CV review session was helpful (93%), provided new information (87%), and identified that they were "on track" for promotion (75%). The mentors felt that their mentees were progressing appropriately in their career (78%) and provided specific recommendations for the mentees (100%). The majority (78%) of mentors felt comfortable mentoring junior faculty outside their department. CONCLUSIONS: Brief interventions, such as a CV review session, can provide additional counsel to junior faculty, helping them assess their career progress as part of a mosaic of mentorship.

Extrinsic risk factors for pressure ulcers early in the hospital stay: a nested case-control study.

BACKGROUND: Little is known about the impact of extrinsic factors on pressure ulcer risk. The objective of this study was to determine whether risk of pressure ulcers early in the hospital stay is associated with extrinsic factors such as longer emergency department (ED) stays, night or weekend admission, potentially immobilizing procedures and medications, and admission to an intensive care unit (ICU). METHODS: A nested case-control study was performed in two teaching hospitals in Philadelphia, Pennsylvania. Participants were medical patients age > or =65 years admitted through the ED. Cases (n = 195) had > or =1 possibly or definitely hospital-acquired pressure ulcers. Three controls per case were sampled randomly from among noncases at the same hospital in the same month (n = 597). Pressure ulcer status was determined by a research nurse on the third day of hospitalization. Pressure ulcers were classified as preexisting, possibly hospital-acquired, or definitely hospital-acquired. Information on extrinsic factors was obtained by chart review. RESULTS: The odds of pressure ulcers were twice as high for those with an ICU stay as for those without (adjusted odds ratio [aOR] 2.0, 95% confidence interval [CI], 1.2-3.5). The aOR was 0.6 (95% CI, 0.3-0.9) for use of any potentially immobilizing medications during the early inpatient period. CONCLUSIONS: Many of the procedures experienced by patients in the ED and early in the inpatient stay do not confer excess pressure ulcer risk. Having an ICU stay is associated with a doubling of risk. This finding emphasizes the importance of developing and evaluating interventions to prevent pressure ulcers among patients in the ICU.

Lactation Space Experiences and Preferences Among Health Care Workers in an Academic Medical Center.

BACKGROUND: Comprehensive workplace lactation support programs can reduce the risk for early breastfeeding discontinuation; however, scant evidence is available to inform user-centered design of employee lactation spaces. This study describes health care workers' preferences for lactation space. MATERIALS AND METHODS: In 2016-2017, a convenience sample of 151 women who pumped at work at an academic medical center reported on demographics, lactation experiences, and room and equipment preferences through an online survey. RESULTS: Respondents worked in research and administration (32%), were nurses (30%), physicians and medical students (19%), or allied health or clinical support staff (19%). Seventy percent had ever used one of the hospital's dedicated lactation spaces. Forty-nine percent ranked hospital-grade pumps the most important piece of lactation room equipment; 83% preferred multiple occupancy lactation suites; and the average maximum acceptable distance to lactation space was 5.6 minutes. CONCLUSIONS: Optimal lactation infrastructure supports the immediate and long-term health of female workers and their children. User needs and preferences can guide design of lactation space to ensure a minimum standard for design, equipment, and distance. Workers may have different preferences depending on roles and experiences; thus, a variety of solutions may be most effective.

Overreliance on symptom quality in diagnosing dizziness: results of a multicenter survey of emergency physicians.

OBJECTIVE: To assess emergency physicians' diagnostic approach to the patient with dizziness, using a multicenter quantitative survey. PARTICIPANTS AND METHODS: We anonymously surveyed attending and resident emergency physicians at 17 academic-affiliated emergency departments with an Internet-based survey (September 1, 2006, to November 3, 2006). The survey respondents ranked the relative importance of symptom quality, timing, triggers, and associated symptoms and indicated their agreement with 20 statements about diagnostic assessment of dizziness (Likert scale). We used logistic regression to assess the impact of "symptom quality ranked first" on odds of agreement with diagnostic statements; we then stratified responses by academic rank. RESULTS: Of the 505 individuals surveyed, 415 responded for an overall response rate of 82%. A total of 93% (95% confidence interval [CI], 90%-95%) agreed that determining type of dizziness is very important, and 64% (95% CI, 60%-69%) ranked symptom quality as the most important diagnostic feature. In a multivariate model, those ranking quality first (particularly resident physicians) more often reported high-risk reasoning that might predispose patients to misdiagnosis (eg, in a patient with persistent, continuous dizziness, who could have a cerebellar stroke, resident physicians reported feeling reassured that a normal head computed tomogram indicates that the patient can safely go home) (odds ratio, 6.74; 95% CI, 2.05-22.19). CONCLUSION: Physicians report taking a quality-of-symptoms approach to the diagnosis of dizziness in patients in the emergency department. Those relying heavily on this approach may be predisposed to high-risk downstream diagnostic reasoning. Other clinical features (eg, timing, triggers, associated symptoms) appear relatively undervalued. Educational initiatives merit consideration.

Strategies for dealing with emergency department overcrowding: a one-year study on how bedside registration affects patient throughput times.

The objective of this study was to determine if the implementation of bedside registration would affect patient throughput times in an urban, academic emergency department. This was a before-and-after interventional study. An 8-month period before initiating bedside registration in November 2001 was compared to three subsequent 4-month intervals. Four times of day and three triage classifications were examined. Data were analyzed using a three-way analysis of covariance. There were 58,225 patient encounters analyzed. There was a significant difference in time from triage to room after bedside registration began (p < 0.0001). When examined by triage class, there were no differences in triage-to-room for emergent patients, a significant decrease for urgent patients initially and a significant decrease for non-urgent patients. Bedside registration by time of day initially reduced all four time-of-day periods but over the year they returned to pre-bedside registration levels, except for the morning period. Bedside registration decreased triage-to-room times for non-urgent patients and urgent patients initially, but this was not sustained at the end of 1 year. It had no effect on emergent patients who are routinely taken into the patient care area immediately. The sustainable effects of bedside registration were during the morning time when emergency department beds were available.

A Randomized Controlled Trial to Improve the Success of Women Assistant Professors.

BACKGROUND: Given the persistent disparity in the advancement of women compared with men faculty in academic medicine, it is critical to develop effective interventions to enhance women's careers. We carried out a cluster-randomized, multifaceted intervention to improve the success of women assistant professors at a research-intensive medical school. MATERIALS AND METHODS: Twenty-seven departments/divisions were randomly assigned to intervention or control groups. The three-tiered intervention included components that were aimed at (1) the professional development of women assistant professors, (2) changes at the department/division level through faculty-led task forces, and (3) engagement of institutional leaders. Generalized linear models were used to test associations between assignment and outcomes, adjusting for correlations induced by the clustered design. RESULTS: Academic productivity and work self-efficacy improved significantly over the 3-year trial in both intervention and control groups, but the improvements did not differ between the groups. Average hours worked per week declined significantly more for faculty in the intervention group as compared with the control group (-3.82 vs. -1.39 hours, respectively, p = 0.006). The PhD faculty in the intervention group published significantly more than PhD controls; however, no differences were observed between MDs in the intervention group and MDs in the control group. CONCLUSIONS: Significant improvements in academic productivity and work self-efficacy occurred in both intervention and control groups, potentially due to school-wide intervention effects. A greater decline in work hours in the intervention group despite similar increases in academic productivity may reflect learning to "work smarter" or reveal efficiencies brought about as a result of the multifaceted intervention. The intervention appeared to benefit the academic productivity of faculty with PhDs, but not MDs, suggesting that interventions should be more intense or tailored to specific faculty groups.

Pressure ulcers among elderly patients early in the hospital stay.

BACKGROUND: Pressure ulcers among elderly hospital patients diminish quality of life and increase the cost of hospital care. Evidence suggests that pressure ulcers can arise after only a few hours of immobility. The goals of this study were to estimate the incidence of hospital-acquired pressure ulcers in the first 2 days of the hospital stay and to identify patient characteristics associated with higher incidence. METHODS: A prospective cohort study was performed between 1998 and 2001. A total of 3233 patients 65 years old or older admitted through the Emergency Department to the inpatient Medical Service at two study hospitals were examined by a research nurse on the third day of hospitalization. Pressure ulcers were ascertained using standard criteria and were classified as either preexisting, possibly hospital-acquired, or definitely hospital-acquired. RESULTS: There were 201 patients with one or more possibly or definitely hospital-acquired pressure ulcers for a cumulative incidence of 6.2% (95% confidence interval, 5.4%-7.1%). Most of the pressure ulcers were stage 2, and the majority were in the sacral area or on the heels. In multivariable analysis, pressure ulcer incidence was significantly associated with increasing age, male gender, dry skin, urinary and fecal incontinence, difficulty turning in bed, nursing home residence prior to admission, recent hospitalization, and poor nutritional status. CONCLUSIONS: A small but significant proportion of elderly emergently admitted hospital patients acquire pressure ulcers soon after their admission. New models of care may be required to ensure that preventive interventions are provided very early in the elderly person's hospital stay.

The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine.

BACKGROUND: Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. METHODS: We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. RESULTS: An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. CONCLUSIONS: Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

Radiology services in emergency medicine residency programs: a national survey.

OBJECTIVES: To determine who reads plain film radiographs, how quickly radiologists' interpretations are available, how many initial readings require correction, and how satisfied emergency physicians (EPs) are with radiology in emergency departments (EDs) with emergency medicine (EM) residency programs. METHODS: A questionnaire was sent to the chairs of all U.S. EM residencies, asking about EM radiology services. RESULTS: Of 120 sites surveyed, 97 (81%) responded. Respondents reported that, on weekday days, EM attendings or residents performed the radiograph interpretation used for clinical decision making at 66% of sites; on nights and weekends, EPs performed the clinically relevant readings at 79% of sites. Twenty-one percent of sites reported that no radiologist reviewed images before patients left the ED on nights and weekends. Only 39% of sites reported that all images were read within four hours on weekday days, and only 19% of sites reported readings within this time frame on nights and weekends. Median misinterpretation rates were reported as 1% on weekday days and 1.5% at other times. Overall, EPs were satisfied with their interactions with radiology at 63% of EDs. CONCLUSIONS: This study summarizes the perceptions of EPs regarding radiology services; the findings must be interpreted with caution, given the lack of external validation. Nevertheless, EPs report that many EM residency programs depend on EPs' interpretations of radiographs. Emergency physicians report that attending radiologists rarely read images on nights and weekends and that images are misread more frequently at these times. Although EPs were satisfied with many aspects of radiology, EPs expressed the most dissatisfaction with turnaround times and misreads.

Culture matters: the pivotal role of culture for women's careers in academic medicine.

PURPOSE: Women in academic medicine are not achieving the same career advancement as men, and face unique challenges in managing work and family alongside intense work demands. The purpose of this study was to investigate how a supportive department/division culture buffered women from the impact of work demands on work-to-family conflict. METHOD: As part of a larger intervention trial, the authors collected baseline survey data from 133 women assistant professors at the University of Pennsylvania Perelman School of Medicine in 2010. Validated measures of work demands, work-to-family conflict, and a department/division culture were employed. Pearson correlations and general linear mixed modeling were used to analyze the data. Authors investigated whether work culture moderated the association between work demands and work-to-family conflict. RESULTS: Heavy work demands were associated with increased levels of work-to-family conflict. There were significant interactions between work demands, work-to-family conflict, and department/division culture. A culture conducive to women's academic success significantly moderated the effect of work hours on time-based work-to-family conflict and significantly moderated the effect of work overload on strain-based work-to-family conflict. At equivalent levels of work demands, women in more supportive cultures experienced lower levels of work-to-family conflict. CONCLUSIONS: The culture of the department/division plays a crucial role in women's work-to-family conflict and can exacerbate or alleviate the impact of extremely high work demands. This finding leads to important insights about strategies for more effectively supporting the careers of women assistant professors.

Tradition meets innovation: transforming academic medical culture at the University of Pennsylvania's Perelman School of Medicine.

Traditional performance expectations and career advancement paths for academic physicians persist despite dramatic transformations in the academic workflow, workload, and workforce over the past 20 years. Although the academic physician's triple role as clinician, researcher, and educator has been lauded as the ideal by academic health centers, current standards of excellence for promotion and tenure are based on outdated models. These models fail to reward collaboration and center around rigid career advancement plans that do little to accommodate the changing needs of individuals and organizations. The authors describe an innovative, comprehensive, multipronged initiative at the Perelman School of Medicine at the University of Pennsylvania to initiate change in the culture of academic medicine and improve academic productivity, job satisfaction, and overall quality of life for junior faculty. As a key part of this intervention, task forces from each of the 13 participating departments/divisions met five times between September 2010 and January 2011 to produce recommendations for institutional change. The authors discuss how this initiative, using principles adopted from business transformation, generated themes and techniques that can potentially guide workforce environment innovation in academic health centers across the United States. Recommendations include embracing a promotion/tenure/evaluation system that supports and rewards tailored individual academic career plans; ensuring leadership, decision-making roles, and recognition for junior faculty; deepening administrative and team supports for junior faculty; and solidifying and rewarding mentorship for junior faculty. By doing so, academic health centers can ensure the retention and commitment of faculty throughout all stages of their careers.

A culture conducive to women's academic success: development of a measure.

PURPOSE: The work environment culture inhibits women's career success in academic medicine. The lack of clarity and consistency in the definition, measurement, and analysis of culture constrains current research on the topic. The authors addressed this gap by defining the construct of a culture conducive to women's academic success (CCWAS) and creating a measure (i.e., tool) to evaluate it. METHOD: First, the authors conducted a review of published literature, held focus groups, and consulted with subject matter experts to develop a measure of academic workplace culture for women. Then they developed and pilot-tested the measure with a convenience sample of women assistant professors. After refining the measure, they administered it, along with additional scales for validation, to 133 women assistant professors at the University of Pennsylvania. Finally, they conducted statistical analyses to explore the measure's nature and validity. RESULTS: A CCWAS consists of four distinct, but related, dimensions: equal access, work-life balance, freedom from gender biases, and supportive leadership. The authors found evidence that women within departments/divisions agree on the supportiveness of their units but that substantial differences among units exist. The analyses provided strong evidence for the reliability and validity of their measure. CONCLUSIONS: This report contributes to a growing understanding of women's academic medicine careers and provides a measure that researchers can use to assess the supportiveness of the culture for women assistant professors and that leaders can use to evaluate the effectiveness of interventions designed to increase the supportiveness of the environment for women faculty.

Factors impacting the departure rates of female and male junior medical school faculty: evidence from a longitudinal analysis.

BACKGROUND: High rates of attrition have been documented nationally in assistant professor faculty of U.S. medical schools. Our objective was to investigate the association of individual level risk factors, track of academic appointment, and use of institutional leave policies with departure in junior faculty of a research-intensive school of medicine. METHODS: Participants included 901 faculty newly hired as assistant professors from July 1, 1999, through December 30, 2007, at the Perelman School of Medicine at the University of Pennsylvania. The faculty affairs database was used to determine demographics, hiring date, track of appointment, track changes, time to departure, and use of work-life policies for an extension of the probationary period for mandatory review, reduction in duties, and leave of absence. RESULTS: Over one quarter (26.7%) of faculty departed during follow-up. Faculty appointed on the clinician educator or research tracks were at increased risk of departure compared to the tenure track (hazard ratio [HR] 1.87, confidence interval, [CI] 1.28-2.71; HR 4.50, CI 2.91-6.96; respectively). Women appointed on the clinician educator track were at increased risk of departure compared to men (HR 1.46, CI 1.04-2.05). Faculty who took an extension of the probationary period were at decreased risk of departure (HR 0.36, CI 0.25-0.52). CONCLUSIONS: At this institution, junior faculty on the tenure track were least likely to depart before their mandatory review compared to faculty on the clinician educator or research tracks. Female assistant professors on the clinician educator track are of significant risk for departure. Taking advantage of the work-life policy for an extension of the probationary period protects against attrition.