 So let me just introduce, welcome to our third gender equity and ethics McLean, 41st public lecture series. We're really excited for this series. As you know, it's alternating between virtual and in-person, and I'm excited to introduce Dr. Jagsy today. So let me go ahead with the introductions for her. Dr. Jagsy is the Newman family professor and deputy chair in the department of radiation oncology and the director of the center for bioethics and social sciences and medicine at the University of Michigan currently. She's the author of over 400 articles and peer reviewed journals, including the New England Journal of Medicine, The Lancet, and JAMA. Her research has been funded by the U.S. National Institutes of Health, the Susan Komen Foundation, and numerous other foundations. She's both a clinical trialist and a health services researcher. She's internationally recognized for research to strengthen autonomy in breast cancer patients and to individualize breast cancer care. She leads multi-center randomized clinical trials for forgoing radiotherapy and lower risk patients, intensifying in patients with more aggressive disease, and enhancing patient-centered communication. She's a recipient of multiple RON grants from the NIH and independent grants from foundations, including the Komen Senior Scholars Award. She's authored over 400 publications and delivered scores of keynote addresses and visiting professorships and received many honors, including the Lead Oncology Woman of the Year Award, Astro's inaugural Mentorship Award, and AMWA's Woman in Science Award. She serves on the steering committee of the Early Breast Cancer Trialist Collaborative Group and has served on the program committee for the San Antonio Breast Cancer Symposium and the Board of Directors for ASCO. In November, Dr. Jagsy will become the Chair of Radiation Oncology at Emory University, and we're excited to welcome her back for the second time. She spoke for the Department of Medicine Women's Committee for our last in-person speaker in February 2020, so it's great to have you back, Dr. Jagsy. Welcome. Thank you so much. You guys were the last talk I gave before the pandemic, and so it's just a real treat to feel like I'm coming full circle to be back with you in this new virtually connected world that we have. So I will be speaking about how promoting equity for women in medicine is a matter of professional ethics, and I'll begin by just laying out that argument, which I will do very briefly given the sophistication of this audience. But in a nutshell, there are both deontological and teleological arguments that standing up against gender bias and harassment is itself a matter of professional ethics. Of course, duty-based arguments, deontological arguments abound in that if we are to respect the categorical imperative, which states that we must, out of respect for human beings, fundamental dignity that derives from our capacity for freely willed action and rational thought, that in order to demonstrate respect for persons-quad persons, we must treat each person as an end in himself, and so in so doing, we must accord respect to persons in a way that creates fair equality of opportunity to positions that are highly sought after, and that includes senior positions in academic medicine, and it certainly means not treating one another in biased and harassing ways, right? Disrespectful ways. Those are very powerful arguments, as we all know, and yet they may not be the most compelling to everyone. In fact, as I've learned in a long career as a bioethicist who has studied these issues, and I'm sorry that the bio got muddled because I think my assistant well-meaningly updated my bio because I'm moving to Emory and gave you my breast cancer bio, but I have been studying these issues of gender equity for quite some time, and in so doing, I have come to receive a number of quite disappointing reviews from people who feel that when you use even the word duty or the word fairness, the word respect, that somehow you're criticizing them for intentionally acting in an unfair way, and of course that's not what any of us mean to do, especially when we're advocating for equity or advocating for resources to promote diversity, equity, and inclusion, and I have found that the most powerful arguments to bring in the inclusive crowd of people that lead us is to frame things on the consequentialist, the teleological arguments, and those include the arguments that academic medicine has a tripartite mission, that we are engaged in education of the next generation, that we are engaged in clinical care, and we are engaged in research, and that we are better at delivering on all three aspects of the mission if we have a diverse group of individuals on faculty, and so that includes role modeling for the half of the medical school class that is now women, that includes diversity in terms of asking the most insightful research questions using the most rigorous methods and being more likely to achieve solutions, of course we know that collective intelligence is improved by diversity and turn taking and sharing our voices, and then finally there is the clinical mission where the teleological arguments are quite profound, and I know that you're hearing from other speakers in this session who will emphasize some of these studies, and so I won't go into them in great detail, but will only emphasize that these are not studies that say that everyone must have a healthcare provider who is a perfect demographic match, rather what these suggest is that diversity in the delivery system, diversity amongst providers, such that the physician population is more representative of the patient population we serve is likely to improve our ability to deliver care, and so what I'll do over the next 45 minutes to hour or so is to outline for you some information we have gathered my team and others about the nature and causes of gender inequity in academic medicine, and make the argument that I made two years ago when I visited in person that this is not simply due to a slow pipeline but rather reflects the differential impact of unconscious biases, gendered expectation of society, harassment, and more, and I will use that to frame us on evidence-based interventions that actually we knew about before the outbreak of the pandemic. In fact, the National Academies came out with a landmark report on promising practices that was released in February of 2020, and yet of course it didn't get as much attention as it should have or would have, because we all had our attention turned elsewhere because of the outbreak of the COVID-19 pandemic, which I would like to then turn to as a reframed disruptive opportunity for us. Certainly there is evidence that things have gone in the wrong direction that some of those challenges have actually been not only highlighted but amplified during the pandemic, but we can also use this time as an inflection point, as a time that we can actually make meaningful progress towards change. So this is a curve showing women's representation in the medical profession, and what you can see here is that women are now an increasing share of the medical student body, but that it wasn't always so, and so it wasn't until the enactment of Title IX in 1972 that it actually became illegal for medical schools to discriminate against women in admissions, in hiring, and in promotions, and so with Title IX we saw a rapid increase in women's participation such that three decades ago women broke 40%, and women have been a substantial minority of the medical school class for quite some time in that 40 to 50% range, and then more recently, of course, have hit that 50% mark. But this is not the case in leadership positions. As you can see in the most recent year for which we have the AMC benchmarking report, women constituted 18% of department chairs and deans, the senior most positions that are most influential in academic medicine, and this extends to other influential positions including authorship of medical journal articles, membership on editorial boards of influential medical journals, and of course this is really important because we know that the way that we communicate in academic medicine is the discourse that we have with one another via publications, and this is how we set the agenda for where research goes in the future, so it is extraordinarily important. But there is this pipeline hypothesis that says, yes, but if we just wait, if we just wait long enough, things will work themselves out, and Lynn Onamaker did the best type of study to evaluate this. Back in 2000, she didn't look at just a static cross-sectional slice like the two prior slides that I just showed you, the leadership positions and the authorship, what she did and the authorship slide I showed you, I will point out, was from a long time ago, it was the first study that I did in this area, but sadly has been replicated time and time again, we still haven't really solved that problem, but what I will say is those static slices in time are nowhere near as gratifying or informative as studies that actually look at cohorts over time, and so Onamaker did this, and she looked at cohorts who graduated medical school between 1979 and 93 and found the proportion of women who reached the rank of associate professor was significantly lower than expected in all but two of the cohorts, and that was even the case when you reached the rank of associate professor, women were still less likely to become full professor, and it wasn't a small difference. The difference between observed and expected was five standard deviations off. So this was a compelling study that suggested that the pipeline had not worked itself out, but you could make the argument, well, you know, 1979 and 93, maybe if they had looked at more recent classes where women were more than 40%, maybe then they would have seen a change, and so Kimber, Richter and colleagues actually did just that and published in the New England Journal of Medicine their analysis of AMC data, and they found exactly the same thing that the difference had not actually narrowed over time, but these types of studies relying exclusively on AMC data on the entirety of the academic medical workforce are subject to a different form of criticism, which is that we may be combining apples and oranges here, that women and men may enter academic medicine for different reasons, and that women are known, thanks to Julia Files and colleagues, their research has shown that women are more likely to be on clinician educator tracks, and so perhaps when we see that women aren't advancing at the same rate as men, it's not that similarly situated apt and motivated research faculty aren't advancing at the same rate, but rather that women are more likely to be clinician educators and that medical schools place disproportionate value on the scholarly discovery aspect of their mission. And we know that that's likely to be the case, and of course there would be policy implications to that, but they are different policy implications than if we had evidence that research oriented faculty were also having different outcomes based on their sex or gender. And so this is what led me to a whole line of research that I have pursued over the past couple of decades. We looked at NIH's K award recipients, K08s and K23s, which are awards that are made at the national level to individuals who have clinical doctorates, they're highly competitive awards, to get these awards you have to have a demonstrated aptitude and motivation to become an independent investigator, and the goal of these awards is to create independent investigators. And so this was the first time that anyone took the publicly available data, and instead of looking as NIH had done before at the rates of success of individual applicants for an individual award, so saying, hey, did the applications that came in for this grant mechanism do any worse because they were submitted by women, rather to look at individuals who would have been assumed to succeed, individuals who got these incredibly competitive K awards and had the resources that these K awards provide for protected time and dedicated mentorship and training, and see whether they ultimately went on to reach the end point they were supposed to achieve, which was attainment of independent investigator status. And not that R01s are the only kind of independent investigator award, but as we all know, R01s are held out as a benchmark of the transition to success, and they were available and they're the most common independent award given by the NIH. And so we looked at the NIH's CRISP system and applied actuarial analysis, because I'm an oncologist and I think of everything in actuarial survival curves, and this was a fortuitous coincidence because it turns out it's a really good way of looking at these data. And what you see there is that the survival curves separate, kind of like I have a great treatment. Sadly, I don't have a great treatment. But the difference here is between a crude binary attribution of male versus female based on the first name of the individual and Google searching to find them. And this is by no means the best way to do this, but this was an early study and this is how we were able to discover that even in an apples to apples cohort where everyone would have agreed, even Larry Summers himself would have agreed that there's no difference in the aptitude of these individuals or their commitment to research careers. We were seeing that gender was an independently significant predictor of our one attainment. And that was true even on a multivariable analysis that controlled for everything that we could control for in the publicly available data. And that includes the K award type KO 8 versus 23. That's laboratory oriented versus patient oriented research. The year of the K award because we know that the funding environment became increasingly challenging and that women were constituting a larger proportion of the more recent classes of K awardees. We controlled for funding Institute because we know that women apply to the less well funded institutes. So if we're if we're funding heart, lung and blood and cancer very well and we're funding mental health and children's health very poorly, that might explain things. We controlled for institution because it turned out that women were less well represented at the institutions that overall had the higher amounts of extramural research funding and we controlled for specialty and again gender was independently significant. We then went on with the support of a grant from the Robert Wood Johnson Foundation to survey K awardees and I was a little nervous about surveying because we thought who's likely to have a you know non-response buys who's likely not to respond. It's going to be people who maybe weren't successful weren't still in academia but we actually had over 70 percent response rates to all of the survey studies that I'm going to show you. So K awardees are amazing in many ways including being very curious and when they got a survey questionnaire this is our most recent one some of you in the audience may have received it but they got survey questionnaires that say at the top survey of NIH K award recipients funded through an R1 grant from the NIH they realized that it would actually be really important for them to participate. And so what we went on to do was ask about their other forms of success were they getting other large grants were they succeeding in other ways you know one hypothesis that was thrown out to me after that prior study was that promising K awardees who were women who had you know gotten their K awards were so promising for leadership that they were being immediately plucked and elevated to be division chiefs and department chairs and never had a chance to get their own RO1s because they were ending up mentoring the RO1 development of an entire department and how could I argue that that wasn't success. So we asked and it turns out that's not the case but we looked at leadership positions we looked at other forms of grants we looked at other ways that individuals could be productive at work and we also asked about compensation and what we found was that even after controlling for all of these other forms of productivity and differences that might exist in terms of demographic characteristics we found that the women were paid less than the men and the original difference was a $32,000 difference it was about $200,000 for men $168,000 for women that difference was cut in half by adjusting for specialty alone. Now my hypothesis going into this was that that was going to be the case that specialty would explain a lot of this the studies that had come before had often shown that there was a gender difference in compensation but had lacked access to any information about the characteristics like forget productivity they often didn't even have access to specialty information and my hypothesis was that specialty was going to account for a whole lot of the difference and everything else was going to account for a whole lot less which was true but what ended up placing this in JAMA I think was what no one expected was that there would be such a substantial unexplained gender difference in compensation after we controlled for all of these factors and more and that $12,000 difference a year we crudely said over the course of a career is quite substantial because of course there are increases that occur with COLA and you know adjustments especially in an inflationary environment that will increase that difference over time these individuals were about 40 when they answered this survey so you know they had a long career ahead of them for those things to continue to diverge and that that was quite a substantial amount of money and there was a just recently a really nice simulation study that included some of your colleagues that that that showed that when you actually accumulate the difference in in current dollars and in current differences it's over two million dollars over the course of a career so what's going on here one thing as I've mentioned is specialty choice you'll realize that when I put things in quotation marks I think they're not freely willed choices but women may be encouraged to occupy lower paid specialties and specialties chosen by women may pay less partly because they're predominated by women or because they involve less valued feminine behaviors what do I mean there well I mentioned earlier right that women are more likely to be clinician educators women have been socialized from a very young age to demonstrate communal behaviors caretaking evaluation and management services anyone so women are more represented in those specialties that deliver counseling-based interventions and men have been socialized from a very early age to demonstrate agentic behaviors and those include scholarly discovery right and interventions like surgical interventions like interventions that people consider actual interventions when they pay for interventions and procedures more in our in our CPT coding system and so when we determine WRVUs for compensation they have integrated those biases and so that's very important to keep in mind it's also important to recognize that there are differences in productivity hours and willingness to change institutions but that these choices are made within the constraints of a gender structured society whereby we expect as a society don't mean me as a society we expect women to partner with men and please hear me I am not saying that I expect women to partner with men we expect women to partner with men who are at or above their age and at or above their educational status that is by far the most common partnership pattern in our society right and what does that mean that means that even if two people are in a two physician relationship and we've published this in in the Journal of General Internal Medicine the woman's career in the couple comes second and the woman isn't because the man is just a little older and maybe a little bit ahead of her so even when you have the same educational status that ends up being an issue and so if the way that we increase salaries is by having someone threatened to leave or leave the institution for a better job then that is constrained by the ability to make a credible threat to leave there are differences in rank and leadership positions and we controlled for this in our model but it's also important to realize that in so doing we probably over controlled right because unless the processes for determining advanced rank and leadership positions are themselves entirely unbiased then it's a double whammy right so if it's bob the department chair plays golf with john on sunday and decides on monday he needs a new division chief and gosh john's a good guy and i just heard about all the good work john's doing and makes him the division chief and then a few weeks later has jane in his office saying i realized that john is making more compensation than i am why is john earning more money than me and bob's response is well you know john's the division chief so he's doing all that work that's a double whammy for jane she doesn't get to have the influence and the authority that a division chief has and to provide that that voice and she gets compensated less so that's all very important but also important is that there is that substantial unexplained gender difference that did remain after we accounted for all of these factors and more so what else could be going on well there could be gender differences in values of behavior perhaps mothers are sacrificing pay for unobserved job characteristics like flexibility fathers are trying to earn more to support their families those would be concordant with our gender stereotypes but in this study there was a relatively homogeneous job type remember these are k awardees so they were primarily still doing quite a bit of research there was also so they're not the people that are you know super engaged in clinical care and frequently taking overnight call and long shifts and we saw no interaction between gender parental status even the women without children in this sample had lower pay than men but of course we know that there are other patterns of family caregiving including elder care that vary by gender and so perhaps this was somewhere in there um anthony losasso who's a health economist actually had that hypothesis he spoke to the wall street journal um i think it was the wall street journal about this um this study and said yeah but there's got to be something they didn't measure and to his credit he got new york state starting salary data and just published in health affairs a couple of years ago um a study that actually tried to dig into this question and what he ended up doing was replicating the study perfectly um specialty accounted for half of the difference um and and actually uh preferences for family flexibility accounted for none of the gender difference in compensation that he observed what about the possibility that women don't ask we all know the book by babcock and lashever that details the abundant social scientific evidence that has shown that women do not negotiate in the same way as men and that is adaptive because if they do they're penalized for using some of those same strategies um and you know i try to make my talks um about the the science and understanding and how we can transform systems um but every once in a while there's someone on the call who says what can i do to help myself and i'm not really about adapting to broken systems but um one thing we all can do whether we're leaders or whether we are just beginning in our careers is to make to make ourselves familiar with the negotiation literature with um understanding um you know getting to yes and women don't ask and ask for it and never split the difference those are all books that are out there that if we had gone to law school or business school we would have been required to read um and yet in medical education uh we do not um uh require and it's to the detriment of all of us right because um many of us and we we interviewed our k awardees and we found this that many of us have a naivete about what negotiation is we think it's like buying a used car we think that it is positional bargaining where one side wins and the other side loses and there is just a fixed pie and that's it and that is not the case in real life most negotiations um can benefit from a viewpoint that there is a possibility um for mutual interest and shared gains to actually increase the size of that pie um and so techniques of principal negotiation are really important it may not all be on the employee side of course um gender differences in compensation can also reflect differences in employers behavior including statistical discrimination whereby they're making inferences based on group characteristics rather than individual characteristics when they set salaries and also this really really persistent notion of the family wage whereby we assume there is a single male breadwinner at home um sorry a single male breadwinner with a wife at home who's caring for the family and so we need to pay the man enough to support that whole family and when we see a woman asking for a raise we think to ourselves what's she gonna use that for um you know she's gonna go buy a pair of fancy high heels yeah I mean I know what he's gonna use it for he's gonna use it for um you know his kids call it tuition and he's gonna use it to to put food on his family's table she's got a husband who works who needs to pay her more and of course that is really problematic um we also have a real problem with structural sexism and I know that you've just heard from Amy Gottlieb in this series so I will simply um point out that Amy is amazing and that in the most recent 2021 AAMC report um that we saw that in every racial subgroup women are earning somewhere on the order of 70 something cents per dollar earned by men and that is not acceptable and what it does is reflect the ways that sexism is imbued into all of our structures into all of these constructs that we use to determine what total compensation should be so you know those things that I've talked about um penalties for negotiation um I know Amy will have talked to you about um occupational gender segregation and of course what I'm talking about in terms of specialty is just one one form of occupational gender segregation um productivity metrics um a premium for leadership and rank and seniority all come into play here there is also problem of unconscious bias which is the phenomenon of deeply ingrained notions held by all of us this is not this is not one group trying to intentionally oppress another group this is sadly all of us um holding these deep notions um that have been demonstrated in a national academy's report um as an impressive body of controlled experimental studies and examination of decision-making processes in real life that show that on the average people are less likely to hire a woman than a man with identical qualifications less likely to ascribe credit to a woman than a man for identical accomplishments and when information is scarce far more often give the benefit of the doubt to a man than a woman and so we have seen this the classic demonstration of this is the blinded cv study so uh stein pricing colleagues did the seminal study um in this area um whereby they asked their colleagues in academic psychology um you know this is a sham cv would you hire this person on your faculty and could you just give us some ratings for their teaching their scholarship and their service and they sent half the people a cv titled brian miller the other half a cv titled uh uh caron miller and it turns out that brian miller is not only more likely to be hired than brian than caron miller but actually gets higher ratings on uh you know the objective metrics of teaching and scholarship and service and so that false dichotomy that i hear over and over and over again um in my life which is you know why do you care so much about diversity equity and inclusion why can't we just focus on excellence um is that we're not very good at objectively determining excellence this has been shown um in the lower left the pns study um in academic medicine and in the most disappointing study ever um emily and greg are so much more employable than lakisha and jamal that lakisha and jamal need nine more years of experience to get job interviews at the same rate as emily and greg and this brings me to the most important slide in this talk which is a a slide on intersectionality because up until now i've been speaking about gender as though it's binary and as though it's the only thing and i've been conflating sex and gender which we know are not the same thing um and that is how and i've done that deliberately because that is how the research up until more recent um studies has evolved and we now recognize uh thanks to the um the the thought leadership of kimberley crenshaw who who coined the term intersectionality which refers to the fact that individual human beings are not simply one characteristic but an amalgamation of many different characteristics and they inhabit a unique intersection of those characteristics whereby we can only understand their lived experience by considering all of those characteristics um in in their totality and not not by looking at one versus the other so for example um the experience of being a black woman in the united states today is not simply the additive effect of binary racism and binary sexism right there's there's a unique experience um that exists there that must be understood and for those who will ask me in the question and answer where things should go forward i will come back to this because of course um the the work we really have ahead of us really needs to focus on the understudied intersectional issues that exist and that has been increasingly emphasized over the years by the national academies of of sciences engineering medicine reports so i am now very pleased to be on the national academies committee on women in science engineering and medicine but i was not part of the first two reports i've already quoted to you first three reports the i've already quoted to you from beyond bias and barriers in the next few slides i'll show you a little bit from the report on sexual harassment of women and from promising practices and then i'm going to close by reflecting on the report that i the first report that i've had anything to do with directly which is the impact of covid on the careers of women because it is such an important disruptive opportunity so before turning the sexual harassment report i just want to reflect on a couple of other drivers of these differences we are not on a level playing field seemingly gender-neutral norms practices and policies do have a negative impact that is disparate upon women and the other last talk i gave before the pandemic broke out was also in chicago and it was also in february of 2020 and it was to um it was at acgme headquarters it was two leaders within the abms and the acgme to talk about policies that govern leave from medical training because even though our own american academy of pediatrics has come out in support of policies at that would permit 12 weeks of paid parental leave for everyone we for many years in our profession seemed to carve out an exemption for our future colleagues and so many residents have been unable to take civilized amounts of leave and those policies do have a disproportionate impact on those who bear children and lactate there are expectations regarding work hours really early morning meetings really late evening meetings 10 o'clock limits on grant eligibility all of which conspire to have a disproportionate effect on those who in our society are disproportionately likely to take on family and caregiving tasks so this is a forced collision of biological and professional clocks that magnifies the inequities of the traditional gender division of labor and this is like my favorite study ever and i'm pretty sure i showed at the last time i spoke at the university of chicago but i do think you guys are a slightly different audience and i just have to show this again because this is a study where we actually asked our participants these were k awardees these were k awardees from 2006 to 2009 so this is the most meta study i've ever done these are people who are roughly my vintage so they're generation xers in case you're wondering what my vintage is at the time they answered these surveys they were in their early 40s this was my very first ro1 grant and it was an ro1 grant on ro1 attainment it was understanding why people did go on to get our ones and in this incredibly meta in so many ways study we asked about how people were spending their time and we asked in the way that labor economists think about time there is paid labor and there's unpaid labor and no surprise to anyone the women were not doing less labor than the men however if you looked at paid labor the hours were lower for women and what was squeezing out the paid labor which is those first one two three four bars right out to the number six was the unpaid labor the domestic labor the parenting and domestic tasks and so you can see there the unadjusted difference between married and partnered women with children and married partner men with children which were the two largest groups and even after we adjusted for many other factors because you guys have heard me say earlier on that we live in a gender structure society so you know what spousal employment status is different in fact over half of the men in the sample have part-time or non-working spouses 90 percent of the women in this sample have full-time employed spouses so that's just how it plays out when i talk about you know prioritizing careers and families right even after you adjust for that and many other factors the women are spending eight and a half more hours per week on parenting domestic tasks these are k awardees can you imagine how many more papers and grants could have been written in that eight and a half hours per week and in the subgroup with spouses or domestic partners who were employed full-time we said what do you do when your usual childcare arrangements are disrupted and believe me this was 2014 when we fielded these surveys i was not anticipating the pandemic i did not envision an arbor public schools shutting down in march of 2020 and not having a single day of in-person instruction until may of 2021 which is actually what happened here but i was envisioning you know snow days or the kid being too sick to go to daycare the nanny being too sick to come in something like that and so we asked what do you do when your usual childcare arrangements are disrupted and 43 percent of these incredibly high achieving k awardee women dealt with it themselves as opposed to 12 percent of the men the choices were i deal with it myself my sparser partner deals with it we split it pretty evenly we have someone else we turn to so that has real consequences so we because it was an r1 grant we were actually able to survey these individuals in a longitudinal fashion and look at what factors at time one predicted for outcomes at time two and so one thing that we found at time two in these individuals who we started surveying during their k awards was that four years later the women were more likely with a binary cutoff for burnout using the Copenhagen burnout inventory the women were more likely to be burned out than the men and if we use it as a linear scale the women were more burned out than men and that's not news that's you know every study of burnout shows this and also shockingly high proportions of of men and women were burned out and again not news physicians are really burned out it's you know certainly the case now post-covid right but what prior studies hadn't been able to do was to unpick why the gender difference exists and so what we were able to to see with that longitudinal design was that the difference between men and women was explained by those time pressures that i just showed you for parenting domestic tasks and by perceptions of work climate so why might women perceive the work climate to be negative and this takes me to the iceberg of sexual harassment which was a metaphor that was initially developed by lilia cortina who's actually a women's studies professor and colleague of mine here at the university of michigan and it's very important in several ways and one is that of course the tip of the iceberg is what people focus on and it is much smaller than the very large base which is the foundation upon which it grows right and so the tip of the iceberg is those coercive advances the quid pro quo the harvey Weinstein type of experiences that people think of when the word sexual harassment is used and yet far more common in the three decades of organizational psychology research that has been done on sexual harassment in organizations is gender harassment and crude remarks sexist remarks crude behaviors all of those things that are underneath the surface that actually have been shown in that three decades worth of work to have equally detrimental impact on the outcomes we care about professional well-being mental well-being physical well-being of our colleagues and when we did this study back in 2014 when we surveyed our k awardees we actually asked them about their sexual harassment experiences using the same item that had been used back in a 1995 survey which was the last time anyone had really done a good study of academic medical faculty in the united states it was a 1995 cross-sectional survey that asked in your professional career have you encountered unwanted sexual comments attention or advances by a superior or colleague and so back then and this was phyllis carren colleagues with the support of the robert wood johnson foundation they found that 52 percent of the women had experienced that but it was a cross-sectional cohort so they had women who had gone to medical school in the 1970s where i showed you women were only a small minority of the medical school class and certainly were not well represented on faculty and so perhaps their experiences had occurred during that time of transition and so if we asked this modern generation x cohort who grew up like me expecting an egalitarian division of domestic labor which didn't pan out but expecting to be treated respectfully in the workforce surely at least the latter would pan out this really was um it may sound incredibly naive now but it didn't seem naive back then people thought this was going to be my good new study um glass half full i mean it was 30 percent instead of 52 percent um but it was 30 percent right and this was shocking and look at the date of publication this is before the real awareness of the me too movement this was before the 2016 presidential election when this was published and this got a lot of attention as a result right and what we found was that the experience of harassment did have consequences nearly 60 perceived a negative effect on competence themselves as professionals and nearly half of those who were harassed reported that the experience has negatively affected their career advancement and so what we have to do is learn from the evidence and intervene we need to gather data and you can say well but didn't you just show us some data yes i showed you some data but that was with a single item question which is by far from it's it's not the best way to measure sexual harassment what you really need to do is detail all the behaviors that constitute the iceberg and say has this happened has that happened has the other thing happened um you you are much more likely to actually pick up on harassment and so that the gold standard is the seq and when you administer the seq as we have done here at the university of michigan as we've done in the the specialty phonology and others have done in other settings you find that the majority of men and women alike but the vast majority of women and the majority of men have experienced sexual harassment um we need to gather more information about women in those multiple intersecting marginalized groups we need this information both to inform our interventions and to demonstrate the commitment of the organizations that are gathering the data because we know that the predictor of the in meta-analysis of sexual harassment and organizations the most important predictor is that the perception of the employees that the institution the organization tolerates harassment and then we also know that the lowest rates of sexual harassment occur in organizations that proactively develop disseminate and enforce sexual harassment policy and that includes facilitation of reporting and offering choices in terms of complaint handlers who are diverse in every way anonymous and and confidential reporting systems all of those things are important but we've just published in academic medicine a report that really demonstrates quite compellingly that even when one has experienced harassment one is extraordinarily unlikely to report that experience it is it is out of a fear of retaliation about a fear of being stigmatized or marginalized as becoming the person who was harassed as opposed to the scholar that one spent one's entire career seeking to be and we also need to address harassment by patients and families because we do inhabit a really unique setting within which that is a phenomenon and it is not outside our control by any means our own ethics center here played a big role in developing the patient rights and responsibilities policy here at the University of Michigan and there are other exemplars that have done the same elsewhere ultimately the causal mechanisms at play that lead to women's under representation in senior positions of influence and authority are bidirectional so unconscious bias sexual harassment in the gender division of domestic labor all lead to gender inequity in senior and influential positions but the lack of diversity in those senior and influential positions is exactly the environment within which those other behaviors thrive and so what we really need to do is move beyond the iceberg to thinking about what's in the water and allowing that iceberg to form in the first place and if every person on this call could look at those factors in the water which we've discussed over the course of this talk and think what's that I'm sorry this is the problem of hybrid things I can't make that stop but just ignore it it's probably CVS pharmacy calling to remind me of a prescription um so those factors in the water I'll give you just a second to look at them pick one and come up with an evidence-based intervention that you can implement to allow that cause to be solved because this is incredibly complicated but this is also what um what diagrams of carcinogenesis look like right and each investigator in oncology chooses one driver one molecule that they spend their whole career fixing and they realize that yes there will be escape and there will be interventions that will um that will eventually develop resistance but they count on their colleagues to be targeting another factor and if we can just attack this in that way I think we can be very successful and ultimately change the structures that support harassment by employing more women promoting more women and integrating more women into every level of the organization so we end up with well integrated structurally egalitarian workplaces in which everyone equally shares empowering authority if we don't inflect this curve this is going to be the case that women will not reach parity amongst the deans until our current class of medical students who are 50 female have retired we have to inflect this curve and so there are some promising practices that as I pointed out were identified even before the pandemic and they include mentorship and sponsorship programs at the institutional level I'm not saying fix yourself and find a mentor um I am saying we as leaders within organizations need to create intentional mentorship and sponsorship programs so that everyone is equally um able to avail themselves of these opportunities we need evidence-based implicit bias training no not all implicit bias training works but Molly Carnes has certainly developed some interventions that do appear to work um well in academic medicine um cultural transformation initiatives are incredibly important and you guys are among the leaders in those types of initiatives and transparent and consistent criterion based evaluation promotion and compensation processes are absolutely essential we need to promote work life integration and as we've learned in the pandemic as I'll share in a moment work life boundary setting and these include creative interventions like policies that um support individuals who are um are bearing substantial family caregiving demands supporting the use of funds that are already permissible um to use to support dependent care expenses but the many academic institutions have not uh previously had policies in place to permit um be used in that way time banking initiatives from stanford has a really neat pilot that they used where um the invisible service that women provide um more than men and other members of marginalized groups as well um are often called upon to be on many thankless committees um those things are then redeemed for points that can be actually used for anything that individual needs whether it's um grant writing support at work or food delivery service at home really creative initiatives we inhabit a really exciting time now social media brought us together even before the pandemic and perhaps even more so now um i am at reshma jagsy if you want to follow me i do tweet on these things nowhere near as well as your leaders though so um i mostly just retweet what they say um and then i want to conclude by talking a little bit about the impact of COVID-19 so again the last time i was there COVID-19 um had not developed we didn't have a name for it um but the impact was profound i think we all know the negative effects that it has had on our productivity boundary setting and boundary control networking community building and mental well-being and we know that the women who answered this survey that was um part of this national academy's report um did report increased workload decreased productivity greater difficulty interacting with colleagues and students and challenges of remote teaching remote clinical practice a negative impact on research and less time to work we saw a real impact on authorship this was a very early study where um i had actually i'd written my perspective piece um in march of 2020 knowing that this was likely to occur and there was no evidence showing that it was actually occurring um i could see all around me that there was a disproportionate impact on my female colleagues um and some editors wrote back to me and said yeah but there's not actually any data and if anything the data show that COVID-19 is going to have more impact on on men in terms of mortality so i don't think we can write something about the the perils for women just yet so i thought well where can we get early data until we looked at papers that were published about COVID-19 assuming that they had been written at least partly um and developed at least partly since we knew about COVID-19 and were disrupted by COVID-19 and compared um authorship patterns to papers published in those same journals the year before and we've gone on um to do a more mature uh study that just came out in elife that um shows that unfortunately there has been a real and sustained um impact the survey led by the national academies showed that there were some boundary management tactics that women were already starting to use during these disruptions including spatial boundaries having a separate space that they could go to even if it was a closet that was held together with a bobby pin there's actually a compelling study a story in the in the report about how uh a one woman's toddler had figured out a way to get into the closet so even when she was trying with the the zoom backdrop to to get her space she couldn't maintain that spatial boundary temporal boundaries technological boundaries and yet um these boundary management tactics were likely to be insufficient um anxiety levels were extraordinarily high in a study that we let out of the physician mom's group um we actually found that 41% were scoring off the cutoff for moderate or severe anxiety in April of 2020 and we really found that there were also some silver linings there were some disruptive opportunities to learn things that we thought were absolutely impossible before the pandemic were accomplished overnight during the pandemic right and one of those things includes the transition to virtual platforms for conferences and I really want to give a shout out to your organizers for making these hybrid conferences and I know that you've had some in person speakers and I'm a virtual speaker and then you're gonna have some more in person speakers and then you're gonna have some more virtual speakers and really I think that opens up the ability for people who have other responsibilities to participate and to to be included in these ways I just can't emphasize that enough but there are always unintended consequences right so with hybrid meetings it does become possible to be at a professional society meeting pretty much 24 hours a day 365 days a year and so there can be over flexibility there are opportunities for bias to play out in new and different ways I am not monitoring the chat but I and so I hope to God this isn't happening the chat I only see four things in the chat so hopefully there's not anyone saying wow she's talking too fast I can't understand her let's all go away you know wow I've heard all this before but I have seen that and I think some of you may have seen that as well in meetings where people just start having their own discussion in the chat while someone is has been asked to deliver a lecture which is really quite disrespectful there are also some ways that we can learn about how to improve our grant making processes so the Canadians when they launched their first rapid response COVID-19 funding competition found that fewer female scientists were applying for for funding and so in real time actually implemented a series of data-driven policy interventions before their second call for proposals in April May of 2020 and they increased the application intake window allowed submission of a bridge biosketches required reviewers to evaluate the integration of sex gender and other identity factors at all stages of the research process they offered compensation for dependent caregiver cost extended early career status double parental leave status and a credits and they allowed an optional COVID impact statement to be submitted and what happened was the proportion of applications that were submitted by individuals who self-identified as female increased substantially as did the proportion of successful applications with the female PI there were also some creative extensions of existing programs the Doris Duke Foundation has had a fund to retain clinical scientists that focuses on individuals who have family caregiving demands and they partnered with a number of other funders to create a one-time collaborative funding opportunity to build on that program and to support individuals who had increased caregiving demands during the COVID-19 pandemic we have many ways of accounting for the hidden labor that exists and so your own colleague Dr. Aurora has led a really important study together with your colleagues there and showing how we can actually operationalize this by a supplement to the CV that captures things that existed even before the COVID-19 pandemic right all those forms of invisible service and in emphasizing the service related to the COVID-19 pandemic it actually highlights the invisible service that existed and was disproportionately borne by certain groups even before the pandemic and so I see COVID-19 as our disruptive opportunity it's our chance to inflect that curve so you know as I said if we keep going on that path the current class of medical students is going to have retired by the time we reach parity in the senior positions and that's not okay and I get that it actually looks like the curve is bending in the wrong direction right now but I'd like to think of it as a point of instability in that curve and it's wiggling and we're going to inflect it in the right direction together so we really do inhabit a momentous time in history the pandemic has both highlighted and amplified challenges but provided a disruptive opportunity to move from awareness to action and really given us an opportunity to apply the very familiar health care quality improvement framework whereby we plan to study act to improve structures processes and outcomes for the benefit of all I would like to acknowledge some of my many many many collaborators who don't all fit on one screen my family who all of us have aged considerably since this photo as I think we all have and all of you for your attention and for allowing me to participate virtually so I will stop the share with that and turn it over to questions. Thank you Dr. Jansy and we have a couple questions in the chat which I'll read in a second I just want you mentioned the transparent promotion processes and I chair the department of medicine women's committee I get a lot of questions about that I think we have our dean for academic affairs also in and I was just wondering if you can comment on any views about how to make that process more transparent for faculty. Yeah so I think that having recorded lectures and written documents on your website again because not everyone can attend the one meeting that someone delivers that explains and demystifies the promotions process right but having that available online and in written documentary form so that people can see and showing people medians for what does it take to be promoted to this rank on this track and what does it mean and what is valued is very important because I think women are very unlikely to promote themselves women are very unlikely to call attention to their accomplishments and so if a busy department chair is thinking of who has come to their attention as having written a great paper or gotten a new grant it may be that we've taught little boys a little bit more about how to gracefully promote themselves and we also excuse it more from little boys than little girls and so it is important for us to inform people of what other people who've been promoted to that rank brought to the table when they went up for promotion and then it's really incumbent upon us in leadership positions and this is the hardest thing not to bend or break those rules and those expectations and I have heard this and it's been such a disappointment to me I have heard this from so many leaders well but I know I know a superstar when I see it and and I just don't want to lose a superstar and yes these rules will apply to 99% of people but you know if a guy has these characteristics it's just we've never seen anything like that before and the problem is you have seen it before we've had women who've done it before but they never thought about coming to you and saying hey can you actually bend the rules for me so we have to stick to the criteria yeah I'm not super helpful and to your point about recording like you know how to get promoted videos and things somebody said will this recording be sent out yes and the recordings are always placed on the McLean YouTube channel and so that's how you'll access them in the future I'm going to read it's a little bit of a long question I'm going to paraphrase it they said there's a disconnect between the literature that demonstrates the disparity between men and women's salaries and how academic medical centers actually deal with those disparities when it's brought to their attention the typical response is to report the salary disparity and then opaque HR investigation where they're findings and very glad that there is no disparity and certain factors contribute to the difference of the observed salary this leads to the faculty and the member reporting the disparity feeling really gaslighted for those of us experiencing this how do we deal with it it's the only solution to leave the broken system there anyway to fix the HR system which reinforces these biases while I appreciate the call to employee promote and integrate more women as long as the systems of broken women are going to be harmed I'm from entering them in the first place I could hopefully you got that or read that yourself I think you know I didn't I didn't read it myself but I heard it yeah it's it's a really good point and so let me begin by unlighting the gaslighting flame which is yes you're absolutely right you can have two people and and I often think of two chair candidates now that I'm going to be a department chair I haven't been thinking a lot about chair candidates but we can even specify criteria we can say the criteria to be chair and to get paid like a chair is that you're going to be outstanding in clinical program building you know an internationally recognized scholar with substantial experience leading funded laboratory work and you are a dedicated teacher and mentor right first of all women are less likely to apply for those jobs because they're like well like internationally recognized what I mean I know people know me in the US and like a few people know me in like England and Canada but like I don't know if anyone in China knows me and like you know like we talk ourselves out of like well maybe I just need a few more years when the woman applies the committee then gets let's let's just have candidate a and candidate b and I won't give them genders there's candidate a who ends up being like really extraordinary in terms of clinical program building like has actually established a new multidisciplinary clinic that has transformed care for a certain type of cancer in the region is is always turned to you for clinical care is extraordinary in that and is definitely a strong researcher has funded grants you know not a ton of funded grants only like you know maybe one or one in their history but like definitely did that stuff could do that stuff but was focused on the clinical program building and then you've got candidate b who has been a valued member of the clinical team who certainly is your go-to person if you've got a tough clinical case is really good in the clinic attends every multidisciplinary clinic but like didn't build their own multidisciplinary clinic because they're on the international stage always they've got four active r1s and they're seeing patients and like they're probably the residency program director and you know they're doing all of these things and now you've got to evaluate which one you hire as chair and what people do is they end up altering the prioritization of this criteria for chair based on the gender of the individual what we were really looking for was the clinical program I know what we were really looking for was this and it's exactly what you're talking about in the salary setting too so let's say you happen to have both those people on your faculty and you're the chair and you're actually setting their salaries you're like well the clinical program builder if he gets stolen away I you know our revenues will drop that's really where our money comes in you know so I'm sorry we've really got to focus on the clinical and I'm sorry I know you're on every international stage and I know you've published in this journal in that journal and you have four r1s and they bring in money but you know honey they they only bring in the NIH cap and you know we as a department really rely on him so I'm paying him more because he's more important um flip through genders well you know anyone can build clinical programs and do that kind of thing you know it you certainly you know sort of rolled up your sleeves and we really appreciate your keeping the trains running on time and you know we know that you're essential to our clinical service but ultimately you're replaceable honey you know you you've done the good clinical work but what's really important in academic medicine is is getting grants and being internationally recognized and that's really rare and so honey I pay him more because you know he's really unique it's it is absolutely the case and so how do we fix that first of all I have not yet found a system where that doesn't exist um so leaving um in some cases may be right I'm in the process of a career transition myself but leaving leaving may be right but it really should be to go to an opportunity that you think is different and better not simply because you assume that the equity will be better because I think I've spoken at almost every medical school at this point and I haven't found any place that's perfect there are some that are further along than others um but I think that the big issue there is that they can't be one off equity reviews of the individual um person but rather the dean sitting down with the chairs and saying you're required to have a transparent consistent system that everybody knows about and this is how you're compensated so if it is that we reward the clinical program builders and that's what's important to us in our department and we don't care how many or ones you have then at least you can adapt your behavior knowing that if you start spending your time on this you will get compensated um it is the transparency and the consistency that I think is absolutely key sorry for the wrong answer. Thank you Dr. Jagsy it's wonderful to have you and see you again and especially at this transition for you uh you know as you're about to embark on being a chair um my question is actually a question that I received when I opened this lecture series that I'm going to toss over to you um because I think it's a question that I know many of us first you know hear about and it's actually salient to the comment you just made about visiting all these academic medical centers and all of us are on the journey but we're not there yet and as you think about places that are there or closer can you comment on you know I've seen structures you know like like for example in well-being you know a lot of people are appointing an officer to do well-being there are sometimes um specific leaders that have this title and so I'm wondering if anyone's ever looked at you know institutional structures so that the that the meeting that you described between the dean and the chairs is actually not you maybe it occurs organically but maybe there's somebody who's like job it is to make sure it occurs and so I'm curious if you can reflect on that a little bit as I know um through our fund to retain clinical scientists which we're part fortunate to have we're having those same same discussions here yeah I think it's incredibly important but um I think that many I mean you know it certainly if the organization doesn't have a wellness officer or diversity equity and inclusion officer in their senior executive leadership they're starting to become outliers right most institutions have figured out over the course of the pandemic at least that um that those individuals need to be appointed but what's really important is that they're not just appointed but that they are in the room where it happens that they are part of the true executive leadership team and so we see differences the AAMC is about to come out with a report on the the deans the dean suite both who is in those positions and how they're compensated and I think it would behoove us to look at what we call those roles do we call them senior associate dean do we call them executive vice dean or do we call those simply associate dean and those are people who are lower down in the hierarchy and ultimately their voices aren't heard and so this I think the institutions that are doing better are the ones who exactly as you described have them in the room where the meeting happens between the dean and the chairs because at most academic medical centers the chairs are the ones who have an incredible amount of the authority and so if there's a deendum that meets sort of separately and the deans all talk to each other and it's lovely and you know they have great ideas but they never actually interact with the chairs who are the real executives um in the organization that's a problem to have that disconnect no that makes good sense you know I also have one more question and we also welcome your questions either um I think through the q and a function um and so I know that you know Dr. Jackson is a wealth of information I'm also wondering you know I know we've talked a lot about system solutions but you mentioned something about you know I I mean actually as a mom just young kids you know I think about this with my daughter and you mentioned are we doing something differently for boys you know and where they feel more confident you know and um are able to ask for what they need and so my question to you is actually reflecting on your transition to being a chair and um and in moving um you know what are some of the ways that you think in all the guidance and counseling you've given to women that that we need to be what do we need to be telling women um and and others who may be coming from you know um you know intersectional identities to make sure that they're able to advocate for themselves yeah so I have taken just about every leadership development course you can and I think they're wonderful and I think the ones that are intentional so AAMC has the early career women in medicine in the mid-career midwims um uh sessions um ELAM does it for more senior women um my own professional society ASCO does it for um it's a leadership development program for men and women and all genders alike um that are um mid-career uh and all of these programs are really thoughtful and intentional about not fixing the individuals but empowering them and positioning them and making them visible to the senior leadership in ways that will then seed the system's leadership with people who have received a certain kind of training so I think it's a really clever thing right so ELAM actually was in its 25th year I was a part of his 25th anniversary class and the founder of ELAM Paige Morahan actually said to me she didn't actually think ELAM was going to last anywhere near this long right because it started in 1995 that's the year I matriculated to medical school so I started medical school when she started ELAM and the idea was in 1995 that the women who had gone to medical school in the 1970s right after Title IX had been enacted were finally reaching the level of seniority that they could become senior leaders and hey there wasn't anyone like them before so we needed to create a program for them and then after a little while they would be there and the problem would have worked itself out and actually you know ELAM has gotten larger and larger and larger it's oversubscribed um we're running a randomized trial right now and I you know I think some of you may be participants in the randomized trial I don't look at my participant list don't worry but um I I do see sometimes like the the names that are going out right now for invitations for meetings and stuff so we're running a randomized trial of an ELAM like virtual intervention um and there's such demand for this because if we can have a scalable approach to this there's so many people who want to be in at ELAM who can't and so the things that they teach and so what are we doing in our curriculum we're looking at you know there's a whole quarter on negotiation there's a whole quarter on strategic career development that includes graceful self-promotion developing your elevator pitch uh pitch um you know so recognizing what your strengths are creating something called a star statement all of these kinds of things that um can can help us um to advance our own careers not with the end of fixing ourselves and fitting a broken system but actually positioning ourselves in a place where we can actually create sustained change I love the idea for the internal ELAM Rosie um wanted to raise your hand and ask a question in person yes yes I really really enjoyed the talk I have a million questions but to I just ask one don't worry um I know I have a lot of personal problem being a women for example I got our one I have several our other grant and papers in the being 11 years I haven't had any promotion the reason is I don't want to compromise for example move to different institute or go to different city because to be mom I have to stay here so that's I have to compromise the second thing is I actually serve a lot of leadership for example organizing different meetings including AHA BCVS meetings do spend a lot of time but do you think I I don't know what is a good way to share with our leader or boss to let them know actually I do a lot of activity because I worried people think oh you spent a lot of other time so whether you can focus your study your your research or not so that's the question I want to you those things how can I or how should I share with the leadership the people who in charge of my promotion other thing thank you yeah so this is where I think allyship can be really helpful because it is really difficult to promote oneself without um it just is what it is we we do not like women who promote themselves um and uh I actually I I will tell you this can we cut off the Q&A here um for the recording can we like just cut it off so that this doesn't end up being recorded because I'm happy to share it with a small group but I don't want it in perpetuity thank you thank you yeah but I know no I'm just saying yeah I'm a beat again you turn out the