President’s Letter

By Mildred J. Willy, MD

Guest Writer: Ken Milne, MD, MSc, CCFP-EM, FCFP, FRRMS - Emergency Medicine Physician

The term evidence-based medicine (EBM) was originally defined by Dr. David L. Sackett 24 years ago. He defined EBM as: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett et al BMJ 1996). This definition can be represented in a Venn diagram. Many people think that EBM is just about the scientific literature. This is not correct, and EBM is more than just the published literature. The evidence is only one of three pillars of EBM. The published literature informs and should guide our care, but it should not dictate our care. EBM also needs physicians to use their good clinical judgment based on their experience. We also need to engage with patients and ask them about their preferences and values.

It is these three components that make up EBM: The literature, our clinical judgment and the patient’s values/preferences. However, there are limitations to EBM. One is the gender inequity that can be found in each of these three pillars of EBM.

There are many examples of gender inequity in medical literature. • Females are less likely to get their research funded than men. • Women are less likely to rise to the top academic positions at universities compared to men. • Men are more likely to rise to the top academic positions in medicine. • Men are more likely to rise to the top academic positions in emergency medicine. • Men are more likely to be the first author on a medical publication. • Men are more likely to be the first author on an emergency medicine publication. • Pediatric emergency medicine (PEM) is 62 percent female, but women are the lead author of only 42 percent of PEM papers. Women are also often excluded from being participants in medical research. We need to ensure that women are getting equal access to grant money, so they can ask the questions important to women and create the medical literature that informs our care of women. This will also lead to more women being first author on a medical publication. We need to include rather than exclude women as participants in medical research and not just extrapolate from male subjects.

There are many examples of gender inequity in the second pillar of EBM, the clinician. Men have historically been the physician in the room. Men are more likely to rise to the top leadership positions within the hospital. Only three percent of healthcare CEOs are women, six percent are Department Chairs, nine percent are Division Chiefs, and three percent are serving as Chief Medical Officers. This is despite women comprising 80 percent of the healthcare workforce.

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There is a gender pay gap in the house of medicine. Men get paid ~$20,000 more per year in medicine than women. Men get paid ~$17,000 more per year in academic medicine. Men get paid ~$12,000 more per year in academic emergency medicine. A recent study showed that female surgeons made 24 percent less per hour than male surgeons. This pay gap persisted even after adjusting for various factors (Dossa et al JAMA 2019). The Ontario Medical Association recently released a report called Understanding Gender Pay Gaps Among Ontario Physicians. It documented that male physicians on average bill 15.6 percent more than female physicians even after controlling for a number of variables. This is similar to the 17 percent gender pay gap found in the United Kingdom for hospital doctors. Women make up at least 50 percent of medical school graduates at many institutions. A system must be in place to support those women who want leadership roles in healthcare. Pay inequity must also end. Dr. Michelle Cohen and Dr. Tara Kiran wrote an article called Closing the Gender Pay Gap in Canadian Medicine. It defines the problem of gender pay gap and dispels some of the myths like, is the gender pay gap real and do women just work less or less efficiently than men? They describe some of the root causes of the gender pay gap and what can be done to close the gap.

The third pillar EBM also shows evidence of gender inequity. Women are more likely to access and utilize health care compared to men. Mothers make approximately 80 percent of health care decisions for their children. Women are systematically undertreated for painful conditions. They are seven percent less likely to get any analgesia and 10 percent less likely to get an opioid compared to men. Even for a life

threatening illness like a myocardial infarction, women receive less treatment and have double the odds of dying. We need to ensure that everyone gets the emergency care they need regardless of whether they identify as a man or woman. The emergency department is like a lighthouse. It is the one place in the house of medicine that the light is always on and will treat anyone at any time for anything. The gender inequity discussion does dichotomize things into men and women. This is a false dichotomy. There are people who do not identify as a man or woman. Gender is complex and on a spectrum. There is how a person identifies, expresses themselves, the sex assigned at birth, who they are physically attracted to and who they are emotionally attracted to. I would suggest that Feminist-Based Medicine (FBM) is just the starting point and we need to take it one step further to Gender-Based Medicine (GBM). The Gender Unicorn is a graphic representation demonstrating the complexity of gender and sexuality. We need to make sure that the house of medicine is not just inclusive and tolerant, but accepting and welcoming to everyone regardless of how they identify. The progression, in my opinion, should be from EBM (male dominated) to FBM (recognizing the gender inequity) to GBM (more inclusive) and ultimately to Humanist-Based Medicine (HBM). There are other inequities in medicine besides just gender. There are problems with race, religion, socioeconomic status, mental health, physical ability, etc. In order to provide patients with the best care, based on the best evidence we need high-quality, clinically relevant research that is inclusive and representative of everyone; remove inequities for those who generate research and provide care at the bedside; and finally, recognize everyone has value and should expect and deserve great care.

Comments from Dr. Willy: Please join me in acting to close this gender gap given that our medical school classes generally consist of >50 percent females as does the younger physician population at large, and the importance this plays for providing better patient care as well.