If you’re a woman needing surgery, you may be far better off in the hands of a female, rather than a male, surgeon. A study recently published in JAMA Surgery reviewed outcomes for more than 1.3 million patients and found that women were 32 percent less likely to die (and 16 percent less likely to experience complications) if treated by a female surgeon rather than a male one. It found that men were also less likely to die in the hands of female surgeons. While doctors’ individual skills vary — there are good doctors of all genders — if these data are any indication, female surgeons are likely to provide, on average, safer treatment to patients of all genders.
This particular study demonstrates correlation, not causation. But this data is supported by decades of evidence documenting differences in patient care provided by women compared with men. However, because of a long history of sexism in medicine, the contributions of female doctors have been overlooked, downplayed or erased.
Women’s participation in medicine has soared since the 1970s, and their entry into the field has benefited patients. Female physicians are more likely to follow guidelines, collaborate with specialists and ask patients about social circumstances that may affect their health; they also spend more time with patients. And yet, female doctors have consistently faced discriminatory conditions: double standards, implicit bias, sexism and overt sexual harassment. Moreover, the profession has historically prized those qualities more often ascribed to men: confidence, assertiveness and ambition.
Although women have earned medical degrees since 1848, most graduate programs limited their admittance to 4 to 6 percent of programs over the following century. Even in 1948, more than 10 medical schools rejected Patsy Mink, a pre-med college graduate and future member of Congress, because of her gender. Her rejection came amid the influx of G.I. Bill applicants to medical schools in the early years of the Cold War, those veteran candidates being prioritized. Indeed, so few women became physicians in the postwar period that a 1961 book on medical culture, “Boys in White,” excluded them from the title.
Within a decade, though, young feminists started demanding — and then producing — medical knowledge about their bodies, something the male-dominated profession had neglected to create or prioritize. The Boston Women’s Health Book Collective, for example, wrote the exhaustive compendium “Our Bodies, Ourselves” in 1970. Millions of its female readers learned information about their bodies that doctors had historically withheld — for example, about menstruation, sexuality, abortion, pregnancy and menopause — and claimed their new knowledge as a tool for liberation to demand accountability from the mainstream medical community.
Federal policies also opened the door wider for women’s medical training. Title IX of the Education Amendments of 1972 forced schools that accepted federal funding to treat the sexes equally; this meant the end of gender quotas and an influx of women into medical schools. As the historian Wendy Kline explains, women also envisioned their health activism as a shared feminist commitment across race, ethnicity and class — an unfinished project at best, as the barriers that women of color faced in medicine continue to plague the profession.
By the early 1980s, women made up 28 percent of medical students. After graduation, though, their progress stalled. Female academics endured ridicule and harassment, and their work was undervalued or misattributed. They were often underrepresented in leadership positions; between 1975 and 1992, only two of 127 medical school deans were women. Furthermore, the fields in which women did establish strong footholds by the early 2000s were obstetrics, gynecology and pediatrics — specialties long gendered as “female,” were considered less prestigious and were consistently less lucrative. Men continued to dominate higher-status specialties such as cardiology, orthopedics and neurosurgery. Female doctors of color fared even worse; in medical schools, female faculty skewed heavily White — only 16 percent of them identified as Asian, Black, Native American or Latina.
Women also faced a cultural double standard at work through the 1990s. Men had, decades earlier, established an aggressive culture in hospitals. Their behavior in operating rooms, for example, ranged from barking orders to pitching “tantrums” to throwing instruments.
When female physicians spoke assertively, however, they sparked resentment among colleagues, while any politeness was considered weak. “You had a leadership choice,” one female surgeon recalled in 1997, “you could be a pushover or a b---h.” Such judgments had real implications for salaries and career advancement, contributing to women’s underrepresentation at the top of the profession.
Women challenged such sexism by roasting discriminatory bosses or persisting through abuse. At the State University of New York Upstate Medical University, Patricia Numann staged a bake sale outside the office of a dean who denied pay raises to female support staff. Sheri Slezak, a doctor, persevered in a Johns Hopkins fellowship in 1986 despite the threat of firing if she became pregnant.
The double bind for female physicians continues today, as they report being taken less seriously than men on the basis of demeanor and physical characteristics, such as tone of voice, and do additional work to gain collaboration from other health-care workers. Women in medicine also suffer from sexual harassment — a danger many are reluctant to report for fear of retaliation. Finally, retrograde assumptions about parenting continue, as women with children fight to show their fitness as workers — a double standard rarely applied to men — while women without children may lack work-life balance and support for conversations about starting families. These factors combine to impede women’s careers and help explain why, despite the larger number of women in medicine today, only 18 percent of department chairs at medical schools are women.
These stereotypes and attitudes have the direct consequence of undermining women’s authority as doctors by creating an environment in which women’s skills and expertise are routinely questioned. In a study of more than 40,000 health-care workers, men and women held implicit biases associating men with careers and women with family. These data explain why patients routinely ask questions such as, “When will I see the doctor?” after having just spoken with her.
All of this creates a challenging work environment and significant pay disparities. Physician referrals, which are critical for income generation, are bifurcated by sex; male physicians preferentially refer patients to other men, including those who need procedures compensated at higher rates. They also decrease referrals to all female physicians after one bad outcome with a female physician, thereby generalizing the bad outcomes of individual female doctors to all female physicians, but don’t do this when male doctors produce bad patient outcomes.
All these factors probably contribute to the significant gender pay gap in medicine. Even when researchers account for factors such as specialty, years of experience, hours worked and the number of patients seen, significant differences in compensation remain. An article published recently in Health Affairs estimated this difference to exceed $2 million over the course of a woman’s career.
The JAMA Surgery study reminds us, however, of something even more glaring. Female physicians, including surgeons, provide outstanding care. However, when women advocate for their patients, they sometimes face steep consequences, including dismissal. By paying women less, punishing their patient advocacy and rewarding male doctors for gendered traits rather than records of success, the system potentially diminishes the quality of care that patients receive.
Preventing the loss of high-performing female physicians from the health-care workforce is not just a matter of representation and equity, but of access to high-quality care. To support women in medicine, health-care professionals and patients alike can speak up by requesting female physicians, sending positive feedback about them to hospital and medical school leaders and, perhaps most important, checking our own biases about what we think a doctor looks like. She will see you now, if you’re lucky.