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Recruitment Strategies for Improving Gender Divers ...
Recruitment Strategies for Improving Gender Diversity in Critical Care Fellowship Programs
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Thank you guys so much. So I hear that we have slightly more minutes for each of us, which is good, because I usually speak quickly and still worry I have too many slides, but we'll see how this works. So I get to talk to you guys about recruitment strategies to improve gender diversity in critical care fellowship. So my disclosures are here, but I think the most notable one, when I talk here, I'm going to be talking about the dichotomous gender of women versus men. I recognize that this is not all inclusive, but this really is where our data is, and there are likely unique strategies for people who don't identify as women or men, but I'm not going to cover that here. So briefly, what I'd like to go through with you guys is a little bit of review of why I think we need to diversify our critical care fellowships with relation to gender, what evidence exists that might affect why recruitment may be challenging, and then what potential strategies might have. And again, this will be a brief overview. So just to orient us, I think we all know women represent 50% of the US population, the global population, as well as, as you guys may know, for the last 20 or so years of our medical school graduates. So it's not that we don't have a pipeline of people. However, when you start to talk about physicians at large, and then particularly in the US, we see that we no longer represent 50% of the population. This is a little bit old, this data, but looking about five years ago, in the few countries where I could find this published, in the UK, the US, and Australia, New Zealand, you can see that the numbers or the percent of critical care physicians who are women is even lower than the overall percentage of physicians across all specialties. And then what I thought was interesting, and this is data from just this past year, that within US critical care fellowship programs, if you look compared to the base specialty trainees, so this is from 2022, if you look in the first column is internal medicine, then anesthesiology, pediatrics, and surgery. On the left-hand bar is their general residence, what percentage of them are women, and then following that is in the critical care specialties. Internal medicine broken it out into both critical care and pulmonary critical care. And what you can see is with the exception of anesthesiology, the percentage of our critical care trainees within each field that are women are notably lower than the base specialty trainees. So there's something about critical care that's causing us not to attract these folks. So at least for me, I don't think it's obvious what the right percentage is, but I hope that we can agree that probably the right percentage is more than it currently is, and might there be things that we can do to improve. So I'm going to try to go through what a little bit we know, at least from what I could tell from the literature, about why trainees might make decisions that they do about what fields to pursue, and therefore use that to help us understand how we might recruit more diverse gender trainees. So women and men might value different things, and I'm just going to show you a couple of studies. I purposely picked two that are fairly diverse, both in the fields that they represent, but also the geographies. So this is actually a survey of about 200 orthopedic trainees in Saudi Arabia. And of them, about a fifth that they interviewed or surveyed were women. They asked them about many factors that might contribute to why they might choose a certain field, and they were meant to rate them on a scale of 1 to 5, where 5 was more indicative that that factor might matter. And as you can see, I've highlighted in gray the ones I've blacked out, or whited out the ones that are not significantly different between men and women, but there are many factors that are different. But I just want to call your attention to one that I want to come back to later, which I think shouldn't surprise us, that at least within this specialty, within this context, there were differences in the importance of family and social commitments among female and male trainees. And then this is a totally different context. This is gastroenterology fellows in the US. This was a survey that was done of both advanced endoscopy fellows and fellows prior to advanced endoscopy training, seeing if they might be interested in that. And again, similar construct. They asked them to sort of rate what things mattered most to them. Again, I've whited out the ones that weren't different between men and women, and I've highlighted a bunch here that I think, again, are possibly levers that we can look to. So women tended to find that having mentorship was more important to them than men particularly found it. The presence of bias in whatever field they were looking at, pay equity, and family planning. And what you'll note is there actually wasn't a particular difference between men and women fellows about work-life balance. But what I put out here, this survey also looked at attendings who had made a decision either to go into an advanced endoscopy field or not, and asked them to look back about why they had made those decisions. And amongst those attendings, the women felt that work-life balance really directed them away from advanced endoscopy. And then this is the one sort of study I could find looking at sort of differential perspectives within critical care. And so this was an interview study that looked at 48 practicing adult intensivists across 13 ICUs in Canada. And you can see the demographics of the cohort there. About half of them were women, about a third of them were trainees, and they basically said to them, tell us about what things you think drive inequity in your specialty. And the main ones that came out between both men and women were organization of ICU work, that the long hours might cause there to be a gender gap in who chooses to go there, and that the presence of predominantly male leadership in most of their programs meant that women were less attracted to that area. Women also pointed out, men did not find this, but women also pointed out that the sort of perception of value placed on what they consider traditionally male traits, which they characterize as examples of assertiveness and competitiveness, really drove women potentially away from this field. Okay. So from that, I sort of distilled five particular drivers that maybe are things that women and men value differently when deciding what career path they have. And I just want to show you a little bit of what we know about how those things might differ specifically with regard to critical care. So the first pertaining to mentorship, this is a study that I had the privilege of being involved with, led by two of our trainees, looking at academic internal medicine programs around the country. So when we talk about critical care, this is just within internal medicine. I recognize critical care obviously is beyond that. And we basically asked the question, what is the likelihood of having more women as a percentage of your trainees if your leadership within that program were female versus male? So if you're chair, or you're chief, or you're program director. And as you can see, if we make no adjustment whatsoever, we see, I think, what we all kind of imagine, that at least when your program director was a woman, or when your chief was a woman, you were significantly more likely to have more female fellows. Again, not just in critical care across these seven academic internal medicine specialties. But I think what was surprising to us is when we adjusted solely for geography specialty and the individual institution, those differences went away. And what that suggests is that it is not the presence of those people, those leaders, that draws the trainees there. But rather, there's something about the specialty, or the institution, or the location that draws women in general. And so merely the presence of having somebody, and again, this is using a leader as a mentor. Those are not necessarily the same thing. But having somebody there may not be a sole solution to getting more women to come. Looking at pay equity, this is not particularly related to critical care, but this is a study that came out last year in JAMA, where they looked at starting salaries for physicians coming out of training across many medical specialties. And they said, what is the salary for a woman compared to a man? What percentage of a man's salary? And so I've highlighted for you guys in orange the two that were critical care. I did not figure out, I did not pick which subspecialties to show you. This is what they looked at. So within surgery, you can see they did not include critical care. I think what's notable is that although, in general, women's pay is lower than men's, that's across the board, with few exceptions in pediatrics, that at least within internal medicine, this difference is not worse for critical care than it is for other specialties. Within pediatrics, it is. It's on the bottom of three. But I would just point out that this is an issue we have broadly, and not specifically related to critical care. And so while this is important for women, of course, when they're thinking about medicine as a career path, I don't think this should be something that, if we fixed, we would necessarily draw more people into critical care. And then I think the other one is this concept of ICU work organization and work-life balance. I think intrinsically, and it depends on where we all work, either ICU work is clearly identified as shift work, those of us who work in places where I do my 12-hour shift and my colleague comes on and follows me. But I think even if you work in a place where you're on for a week or two weeks, and you're the person who takes call overnight, you're still on for a week or two weeks, and then there's this other week that you're not clinical. And that's very different, I think, than a more traditional medicine field, where you're the primary care doctor and you're the person getting phone calls. So intrinsically, it is shift work, no matter how you define it. And I think we all are aware of all the potential negative problems with shift work, and a number of them are listed here. I pulled these three studies. These are all published in the last year. And basically, we know that shift work, especially if you're being asked to work different times a day, can be associated with bad health consequences. But I think that there are also some benefits to shift work, and I think if we're going to try to increase the interest in our field, both for men and women, especially because this matters for women, I think we need to try to focus on some of those. And in particular, these are just some excerpts from two different sort of commercial websites. And as you can see in orange, the concept of if you care about family and you care about being present for your children or adult parent that you're caring for, it actually is often easier, and you can have defined times to see them if you're in this sort of shift work model. And then similarly, if you have a set number of hours that you're going to work, you can sort of figure out your sort of non-work life around that. So I think there are some potential benefits to here. When it comes to traditional male traits, I think we have the big problem that within critical care, and I think within many medical specialties, especially those that have an emergency aspect to them, right, we know that there's value in having a leader who can be assertive. It doesn't mean that they must be assertive at all times, right, but if you have a cardiac arrest, you need someone to walk in the room and say, I am in charge of this, and I am running it, and you need to have some assertiveness. But I think the problem for women and why this may be perceived as a barrier for them is we know, and this is just a sociologist's position piece that I put up here to sort of draw this point out, that we know oftentimes in the workplace for women, when they are trying to appear assertive or maybe even are appearing assertive, they are viewed as aggressive and that that is negative. And so I think if we all recognize that this is an important component of being a critical care physician, we need to figure out a way to not hold that against our women. And then finally, when it comes to bias, this was a study that was done now about five years ago that looked at, this was Australian and New Zealand critical care trainees. And they basically said to them, they had this sort of understanding that their fellows were experiencing negative experiences during their training, and they said, tell us a little bit about what that looks like. And as you can see, there was unfortunately a very large percentage of people, both men and women who experienced bullying, smaller but still sort of harrowing percentages of people who experienced sexual harassment and discrimination. But I think not terribly surprisingly, especially the sexual harassment and discrimination were felt more commonly by women. And so again, if we are going to have a concern by our trainees that they don't want to be in a place that they feel is biased, we really need to work on this. So what might strategies be with this in mind to potentially improve recruitment? So again, I think mentorship and pay equity are incredibly important. Don't misunderstand, I don't mean to downplay them, but I'm not entirely sure that fixing those are the purview or fellowship programs and will necessarily fix the problem. I don't know that just having more women leaders, having more women mentors are going to mean that women will necessarily come to our field. It won't hurt, I'm sure, but I'm not sure it immediately helps. And then similarly, pay equity, I think, is something we just need to deal with as a society. But I'm not so sure that that's something a fellowship program intrinsically can handle. I do think, though, that ICU work organization and work-life balance is something that we can really repackage. I will tell you, for me, this is very much how I feel about my shift work. Part of it is for my work-life balance, and part of it is for my work-work balance. I'm able to take on administrative tasks, I'm able to do research that I like to do, I'm able to do education, because my clinical work is very defined. And I feel there is distinct value in that, but what comes out instead is the shift work is a bad idea. And I think we can repackage that, and I think for our female trainees, that may have even more impact, especially as they're thinking about work-life balance seemingly more than their male counterparts. And then finally, I think the two hardest, of course, is the way that we can figure out how to rethink about our specialty and how we interact with our trainees and our colleagues in terms of bias and this perception of what are good and bad traits for different people. And I will say, obviously, this is not something that in 10 minutes, even an expert, which I am not, could probably tell us how to fix. But I will just call attention to the fact that simple interventions, and I am fully aware that there have been studies that have shown that it is not effective, but there are some studies that show, and these are two examples, that simple interventions to address implicit bias can be effective. So the one on the left-hand side was done at Stanford University, it was done amongst clinical departments, and they basically gave clinical faculty members a 20-minute lecture, and they tested their sort of implicit bias before and after and found that even 20 minutes of just discussing it helped them to sort of have fewer implicit biases. And then I think sort of more important is the study on the right-hand side, which was a workshop, two-and-a-half-hour lecture and workshop that was done at STEM departments in the University of Wisconsin, so not solely medical faculty. And they followed over time the hiring practices of departments that had undergone this STEM training. And what they found was an incredible increase, two-fold increase, in the number of women who were hired following this intervention. And this is two-and-a-half hours. So I do think that there is some evidence that these biases, although ingrained in all of us, are not fully immovable. And I think if we can focus more on that when it comes to our trainees, we may do something to help our field. So that's what I got. It was not terribly over. And I will hand it over, but I'm happy to take questions later.
Video Summary
The video discusses the need to improve gender diversity in critical care fellowships and explores the challenges and potential strategies for recruitment. The presenter highlights the underrepresentation of women in critical care and provides evidence from studies that suggest differences in factors influencing career choices for men and women. Factors such as mentorship, pay equity, work-life balance, traditional gender traits, and biases are discussed. Strategies to improve recruitment include rethinking ICU work organization and work-life balance, addressing biases, and providing interventions to reduce implicit biases. These efforts aim to attract more diverse gender trainees to critical care fellowships.
Asset Subtitle
Professional Development and Education, 2023
Asset Caption
Type: one-hour concurrent | Recruiting and Retaining a Diverse Critical Care Workforce (SessionID 1203525)
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Presentation
Knowledge Area
Professional Development and Education
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Professional
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Diversity Equity and Inclusion DEI
Year
2023
Keywords
gender diversity
critical care fellowships
recruitment challenges
underrepresentation of women
career choices
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