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AWAEM Toolkit

2020


AWAEM Toolkit 2020 Edition Table of Contents Chapter 1:

A Roadmap for Creating Women’s Groups ����������������������������3

Chapter 2:

Professional Development��������������������������������������������������������9

Chapter 3: Recruitment/Support���������������������������������������������������������������� 13

Special Thanks AWAEM Task Force on a Toolkit for Women’s Professional Development Groups:

Chapter 4: Promotion ���������������������������������������������������������������������������������� 17 Chapter 5:

Gender Specific Needs/Wellness�������������������������������������������� 21

CHIEF EDITORS & AUTHORS

Chapter 6: Mentoring������������������������������������������������������������������������������������33

Komo Gursahani, MD, MBA

Chapter 7:

Grant Writing������������������������������������������������������������������������������ 37

Kat Ogle, MD

Chapter 8:

Developing Scholarship������������������������������������������������������������41

AUTHORS & CO-EDITORS Cassandra K. Bradby, MD

Introduction

Marina Del Rios Rivera, MD, MSc

This toolkit is a collaborative effort from the SAEM Academy for

Nadine T. Himelfarb, MD

Women in Academic Emergency Medicine (AWAEM) and a collective of women in academic emergency medicine who possess a diversity of

Amy Zeidan, MD

career experience and professional goals. This publication provides content and resources that are relevant to the career challenges and opportunities facing women in academic emergency medicine. Each chapter was authored individually and edited by a peer within the task force. Final edits were performed by Drs. Komo Gursahani and Kat Ogle. We hope you’ll find this tool useful in meeting your career development needs and we look forward to any feedback you may have to improve the content and keep it current. Sincerely, The AWAEM Task Force on a Toolkit for Women’s EM Professional Development Groups

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EDITORS Michelle Lall, MD, MHS Tracy Madsen, MD, ScM Caitlin Ryus, MD, MPH


Chapter 1

A Roadmap For Creating Women’s Groups

Kat Ogle, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, The George Washington University. Edited by Komo Gursahani, MD, MBA.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[ ] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[ ] transitioning from community practice to academic emergency medicine

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CURRENT LITERATURE ON THIS TOPIC Needs Assessment

As we contemplate our careers, growth, and advancement, we as women in academic emergency medicine can benefit substantially from the support of a local professional development group (PDG). The success of these groups in helping members throughout their careers is well established in the business literature, and there is a growing body of evidence concerning this need in medicine.1,2,3 To date, a comprehensive resource to guide the creation of local emergency medicine PDGs for women does not exist. We believe that a toolkit designed to help impel women in emergency medicine to organize, could lay the foundation for the development of local, regional, national, and global networks. We hope that these groups and networks work toward a collective mission to mentor, sponsor, coach, advance, and facilitate the retention of women faculty. Considering the variation in institutional guidelines and infrastructure to combat gender disparities in salary, academic promotion, and leadership opportunities, the following program components must be prioritized by the stakeholders of each institution: • Access to and presentation of substantiated evidence to clearly define the problems; • well-designed curricula to educate the institution’s faculty, regardless of gender identity; • a list of potential solutions to challenges which have been identified as specific to the home institution; • mentors, sponsors and coaches to whom these champions can turn when • inevitable roadblocks arise. Some institutions may have existing PDGs for women which cross interdisciplinary specialty and academic lines, including basic science faculty and clinical faculty. When seeking institutional change, there is power in numbers, thus it is important to consider the specific needs of your women physician group. The AAMC has an excellent guide4 to creating a collaborative and multidisciplinary group for women in medicine and science; therefore, this chapter will focus predominantly on creating a local group directed at women faculty in emergency medicine. Women emergency physicians experience different challenges in the clinical and academic space which originate from a unique perspective. Some of those challenges will be further discussed in this toolkit.

STRATEGIES THAT ADDRESS THE CHALLENGE Assess Your Needs

As with most scholarly endeavors, creating a robust women’s PDG will require forward-thinking, intellectual investment, research, funding, and maintenance. First, engage a small group of individuals to champion the effort as a steering

As we contemplate our careers, growth, and advancement, we as women in academic emergency medicine can benefit substantially from the support of a local professional development group (PDG).

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committee or task force. Next, perform a needs assessment to define the scope of challenges within the department or institution. A needs assessment will engage multiple faculty members in identifying and, hopefully, working on issues of particular importance to them. It is essential to foster an environment for your faculty in which they not only feel supported but also a sense of personal responsibility and ownership to enhancing the collective.

Develop a Mission and Vision

Based on the results of the data collected from the needs assessment, the group will be able to develop a mission and vision. The mission and vision statements should define key stakeholders, communicate the group’s purpose and professional goals, and outline how those goals will be achieved. With regard to garnering institutional and departmental support, examine how the mission and vision align with those of the institution. Helpful questions to consider during this process are: • How do your group’s mission and vision align with the departmental and institutional mission and vision? • How do the mission and vision statements honor the professional and personal needs of your faculty? • How do the mission and vision statements simultaneously support the interests of the department and institution? • Are there ways in which your mission and vision can address the professional needs of underrepresented minorities, LGBTQIA, parent and non-parent women faculty? • How do your mission and vision look to sustaining a pipeline for the advancement and retention of faculty?

Create Infrastructure

Based on the mission and vision, start building an infrastructure that will allow the group to grow and flourish. Place key individuals in leadership positions and recruit members to engage in different activities that serve the mission and vision. Establishing an infrastructure includes developing guidelines that describe how the group will function (i.e. by-laws or governance structure). Involving all members in the creation of these rules or by-laws is essential to the success of a sustainable PDG. Given the different functions within a PDG, it is important to also develop committees that will assume ownership of various key activities. Examples of committees: •E  xecutive Committee (chair, co-chair, treasurer, secretary) — Responsible for leading the group •P  rogram Committee — Responsible for content, speakers, and schedules for meetings •C  ommunications Committee — Responsible for transmitting information to the membership via e-mail, newsletter, social media, etc. •S  cholarship Committee — Responsible for engaging the membership in the development of scholarship via research, publishing, meetings, or otherwise •M  embership Committee — Responsible for building, engaging with and highlighting the benefits of membership This is not an exhaustive list, therefore decide what works best for the needs of the local group. Depending upon the various skills and interests within the membership, there are likely individuals who are uniquely suited to a particular area and will help keep members engaged and productive toward their professional goals.

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Enlist Outside Support

There are many professional organizations that advocate for workplace gender equity, professional development, and the promotion and advancement of women in academic emergency medicine. Forming collaborative relationships with these organizations not only fosters the potential for career mentorship and sponsorship, but the sharing of ideas and content for programming, speaking opportunities, leadership positions, and grant-funded opportunities. Sustainability and growth of a PDG will be enhanced with support from not only outside organizations but also the home institution and department. Aligning the group’s mission and vision with that of the institution and department helps facilitate discussions with key stakeholders such as institutional leadership (e.g. deans, chancellor, provost), departmental leadership (e.g. chair, vice-chair, diversity and inclusion officials), and leaders within the AAMC. According to The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership,5 in 2012 nearly 40 percent of medical schools provided salary support to representatives of the AAMC-affiliated Group on Women in Medicine and Science (GWIMS). In 2011, 83 percent of medical schools allocated funding, averaging $100,000, to professional development activities for women faculty in the U.S. Given that the GWIMS structure through the AAMC includes all academicians, clinicians, and basic scientists, our review of the literature and needs assessment with the membership of AWAEM found particular nuances and needs which are unique to women physicians in academic emergency medicine. These topics are covered later in the toolkit.

Maintain Momentum

Once established, a PDG will require maintenance. Some suggestions for ongoing management of a PDG include: • With the intention of making improvements, obtain regular feedback from members with regard to the

programmatic content. Remember to refer back to the mission, vision, and goals of the group when making any modifications. • Enhance the visibility of women colleagues. This regular practice of peer support can be captured in academic portfolios and demonstrate the value added to your department and your institution. This can be accomplished by: o Encouraging the membership to share information about presentations and disseminating it to the entire faculty and institution, and via social media o Fostering networking which in turn fosters further opportunities for speaking engagement, collaborative research, mentorship outside of the institution, and outside sponsorship o Nominating women peers for faculty awards within your institution, region, and at national and international organizations – Create an awards committee whose primary responsibility is to seek out and inform the membership of new awards and grants available for professional development. – Assign and engage internal writers to submit letters of recommendation and support. Engage junior faculty in writing recommendations for senior faculty by pairing them with someone who has experience doing so. • Delegate and engage the membership with opportunities that align with their personal and professional interests. An active membership fosters a sense of autonomy, flexibility, and ownership. • Organize a professional development conference that addresses some of the issues that impact the membership. Serving on the Planning Committee or Steering Committee for this activity would provide members with leadership opportunities. Follow these key steps to planning a professional development conference:

Aligning the group’s mission and vision with that of the institution and department helps facilitate discussions with key stakeholders such as institutional leadership (e.g. deans, chancellor, provost), departmental leadership (e.g. chair, vice-chair, diversity and inclusion officials), and leaders within the AAMC.

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o Develop a budget for the event. o Identify your target audience (residents, fellows, junior faculty, senior faculty) and a cohesive theme. o Invite regional academic emergency medicine programs to broaden the conference from a local endeavor to a regional one (and increase the visibility of the PDG). o Reach out to residency and fellowship program alumni to engage them in the conference by facilitating a workshop or delivering a keynote. o Include a networking dinner where members can connect with invited speakers and others from neighboring institutions.

Maximize Participation

There are several ways meetings can be planned and structured to help maximize the participation of and add value to the time invested by busy members who are balancing both clinical and academic responsibilities: • Use focused agendas and distribute minutes which highlight action items for follow-up. • Consider a variety of content which appeals to faculty and residents at varying stages of training and career progression.

• Ensure varied times for the meetings to accommodate our non-circadian schedules. • While the mission and vision may aim for the sky, consider activities that can have a meaningful impact in a short period of time by setting short term goals and long-term goals. • When a goal is reached, celebrate the members who worked to make it happen; share the success broadly and widely, including with the chair and institutional leadership so they can see the positive impact of your PDG. • Continue to delegate responsibilities of the group to stakeholders within the membership; this encourages a sense of autonomy, flexibility, and ownership. • If disequilibrium begins to fester or participation to dwindle, refer back to the mission and vision to refocus activities on the goals. • Invite men from the department to participate in events and to act as advocates, mentors, and sponsors. Their experience and engagement are essential to providing an inclusive message and providing unique insight. • Continually engage and invite departmental and institutional leadership to promote and support your ventures.

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Pass the Torch

Plan for a seamless transition in leadership for your PDG. Setting term limits for your executive committee and other committees creates opportunities for other members to lead the group. Members who have taken on active roles in the inaugural year should be encouraged to advance in their leadership positions. If they are hesitant to do so, articulate the strengths and skills they bring to the group and emphasize the experience they will gain and ways they will grow by advancing in leadership. Consider generating an annual report that highlights the accomplishments of the group and individual members. During the leadership transition, hold a meeting to discuss the challenges and benefits of each respective role. Past leaders should assist incoming leadership with troubleshooting any challenges or difficulties encountered in any of the positions.

STRATEGIES THAT ADDRESS THE CHALLENGES

•D  etermine the target audience of the PDG. Will it include residents and medical students in an effort to enhance the pipeline of women entering academic emergency medicine? Will the focus be on faculty as opposed to learners? •P  erform a needs assessment. This will facilitate the identification of the specific concerns that impact women faculty and will provide a framework for the future goals of the group.

HOW TO MEASURE SUCCESS ON THIS TOPIC

A PDG’s success will be measured based on its goals; therefore, create both short-term and long-term goals and goal progression slows or is halted, revisit the key steps required to accomplish the goal. For example, if scholarship is a priority of the PDG, measure success by following the numbers of publications members create post-establishment of the group. If burnout is a concern, measure it using a validated tool and make efforts to move that metric.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• Consider establishing a scholarship committee to generate research ideas specific to problems identified by the needs assessment. • Measure and review the academic promotion and advancement of PDG members. • Chronicle speaking opportunities that arise directly from networking and engagement opportunities within the PDG. • Quantify the advancement of alumni from the residency and the PDG who subsequently enter academic medicine; survey them regarding their perception of the PDG’s impact with regard to mentorship, sponsorship, coaching, and other means of professional development.

•E  ngage membership by parlaying their individual strengths into symbiotic group function. Without delegation of responsibilities, leader burnout can occur; align responsibilities with the interests and expertise of the PDG members.

To provide feedback and recommendations on this topic, email the author at katogle@gwu.edu; Subject: AWAEM Toolkit: Roadmap for Creating Women’s Groups

Resources Used for Discussing This Topic 1. Committee on Maximizing the Potential of Women in Academic Science and Engineering; Committee on Science, Engineering, and Public Policy; Institute of Medicine; et al. Beyond bias and barriers: fulfilling the potential of women in academic science and engineering. Washington, DC: National Academies Press; 2006. 2. Welch JL, Jimenez HL, Walthall J, Allen SE. The women in emergency medicine mentoring program: an innovative approach to mentoring. J Grad Med Educ. 2012 Sep;4(3):362-6. doi: 10.4300/JGME-D-11-00267.1. PMID: 23997883; PMCID: PMC3444192. 3. Bauman MD, Howell LP, Villablanca AC. The Women in Medicine and Health Science program: an innovative initiative to support female faculty at the University of California Davis School of Medicine. Acad Med. 2014 Nov;89(11):1462-6. 4. Wei JL and Geiger PC. How to Start and Maintain a Robust WIMS Organization. AAMC GWIMS Toolkit. 5. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, a report by AAMC.

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Chapter 2

Professional Development

Nadine T. Himelfarb, MD, Assistant Professor of Emergency Medicine and Clinician Educator, Alpert Medical School of Brown University. Edited by Komo Gursahani, MD, MBA and Caitlin Ryus, MD, MPH.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[x] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[x] transitioning from community practice to academic emergency medicine

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CURRENT LITERATURE ON THIS TOPIC

According to a 2018 position paper1 by the American College of Physicians, women encompass one-third of the physician workforce, approximately 46 percent of physicians-in-training, and greater than 50 percent of medical students. The parity ends there, however. Within medical schools, women make up 38 percent of the fulltime faculty, 21 percent of full professors, 15 percent of department chairs and, as of 2016, 16 percent of deans. These leadership gaps are even more challenging in emergency medicine, where the applicant pool ratio of men to women is more disparate. The Electronic Residency Application Service (ERAS®)2 shows that of the 4,200 applicants into emergency medicine (EM) in 2018, only 34 percent were women. The gender inequities observed in medicine and its leadership are complex and varied, and thus are the approaches to addressing the inequities. Professional development is essential to the advancement of women physicians in academic medicine or community practice. Professional development may involve continuing medical education in career development, training in leadership or negotiation, participation in professional organizations, research, and increased duties and responsibilities. The purpose of professional development is to cultivate competence, improve job performance, and enhance communication efficiency and efficacy. Professional development for women is particularly effective when it focuses specifically on overcoming the unique challenges and barriers faced by women physicians.

ACTIONABLE STEPS YOUR GROUP CAN TAKE

Leadership Commitment to Culture Change

• Obtain a commitment from upper-level leadership because that offers higher returns from the professional development efforts of women in EM. o Track the departmental rates of promotion of women in EM o Track the leadership roles of women in EM o Track recruitment of women physicians • Encourage implicit bias training for departmental administration, search, and promotions committees, as well as medical educators.

Sponsor Membership in Professional Organizations

• Allows for networking, mentorship, and sponsorship of women in EM by women in EM • Women with women-dominant networks have 2.5 times higher job placement than women without or with male-dominant networks • Examples of professional organizations: Academy for Women in Academic Emergency Medicine (AWAEM), American Association of Women Emergency Physicians (AAWEP), American Medical Women’s Association (AMWA), Association of American Medical Colleges (AAMC)

Professional development is essential to the advancement of women physicians in academic medicine or community practice.

Professional development for women is particularly effective when it focuses specifically on overcoming the unique challenges and barriers faced by women physicians.

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Promotions Driven Action

• Create or sponsor formal workshops and written communication about the promotion process, including timelines and requirements. • Form promotion committees to include women and to be composed of members from all academic pathways and different ranks. • Educate promotion committees to encourage, as opposed to penalizing, women physicians who take advantage of “stop-the-clock” (postponement or extension of promotion/tenure review period due to childbearing) policies.

Support Professional Development Conferences

• Allow for CME and professional development and networking. • Create a database of professional development opportunities and target women by rank/interest to encourage application to these. • Provide support for courses in negotiation and leadership. • Encourage participants to bring “lessons learned” from professional development activities back to the department. • Create a speaker series for the whole department that addresses the faculty and career development of women physicians; engage male physician members in the gender inequity crisis in medicine.

• Support participation with departmental funding and time. • Examples of professional development conferences: AAMC Early Career Women Faculty Leadership Development Seminar (EWIMS), AAMC Mid-Career Women Faculty Professional Development Seminar (MidWIMS), FemInEM Idea Exchange (FIX), Revive FemInEM Development Retreats, Harvard’s Career Advancement and Leadership Skills for Women Healthcare, Executive Leadership in Academic Medicine training program (ELAM)

Create a Curriculum/Platform for Gender Inequity

• Allow for individuals in the department to identify and navigate biases and barriers. • Engage the entire department in the gender disparity conversation using an evidence-based approach. • Offer a speaking platform for women in the department to develop talks on women in EM as well as academic interests to educate, develop speaking skills, and advance careers via CV strengthening.

Support Efforts Financially

• Department time and/or budget for women physician mentoring groups and networking o Negotiation facts: – Efforts become a recruiting mechanism for the department – Increasing diversity improves patient care/outcomes

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HOW TO MEASURE SUCCESS ON THIS TOPIC

Take Measurements

Know your department stats (e.g. percentage of women who are vice chairs, serve on committees and task forces, and are in leadership positions; promotion rates — time to promotion, successfully promoted; number of grants applied for and rewarded; number of women applicants and how many interviewed; number of women speakers/ grand rounds; number of publications authored by women; number of women award recipients; salary transparency reports, etc.). Measurements should be regular and ongoing; a baseline should be established. Set a goal to improve 1-2 key metrics within a given time frame.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

Literature

•M  anaging Through Teamwork for Maximal Performance • Writing an Effective Executive Summary •A  Guide to Prepare for Your First Job in Academic Medicine • Implementing an Intensive Career Development Program For Women Faculty • Programs in recruitment, promotion, and retention by social level (Fig 1: Carr PL et al. 2017)

Needs Assessments

The needs of women and departments are likely to be highly variable as are current successes and failures. Performing a needs assessment should direct actions for research. The evidence-based literature on what professional development actions specifically advance women are lacking; therefore, using a scientific approach from the start may lead to outcomes reportable for all women emergency medicine physicians.

Scientific Approach

Given the paucity of evidence-based methods in professional development, approaching initiatives as research projects with pre- and post-assessments and objectives would only add to the literature on this topic.

(Fig 1: Carr PL et al. 2017)

To provide feedback and recommendations on this topic, email the author at nadine_himelfarb@brown.edu; Subject: AWAEM Toolkit: Professional Development Feedback

Literature 1. B  utkus R, Serchen J, Moyer DV, Bornstein SS, Thompson Hingle S. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med. May 2018;168(10):721-723. 2. Association of American Medical Colleges. Residency applicants to ACGME-accredited programs by specialty and sex, 2018-2019. Published on Nov 13, 2018. 3. Choo EK, Kass D, Westergaard M, Watts SH, Berwald N, Regan L, Promes SB, Clem KJ, Schneider SM, Kuhn GJ, Abbuhl S, Nobay F. The development of best practice recommendations to support the hiring, recruitment, and advancement of women physicians in emergency medicine. Acad Emerg Med. 2016;23:1203-1209. 4. Laver KE, Prichard IJ, Cations M, Osenk I, Govin K, Coveney JD. A systematic review of interventions to support the careers of women in academic interventions and other disciplines. BMJ Open. 2018;8(3):e020380. 5. Garrett L. The trouble with girls: obstacles to women’s success in medicine and research. BMJ. 2018;363:k5232. 6. Silver JK. Ethical leaders: use science to advance gender equity in medicine. STAT. Published November 13, 2018. 7. Silver JK. A call to healthcare leaders: ending gender workforce disparities is an ethical imperative. Published September 17, 2018. 8. Carr PL, Gunn C, Raj A, Kaplan S, Freund KM. Recruitment, promotion, and retention of women in academic medicine: how institutions are addressing gender disparities. Womens Health Issues. 2017. 27(3):374-381. 9. Madsen TE, Heron SL, Rounds K, Kass D, Lall M, Sethuraman K, Arbelaez C, Blomkalns A, Safdar B. Making promotion count: the gender perspective on behalf of the society for academic emergency medicine equity research taskforce. Academic Emerg Med. 2019 Jan 9;doi:10.1111/acem.13680 epub. 10. Yang Y, Chawla NV, Uzzi B. A network’s gender composition and communication pattern predict women’s leadership success. Proc Natl Acad Sci USA. 2019 Feb 5:116(6):2033-2038.

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Chapter 3

Recruitment & Support

Cassandra K. Bradby, MD, Assistant Professor of Emergency Medicine, Brody School of Medicine at East Carolina University. Edited by Amy Zeidan, MD.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[x] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[x] transitioning from community practice to academic emergency medicine

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CURRENT LITERATURE ON THIS TOPIC

According to the Association of American Medical Colleges (AAMC), 2018 marked the first time that women were the majority of matriculants into U.S. medical schools (51.6 percent women vs 48.3 percent men).1 As the number of women in medicine increases, the way that we recruit and support these new doctors also needs to change. Dr. Esther Choo, et. al. looked at developing best practices to support the hiring, recruitment, and advancement of women in emergency medicine. They recommend changing the culture of EM to exclude gender bias, create a supportive environment for employees through family-friendly policies, support the development and advancement of women through networking, administrative time, and mentoring, and promote the health and wellness for women physicians — all elements found to be important to women physicians and to consider as possible changes/improvements for many departments and organizations.2 While these recommendations support an inclusive environment, there is no evidence that they have been put into widespread practice. In order for these changes in environment to come to fruition, they need to start at the individual department or organizational level.

STRATEGIES THAT ADDRESS THE DISPARITIES

Recruitment and retention are key to maintaining a diverse faculty or EM group, but in order for this to be successful, there must be policies at both the institutional and the departmental levels that support and promote women in the workplace. Here are some strategies: • Increase awareness of the policies in place at your institution regarding the recruitment of faculty. o Where do they advertise openings? o How many people are interviewed? o How are interviews conducted?

Recruitment and retention are key to maintaining a diverse faculty or EM group, but in order for this to be successful, there must be policies at both the institutional and the departmental levels that support and promote women in the workplace.

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o How are search committees comprised? – Is there adequate representation from women and underrepresented minorities?

ACTIONABLE STEPS YOUR GROUP CAN TAKE

– Is unconscious bias training required for all members of the search committee?

• Know the departmental and institutional policies on recruitment and retention.

• Develop a family-friendly culture in your department and publicize your department’s family-friendly policies (family-friendly policies are important to and benefit both women and men).

o Make sure that your department’s recruiting strategy is one that creates a process that is inclusive of the recruitment and retention of women; if there is no policy, consider working with departmental leadership to create one.

o Encourage the creation of policies that promote extending the time period for tenure and promotion due to childbirth, family leave, etc. o Promote health and wellness. • Support the professional development and advancement of women. o Implement mentoring programs. o Fund mentorship and networking programs. o Provide organizations.

memberships

in

gender-specific

o Support travel to conferences. o Provide administrative time to support and promote the involvement of women on departmental committees or committees within the organization. o Nominate female colleagues for awards and encourage them to consider leadership positions.

• Participate in the search and recruitment process (women are typically more successful at recruiting other women). • Urge that open positions be advertised in a diverse range of publications and websites, particularly those that are geared toward women and underrepresented minorities. Examples: o FemInEM Job Board o SAEM EM Job Link o AAEM Job Bank (members only) o EMCareers • Make it standard practice to highlight the family-friendly policies (ex: family leave) of your department during a candidate’s interview day.

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HOW TO MEASURE SUCCESS ON THIS TOPIC

• Conduct a yearly needs assessment survey to see what has changed in the department in terms of support. o Create a percentage goal of women faculty/physicians in the group; measure and report on the progress annually to monitor change. o Regularly ask current female physicians to help identify barriers to and opportunities for improvement in the recruitment and retention of other women at your shop. o Include the number of people who have benefited from your department’s or organization’s familyfriendly programs and policies; if the number is minimal, explore why.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• What strategies have been implemented in terms of recruitment and retention of women and have definite data to support them? Look specifically at measurable outcomes from recruitment initiatives. • Are the recruitment strategies for academic vs nonacademic female EM physicians different? If so, how do they differ and why? • Has the presence of “women in EM” groups at your institution helped with the recruitment of more female EM physicians?

• Compare your department to the national averages, in terms of number of women faculty, rank, and leadership positions. • Set goals for recruitment and retention and assess your progress annually.

To provide feedback and recommendations on this topic, email the author at bradbyc14@ecu.edu; Subject: AWAEM Toolkit: Recruitment and Support.

Resources Used for Discussing This Topic 1. A  ssociation of American Medical Colleges. AAMC data book: 201 Applicant and Matriculant Data Summary Tables. Washington, D.C.: AAMC. 2. Choo EK, Kass D, Westergaard M, Watts SH, Berwald N, Regan L, Promes SB, Clem KJ, Schneider SM, Kuhn GJ, Abbuhl S, Nobay F. The Development of Best Practice Recommendations to Support the Hiring, Recruitment, and Advancement of Women Physicians in Emergency Medicine. Acad Emerg Med. 2016 Nov;23(11):1203-1209 3. Analysis in Brief. 2009. Unconscious bias in faculty and leadership recruitment: A literature review. Washington, DC: Association of American Medical Colleges. 4. Cydulka RK, D’Onofrio G, Schneider S, Emerman CL, Sullivan LM. Women in academic emergency medicine. Acad Emerg Med. 2000 Sep;7(9):999-1007. PubMed PMID: 11043995. 5. Kuhn GJ, Abbuhl SB, Clem KJ; Society for Academic Emergency Medicine (SAEM) Taskforce for Women in Academic Emergency Medicine. Recommendations from the Society for Academic Emergency Medicine (SAEM) Taskforce on women in academic emergency medicine. Acad Emerg Med. 2008 Aug;15(8):762-7. 6. Parekh KP, Overbeeke T, Halsey-Nichols RM. Implementation of a Departmental Female Emergency Medicine Physician Group. West J Emerg Med. 2019 Jan;20(1):98-99. doi: 10.5811/westjem.2018.11.39827. 7. Sweeting H, Bhaskar A, Benzeval M, Popham F, Hunt K. Changing gender roles and attitudes and their implications for well-being around the new millennium. Soc Psychiatry Psychiatr Epidemiol. 2014 May;49(5):791-809. 8. Villablanca AC, Beckett L, Nettiksimmons J, Howell LP. Career flexibility and family-friendly policies: an NIH-funded study to enhance women’s careers in biomedical sciences. J Womens Health (Larchmt). 2011 Oct;20(10):1485-96. 9. Welch JL, Jimenez HL, Walthall J, Allen SE. The women in emergency medicine mentoring program: an innovative approach to mentoring. J Grad Med Educ. 2012 Sep;4(3):362-6. 10. Westring AF, Speck RM, Sammel MD, Scott P, Tuton LW, Grisso JA, Abbuhl S. A culture conducive to women’s academic success: development of a measure. Acad Med. 2012 Nov;87(11):1622-31. 11. Westring AF, Speck RM, Dupuis Sammel M, Scott P, Conant EF, Tuton LW, Abbuhl SB, Grisso JA. Culture matters: the pivotal role of culture for women’s careers in academic medicine. Acad Med. 2014 Apr;89(4):658-63. 12. Yu PT, Parsa PV, Hassanein O, Rogers SO, Chang DC. Minorities struggle to advance in academic medicine: A 12-y review of diversity at the highest levels of America’s teaching institutions. J Surg Res. 2013 Jun 15;182(2):212-8.

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Chapter 4

Promotion

Judith A. Linden, MD, Associate Professor of Emergency Medicine and Vice Chair for Education, Department of Emergency Medicine, Boston University School of Medicine/Boston Medical Center. Edited by Cassandra Bradby, MD.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[ ] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[x] transitioning from community practice to academic emergency medicine

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CURRENT LITERATURE ON THIS TOPIC

Women now constitute more than 50 percent of incoming medical school classes, yet they are not proportionately represented in the makeup of faculty in academic medicine. One study 1 found that in academic medicine, female physicians make up 38 percent of faculty, but only 21 percent of full professors, 15 percent of department chairs, and 16 percent of medical school deans. These findings were supported by another study comparing women to men in academic emergency medicine. The Association of Academic Chairs in Emergency Medicine (AACEM) conducted a survey of its membership, revealing that as academic rank increases, the percentage of women achieving that rank decreases: 74 percent instructor or assistant/19 percent associate/7 percent full professors for women versus 59 percent instructor or assistant/24 percent associate/17 percent full professors for men. Another study2 utilizing the Doximity and AAMC database came up with very similar findings: 79.6 percent assistant/14.6 percent associate/5.6 percent full professors for women compared 65.9 percent assistant/20.8 percent associate/13.4 percent full professors for men. The reasons behind this are unclear. Some speculate that women in emergency medicine are younger and have been practicing for a shorter period of time while others suggest systematic barriers to promotion exist that preferentially advance men. Recent polling of academic chairs3 probed this question in more detail and found that other reasons include: • Women are more likely to take on time-intensive responsibilities which are categorized as less academic

(e.g. mentoring and teaching medical students and residents) which may negatively impact promotion and advancement in many institutions. • Women have fewer peer-reviewed publications, especially first and last author publications, which is possibly related to disproportionate personal responsibilities. The American College of Physicians (ACP) published a position paper4 describing gender inequities in pay and promotion and recommending steps for achieving gender equity, such as: • Requiring transparency and frequent review of salary equity • Supporting and disseminating family leave policies • Offering faculty development programs, including leadership development for all • Negotiating career development opportunities for all physicians and physicians-in-training • Implementing implicit bias training • Increasing coaching, mentoring, and sponsorship of women and minorities • Creating flexibility in structuring career paths in academic medicine and in private practice • Ensuring diversity on boards and committees Strategies described by emergency medicine chairs to increase the promotion of women in academic emergency medicine include efforts to add women to promotion committees, implementing implicit bias training, ensuring mentorship, supporting attendance at faculty development programs, dispelling the myth of promotion readiness (Table 1).

Strategies described by emergency medicine chairs to increase the promotion of women in academic emergency medicine include efforts to add women to promotion committees, implementing implicit bias training, ensuring mentorship, supporting attendance at faculty development programs, dispelling the myth of promotion readiness

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*Table 1: Chair suggestions for increasing the advancement of women in academic emergency medicine: • Concerted efforts to add women to promotions committees. • Creating a culture for advancing underrepresented groups. Institutional Level

• Medical school–wide training in implicit bias. • Appointment of dean of diversity. • Expanding the criteria for academic productivity to include newer models of teaching. • Concerted efforts to direct women to leadership positions. • Standardize and increase transparency of promotions process.

Departmental Level

• Concerted efforts to add women to departmental and institutional promotions committees. • Create an internal promotion committee that regularly reviews each faculty and their trajectory. • Provide administrative support for faculty going through promotions process (e.g., with preparation of CV or promotion materials). • Ensure effective mentorship for each faculty; consider gender-matched mentor pairs.

Individual Level

• Regular one-on-one meetings with departmental leadership to discuss growth and c areer trajectory. • Support women going to faculty development conferences. • Dispel myth of promotion readiness, a concern that may affect women disproportionately.

*Adapted from Madsen 2019.3

STRATEGIES THAT ADDRESS THE DISPARITIES

In order to initiate lasting change, this issue must be addressed at the highest levels, by the institution promotion committee, the dean, and where appropriate, the university president or provost. • Ask if your institution keeps track of faculty rank by the percentage of female and underrepresented minority (URM). What do these statistics show? • If not already being done, initiate a database to keep track of promotions by gender and URM status in your department. • Actively sponsor and promote speaking engagements, national involvement, and scholarly collaboration of women, and URMs in your department.

ACTIONABLE STEPS YOUR GROUP CAN TAKE

• Appoint a faculty member to oversee and report regularly on female and URM faculty advancement for your department. This can be the same person who is in

charge of all faculty advancement, typically the vice chair for faculty affairs/promotion/faculty development. This person or their designee should hold office hours and meet regularly with those considering promotion. • Meet with the head of the promotions committee at your academic medical center to discuss policies that might be unfair to female faculty (e.g. that the requirement of speaking at international conferences be fulfilled before being considered for promotion to full professor, or the requirement that tenure must be achieved within a certain time limit, without allowing for maternity/family leave to stop the clock). • Offer a biannual curriculum vitae (CV) review session, where faculty can bring their CV to review with the group and discuss suggestions for improvement (e.g. by adding things they hadn’t thought of or by identifying areas for future activities to enhance the CV). • Invite the vice chair for promotions (or faculty development) to your women’s group meeting. • Encourage, support and/or sponsor involvement in national committees, networking, and conferences. The connections that are made will help faculty exhibit national/international reputation. • Utilize the AWAEM Letter Writers Bureau (see resources).

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HOW TO MEASURE SUCCESS ON THIS TOPIC

• Maintain transparency and regularly report on female and/or URM faculty rank. • Measure the change in the numbers of female and/or URM faculty promoted over time (assistant to associate and associate to full professor). • Measure faculty knowledge of and satisfaction with available resources and, where appropriate, add resources for areas where gaps exist.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

RESOURCES USED FOR DISCUSSING THIS TOPIC

• Institution-specific promotion criteria, for example type of tracks (e.g. clinical vs unmodified) and criteria for promotion • Institution-specific CV examples and formatting guidance • List of resources available for promotion at your institution (e.g. professional development website, workshops, professional development sessions, etc.) • AWAEM Letter Writers Bureau (a list of sample letter writers, organized by rank): Log into SAEM > My Communities > AWAEM > Library > Folders > Letter Writer Bureau > Excel Spreadsheet

• What is the effect of interventions on promotion rates for women and URM faculty? • What are the perceived barriers to promotion that women report? To provide feedback and recommendations on this topic, email the author at judylinden@gmail.com; Subject: AWAEM Toolkit: Promotion

Pertinent Literature 1. Lautenberger D, Dandar V, Raezer C, Sloane R. The State of Women in Academic Medicine 2013-2014: The Pipeline and Pathways to Leadership [Internet]. AAMC; 2014 [cited 2016 Dec 20]. 2. Bennett CL, Raja AS, Kapoor N, Kass D, Blumenthal DM, Gross N, Mills AM. Gender differences in faculty rank among academic emergency physicians in the united states. Acad Emerg Med [Internet]. 2019;26(3):281-5. 3. Madsen TE, Heron SL, Rounds K, Kass D, Lall M, Sethuraman KN, Arbelaez C, Blomkalns A, Safdar B. Making Promotion Count: The Gender Perspective On Behalf of the Society for Academic Emergency Medicine Equity Research Taskforce. Acad Emerg Med. 2019 Jan 9. 4. Butkus R, Serchen J, Moyer DV, Bornstein SS, Hingle ST. Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians. Annals of Internal Medicine 2018;168:721 5. Carr PL, Gunn CM, Kaplan SA, Anita R, Freund KM. Inadequate progress for women in academic medicine: findings from the national faculty study. Journal of Women’s Health. 2015; 24: 190–9. 6. Carr PL, Gunn C, Raj A, Kaplan S, Freund KM. Recruitment, Promotion, and Retention of Women in Academic Medicine: How Institutions Are Addressing Gender Disparities. Womens Health Issues. 2017 May - Jun;27(3):374-381. 7. Gottlieb M, Lotfipour S, Murphy L, Kraus CK, Langabeer JR, II, Langdorf MI, Scholarship in Emergency Medicine: A Primer for Junior Academics Part I: Writing and Publishing. West J Emerg Med. 2018 Nov; 19(6): 996–1002. 8. Kaatz A, Carnes M. Stuck in the out-group: Jennifer can’t grow up, Jane’s invisible, and Janet’s over the hill. J Womens Health (Larchmt). 2014 Jun;23(6):481-4. 9. Langabeer J, Michael Gottlieb M, Chadd CK, Lotfipour S, Murphy LS, Langdorf MI. Scholarship in Emergency Medicine: A Primer for Junior Academics: Part II: Promoting Your Career and Achieving Your Goals.  West J Emerg Med.  2018 Jul; 19(4): 741–745. 10. Madsen TE, Linden JA, Rounds K, Hsieh YH, Lopez BL, Boatright D, Garg N, Heron SL, Jameson A, Kass D, Lall MD, Melendez AM, Scheulen JJ, Sethuraman KN, Westafer LM, Safdar B. Current Status of Gender and Racial/Ethnic Disparities Among Academic Emergency Medicine Physicians. Acad Emerg Med. 2017 Oct;24(10):1182-1192. 11. Murphy LS, Kraus CK, Lotfipour S, Gottlieb M, Langabeer JR, Langdorf MI. Measuring Scholarly Productivity: A Primer for Junior Faculty. Part III: Understanding Publication Metrics West J Emerg Med. 2018 Nov; 19(6): 1003–1011. 12. Nunez-Smith M, Ciarleglio MM, Sandoval-Schaefer T, Elumn J, Castillo-Page L, Peduzzi P, Bradley EH. Institutional variation in the promotion of racial/ethnic minority faculty at US medical schools. American Journal of Public Health. 2012; 102: 852–8. 13. Paulus JK, Switkowski KM, Allison GM.  Where is the leak in the pipeline? Investigating gender differences in academic promotion at an academic medical centre.  Prospect Med Ed 2016;5:125-128 14. Westring A, McDonald JM, Carr P, Grisso JA. An integrated framework for gender equity in academic medicine. Academic Medicine. 2016; 91: 1041–4. 
 15. Yu PT, Parsa PV, Hassanein O, Rogers SO, Chang DC. Minorities struggle to advance in academic medicine: A 12-year review of diversity at the highest levels of America’s teaching institutions. J Surg Res. 2013; 182(2): 212-8.

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Chapter 5

Gender Specific Needs and Wellness

Amy Zeidan, MD, Clinical Instructor, University of Kentucky and Komo Gursahani, MD, MBA, Assistant Chief, Emergency Medicine and Associate Professor of Emergency Medicine, Washington University School of Medicine. Edited by Michelle Lall, MD, MHS and Caitlin Ryus, MD, MPH.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[x] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[x] transitioning from community practice to academic emergency medicine

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Pregnancy CURRENT LITERATURE ON THIS TOPIC

Studies show that female physicians often postpone pregnancy due to perceived threats to their careers1 and are more likely to have problems with infertility and complications during pregnancy.2 Job-specific factors, including rotating shift work, night shifts, and physically demanding work, present additional special challenges for female EM physicians during pregnancy. Additionally, in the postpartum period, balancing childcare, domestic responsibilities, and integration back to work can be challenging. Although there is more support now for motherhood during residency than in prior years, residents still report significant challenges during training, including inadequate maternity leave, undesired early cessation of breastfeeding, and perceived negative attitudes

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related to pregnancy.3 Further, program directors assume parenthood affects the training and well-being of female residents more adversely than male residents.4 Interestingly, a study that explores peer evaluation revealed that peer evaluation scores were lower after pregnancy for female residents.5 Some of these findings differ based on specialty, for example, surgical residents reported having less support than non-surgical residents. Notably, residents in programs with female leadership experienced a more supportive environment during their pregnancies. Relevant legal and policy facts related to pregnancy and the workplace: Title VII of the Civil Rights Act of 1964/Pregnancy Discrimination Act6: 1. Discrimination on the basis of pregnancy, childbirth, or related medical conditions constitutes unlawful sex discrimination. 2. Women affected by pregnancy must be treated similarly to other applicants and employees who are similar in terms of their ability to work.


STRATEGIES THAT ADDRESS THE DISPARITIES

• The Ottawa Hospital Department of Emergency Medicine developed a working group to provide recommendations7 for supporting pregnancy among female physicians. They suggest a departmental guide for those who wish to become pregnant or are pregnant. They further recommend a graduated reduction in physically taxing shifts near term, with a 25 percent reduction in shift volume during the third trimester, a reduction of night shifts after 24 weeks, and a reduction of “resuscitation” shifts after 28 weeks. If compensation is tied to relative value units, it is critical that the pregnant woman understands the potential earnings impact of accommodations, and she must be agreeable to having such modifications. • Specifically, for departments with residency programs, recommendations8 exist for accommodating pregnant residents. Many of the recommendations provide suggestions for appropriate scheduling during and after pregnancy to ensure the safety of the pregnant resident with minimal effect on other residents. For example, scheduling electives or modifying rotations during the third trimester that have minimal physical demands and instituting night shift requirements to support healthy pregnancies. Programs should also develop clear policies for making-up for absences and the number of shifts and times this includes.

ACTIONABLE STEPS YOUR GROUP CAN TAKE

• Develop a working group in your department/institution to create a guide or policy for pregnant women. Incorporate residency leadership in the development to ensure the guide includes both faculty and residents. • Consider an event that allows for a question and answer period or panel discussion to talk over strategies for pregnancy. Include parents who have navigated the experience. • Encourage mentor-mentee relationships specifically for pregnancy to ensure that pregnant females are supported. • Get the word out to department leaders as well as residents concerning the law as it relates to pregnancy in the workplace. Consider conducting internal surveys to measure the attitudes towards pregnancy within your shop.

HOW TO MEASURE SUCCESS ON THIS TOPIC

• Survey attitudes regarding pregnancy before and after the implementation of a policy or guide. • Evaluate the number of departments that adopt similar policies/guides, with a goal of hospital-wide adoption of the policy. • Regularly measure attrition rates for women of childbearing age and those who have children and address decreases by creating a culture of inclusiveness.

Resources Used for Discussing This Topic 1. S  tentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and childbearing among American female physicians. Journal of Women’s Health. 2016;25(10):1059-1065. 2. Rangel EL, Smink DS, Castillo-Angeles M, Kwakye G, Changala M, Haider AH, Doherty GM. Pregnancy and motherhood during surgical training. JAMA Surgery. 2018;153(7):644-652 3. Adesoye T, Mangurian C, Choo EK, Girgis C, Sabry-Elnaggar H, Linos E. Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey. JAMA Internal Medicine. 2017;177(7):1033-1036. 4. Sandler BJ, Tackett JJ, Longo WE, Yoo PS. Pregnancy and parenthood among surgery residents: results of the first nationwide survey of general surgery residency program directors. Journal of the American College of Surgeons. 2016;222(6):1090-1096. 5. Krause ML, Elrashidi MY, Halvorsen AJ, Furman DS, Oxentenko AS. Impact of pregnancy and gender on internal medicine resident evaluations: a retrospective cohort study. Journal of General Internal Medicine. 2017;32(6):648-653. 6. T  itle VII of the Civil Rights Act of 1964/Pregnancy Discrimination Act 7. Calder LA, Cwinn AA. Accommodating pregnant emergency physicians. Canadian Journal of Emergency Medicine. 2013;16(4):259-261. 8. Lewin M. Pregnancy, Parenthood, and family leave during residency. Annals of Emergency Medicine. 2003;41(4): 568-573. 9. P  hysician Moms Group (Facebook) 10. O  n Pregnancy and Doctoring (FemInEm) 11. American College of Obstetricians and Gynecologists. Employment considerations during pregnancy and the postpartum period. ACOG Committee Opinion. 2018;131(4):115-123.

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Family Leave CURRENT LITERATURE ON THIS TOPIC

Family leave is generally defined according to the Family and Medical Leave Act of 1993 (see below) and includes time taken off work for the purpose of caring for oneself, a child, or a family member. Most U.S. workers take time off work for the following reasons, given in order: 1) to care for a personal health problem, 2) to care for a new child, 3) to care for a family member with health problems. Many companies have created their own family leave policies, offering paid time off as well as other benefits. The last reference listed in this section is a link to an article that summarizes the maternity policies of major emergency medicine contract management groups. Family Medical Leave Act (FMLA) 1. If an employee has worked for 12 months prior, and there are at least 50 employees within 75 miles of the workplace, they are eligible for 12 weeks of unpaid leave for the care of themselves for a health problem, a new child or a family member whereas family is defined as spouse, child under 18 or parent with some exceptions; also applies to adoption/foster care. 2. Note that FMLA only takes effect if one has worked for twelve months (1250 hours within 12 months). The American Medical Association (AMA) encourages the implementation of parental, family, and medical necessity leave for physicians and suggests that guidelines include the following elements:

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• leave policy for birth or adoption • duration of leave allowed before and after delivery • category of leave credited (e.g., sick, vacation, parental, unpaid leave, short term disability) • whether leave is paid or unpaid • whether provision is made for continuation of insurance benefits during leave and who pays for premiums • whether sick leave and vacation time may be accrued from year to year or used in advance • extended leave for resident physicians with extraordinary and long-term personal or family medical tragedies for periods of up to one year, without loss of previously accepted residency positions, for devastating conditions such as terminal illness, permanent disability, or complications of pregnancy that threaten maternal or fetal life • how time can be made up in order for a resident physician to be considered board eligible • what period of leave would result in a resident physician being required to complete an extra or delayed year of training • whether time spent in making up a leave will be paid • whether schedule accommodations are allowed, such as reduced hours, no night call, modified rotation schedules, and permanent part-time scheduling Many emergency medicine program maternity leave policies do not provide guidance for the scope of family leave as described above. While ACEP has made a concise family leave policy available, the policy does not address all of the elements recommended by the AMA. SAEM and ABEM have yet to make any family leave recommendations.


A study by MacVane and colleagues1 that evaluated maternity leave policies among EM departments found that these policies vary significantly in terms of duration and compensation. Paid parental leave is typically institution-dependent. It can be very difficult to obtain information about parental leave policies during family planning stages, and in some cases this information may not even exist. Further, women are reluctant to ask about parental leave during the negotiation process for fear this may create a bias against them. A recent report2 found that of the 12 top U.S. medical schools, all have a parental leave policy for faculty, yet the mean length of paid family leave for faculty physicians at these 12 medical schools in 2016–2017 was 8.6 weeks. Of the corresponding institution-level policies for residents at the 15 GME sponsoring programs affiliated with those institutions, seven out of 15 offer an average of 5.7 weeks of paid parental leave.3 The ACGME has not endorsed a standardized parental leave policy for trainees and defers to the home institution to abide by federal and state regulations.

STRATEGIES THAT ADDRESS THE DISPARITIES

• Develop standardized family leave policies for institutions that align with other industries, and advocate for their endorsement by specialty societies as well as the ACGME. • During negotiations, ask about sick time, vacation, medical leave of absence. • For parental leave, consider asking for three months of paid leave; ask (your immediate supervisor) about this as soon as possible as FMLA typically needs to be 30 days in advance unless it’s an emergency. • Know your institutional resources which may include the following offices: human resources, faculty affairs, diversity, and women.

ACTIONABLE STEPS YOUR GROUP CAN TAKE

• Survey your group to determine the scope of these issues within your department or interdepartmentally within your institution. • Assemble a task force to develop a departmental family leave policy for your group and residency that addresses problems identified on that survey. • Create leave-sharing programs or guidelines for developing a bank of hours.

• Remember that residents must work 46 weeks per year of training to be eligible to sit for the ABEM board certification examination. • Ask your department and institution to consider using the term “paid parental leave” rather than “maternity leave” as advocating for both parents and removing gender from terminology helps to ensure uniform policies are not viewed as a “women’s issues.”

HOW TO MEASURE SUCCESS ON THIS TOPIC

Monitor attrition of all faculty during each phase of their family lives (pre-pregnancy, pregnancy, preschool, school aged, college, beyond).

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• Study the association between the existence of a parental leave policy and retention of female faculty physicians • The study referred to in the background (Raino) only surveyed 12 medical schools and their affiliated 15 GME programs; a more comprehensive idea of the landscape of this issue across the country is warranted  

Resources Used for Discussing This Topic 1. MacVane CZ, Fix ML, Strout TD, Zimmerman KD, Block RB, Hein CL. Congratulations, you’re pregnant! Now about your shifts…: The state of maternity leaves attitude and culture in EM. Western Journal of Emergency Medicine. 2017;18(5):800-810. 2. Riano NS, Linos E, Accurso EC, Sung D, Linos E, Simard JF, Mangurian C. Paid family and childbearing leave policies at top US medical schools. JAMA. 2018;319(6):611-614. 3. Magudia K, Bick A, Cohen J, Ng, TSC, Weinstein D, Mangurian C, Jagsi R. Childbearing and family leave policies for resident physicians at top training institutions. JAMA. 2018;320(22):23722374. 4. The Family and Medical Leave Act 5. Blair, JE, Mayer AP, Caubet SL, Norby SM, O’Connor MI, Hayes SN. Pregnancy and parental leave during graduate medical education. Academic Medicine. 2016 Jul;91(7):972-8. 6. Lewin, MR. Pregnancy, parenthood, and family leave during residency. Annals of Emergency Medicine 2003; 41(4); 568-573. 7. E  P Groups & Parental Leave: Where We Stand in 2018 (includes a summary of major contract management emergency medicine companies’ paternal leave policies)

• Create a document that clearly outlines your benefits regarding sick time, vacation, medical leave, compensatory time off as it relates to family planning; ensure this document is given to all potential new hires.

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Breastfeeding CURRENT LITERATURE ON THIS TOPIC Current data1 indicate that a large number of female physicians initiate breastfeeding, but cessation rates are high. Many cite work-related barrier including scheduling challenges and inadequate access to space and storage, as reasons for cessation. Studies have demonstrated benefits to employers and employees who support and engage in lactation programs. One study comparing breastfeeding and formula feeding among employed mothers found that in the breastfeeding group infants had fewer illnesses which resulted in less maternal absenteeism.2 Another study evaluated corporate lactation programs and found that mothers enrolled in employer-sponsored lactation programs continued breastfeeding for at least six months.3

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The U.S. Health Resources and Services Administration and Maternal and Child Health Bureau developed an initiative titled, The Business Case for Breastfeeding,4 which provides a tool kit for employers needing assistance in developing lactation support services. In addition, several states have legislation that encourages breastfeeding support in the workplace and five states have specific legislation requiring employers to accommodate breastfeeding mothers. These can be viewed at The United States Breastfeeding Committee website.5 For female physicians, conference attendance supports the promotion and advancement for women and offers an opportunity to present work and network with individuals outside of one’s institution. Historically, few conferences have offered on-site childcare or lactation space, but new insights6 provide recommendations for family-friendly conferences that address these issues. Fair Labor Standards Act 1. Nursing moms can pump for up to a year 2. U.S. Equal Opportunity Commission resources7


STRATEGIES THAT ADDRESS THE DISPARITIES

Current data highlight high cessation rates among female physicians; the following strategies may help: • Ensure adequate time for maternity leave time. • Support strategies and programs that promote breastfeeding duration (early cessation of breastfeeding is common; employees who participate in lactation programs report improved workplace satisfaction and fewer missed workdays). • Accommodate schedules to allow for pumping during clinical responsibilities (e.g. non-clinical duties upon initial return to work, protected time for feeding/ pumping, etc.). • Allocate dedicated breastfeeding space (including storage) and consider on-site daycare. • Develop an official department or hospital policy and/ or program to support breastfeeding. • When planning conferences, consider on-site lactation space, refrigeration, and scheduled breaks for pumping.

ACTIONABLE STEPS YOUR GROUP CAN TAKE

• Evaluate current space for breastfeeding and on shift coverage. Consider the size, amenities (including fridge, computer), privacy, location to clinical space, access to “overhead alerts” or phone calls while pumping • Consider developing a policy or employer-sponsored lactation program that can be used hospital-wide

or department-wide. Refer to The Business Case for Breastfeeding and The United States Breastfeeding Committee website, and the Office on Women’s Health to help with data, rationale, and sample policies.8 • Hold a journal club event to review specific articles on breastfeeding, such as Barriers to Breastfeeding or Comparison of maternal absenteeism and infant illness rates among breast-feeding and formula-feeding women in two corporations.

HOW TO MEASURE SUCCESS ON THIS TOPIC

• Evaluate breastfeeding initiation and cessation rates before and after an intervention. • Calculate the number of departments that adopt breastfeeding policies.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• Explore a sustainable coverage model for pumping mothers on shift, including financial components and long-term outcomes. • Explore how to develop and implement an employersponsored lactation program that is hospital-wide or department-specific. • Survey to evaluate current unmet needs and workplace barriers; refer to Cantu study survey questions as a template.

Resources Used for Discussing This Topic 1. C  antu RM, Gowen MS, Tang X, Mitchell K. Barriers to breastfeeding. Breastfeeding Medicine. 2018;13(5):1-5. 2. Cohen R, Mrtek MB & Mrtek RG. (1995). Comparison of maternal absenteeism and infant illness rates among milk expression among breastfeeding and formula-feeding women in two corporations. American Journal of Health Promotion. 1995;10(2):148-153 3. Ortiz, J, McGilligan K, & Kelly P. (2004). Duration of breast milk expression among working mothers enrolled in an employer-sponsored lactation program. Pediatric Nursing. 2004;30(2):111-119. 4. T  he Business Case for Breastfeeding 5. U  nited States Breastfeeding Committee and the U.S. Department of Health & Human Services Business Case for Breastfeeding Program 6. W  hat’s The Etiquette For Breastfeeding At A Work Conference? 7. U  .S. Equal Opportunity Commission Pregnancy Discrimination 8. P  olicy for Supporting Breastfeeding Employees 9. P  hysician mothers are a high-risk breastfeeding group

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Sexual Harassment CURRENT LITERATURE ON THIS TOPIC

Gender-based harassment and discrimination are still persistent in academic medicine among both faculty and trainees1 and female faculty continue to report higher rates of sexual harassment than male faculty. Studies that evaluate sexual harassment among female medical trainees indicate that almost half of female medical students report being sexually harassed.2 Sadly, women often experience retaliation for reporting sexual harassment; they are also more likely to experience symptoms of depression, stress and anxiety.3

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STRATEGIES THAT ADDRESS THE DISPARITIES

• Use standardized and validated instruments such as the Report on the AAU Campus Climate Survey on Sexual Assault and Sexual4 to survey employees and assess current problems.5 • Educate on types of appropriate behavior, including bystander interventions. • Adopt a policy that is clear, consistent, and transparent; include guidelines for behaviors, investigative processes, support for those affected, and punishment for perpetrators (Title IX mandates that all formal complaints are investigated). In developing a policy, eight key questions6 should be asked.


• Incorporate a reporting process that protects those who are reporting and is easy to understand and follow. Ideally, the reporting process should occur outside of the department to eliminate power differentials and/or conflicts of interest.7

ACTIONABLE STEPS YOUR GROUP CAN TAKE

•A  wareness. Consider an event to educate faculty/ residents on how to respond to behavior that is perceived to be offensive, including suggested language and phrasing (e.g., “I’m sure you didn’t mean it this way, but when you told that joke, it made me and others like me feel uncomfortable and disrespected.”). Discuss reporting mechanisms and real-time responses. Consult your HR department and consider inviting a guest consultant with the expertise to provide recommendations. •S  tudy tools. Consider the use of validated tools such as Report on the AAU Campus Climate Survey on Sexual Assault and Sexual or external consultant groups to evaluate the current needs of the department.

•P  olicy Intervention. Create a working group to develop a policy for the department (if one does not exist) or evaluate the current process to ensure it is effective. • Identify. Select an individual in your group that can serve as a confidential representative for residents/ faculty who experience a negative situation and can connect them to appropriate and helpful resources. Title IX requires medical schools and hospitals to have clear policies regarding sexual discrimination. These specific policies must state whether staff members are mandated reporters versus confidential employees. Consider having an individual in your group that is a confidential representative rather than a mandated reporter, but who can connect individuals to a mandated reporter if desired.8

HOW TO MEASURE SUCCESS ON THIS TOPIC

• If a validated tool is used, evaluate the tool pre- and post-intervention. • Pre/post survey on awareness if policy or reporting improvements are made

Resources Used for Discussing This Topic 1. Jagsi R, Griffith KA, Jones R, Perumalswami CR, Ubel P, Stewart A. Sexual harassment and discrimination experiences of academic medical faculty. JAMA. 2016;315(19):2120-2121. 2. Fnais N, Soobiah C, Chen MH, Lillie E, Perrier L, Tashkhandi M, Straus Se, Mamdani M, Al-Omran M, Tricoo AC. Harassment and discrimination in medical training: a systematic review. Academic Medicine. 2015;89(5):817-827. 3. Bates CK, Jagsi R, Gordon LK, Travis E, Chatterjee A, Gillis M et al. It is time for zero tolerance for sexual harassment in academic medicine. Academic Medicine. 2018;93(2):163-165. 4. R  eport on the AAU Campus Climate Survey on Sexual Assault and Sexual Misconduct 5. van Dis, J, Stadum L, Choo EK. Sexual harassment is rampant in health care. Here’s how to stop it. Harvard Business Review. 6. S  exual Harassment in Today’s Workplace 7. Choo EK, van Dis J, Kass D. Times up for medicine? Only time will tell. New England Journal of Medicine. 2018;379(17):1592-1593. 8. Manning M. What if a resident of medical student is raped? Hospitals’ and academic medical centers’ Title IX obligations. AMA Journal of Ethics. 2018;20(1):3-9.

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Wellness/Burnout in Female Physicians CURRENT LITERATURE ON THIS TOPIC

More than half of U.S. physicians are experiencing substantial symptoms of burnout. Physicians working in specialties at the front lines of care (e.g. emergency medicine, family medicine, general internal medicine, neurology) are at the highest risk for burnout. After controlling for work hours and other factors, burnout is nearly twice as prevalent among physicians as among U.S. workers in other fields.1 Between 2011 and 2014, the prevalence of burnout increased by nine percent among physicians while remaining stable in other U.S. workers. Several studies have also found a high prevalence of burnout and depression among medical students and residents, with rates higher than those of age-similar individuals pursuing other careers. According to the 2019 Medscape National Report on Physician Burnout, Depression & Suicide,2 a survey completed by more than 15,000 physicians, 50 percent of women physicians acknowledged burnout compared to 39 percent of men.

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Why is this an important topic to cover in a women’s group? Women physicians have a higher relative risk of suicide. Evidence suggests that male doctors have a 40 percent higher chance of committing suicide compared to the general population, but female doctors have a risk that is 2-3 times higher. A male doctor’s relative risk of suicide is 1.4 times the general population while female doctors have a 2-3 times relative risk of suicide.3 Women physicians are associated with better patient outcomes. There is evidence that men and women may practice medicine differently. Literature has shown that female physicians may be more likely to adhere to clinical guidelines, provide preventive care more often, use more patient-centered communication, perform as well or better on standardized examinations, and provide more psychosocial counseling to their patients than do their male peers. Hospitalized Medicare patients cared for by female internists had statistically significant lower mortality and hospital readmissions compared to those cared for by male internists and controlled for various factors.4 A 2018 study5 that examined the difference in outcomes by gender of patients presenting with acute myocardial infarction (AMI) and the gender of their emergency physician found that female patients with AMI


had lower survival rates if treated by a male physician versus being treated by a female physician. Women experience burnout differently than men. According to Christina Maslach, a renowned burnout expert, the three dimensions of burnout are emotional exhaustion, depersonalization (cynicism), and lack of a personal sense of accomplishment. An international review examining the relationship of these three dimensions in women versus men revealed that women tend to score higher in emotional exhaustion and men higher in depersonalization across multiple types of professions and countries. Therefore, in women, emotional exhaustion may be the first stop on the path to burnout.6,7,8

STRATEGIES THAT ADDRESS THE DISPARITIES

Individual interventions8,9

• Four domains of resilience: emotional (calming techniques), mental (mindfulness), spiritual (knowing one’s purpose) and physical (including exercise and proper sleep) • Mindfulness-based stress-reduction techniques, educational interventions targeting a clinician’s communication skills and self-confidence, exercise or a combination of all • Physician-directed interventions combined at the organizational level had longer-lasting positive effects (for 12 months or more) than at the individual level alone

Physician leader interventions • Measure it and try to continuously improve it o Maslach Burnout Inventory (full or two-item version) o Physician Job Satisfaction Score o Brief Fatigue Index o Utrecht Work Engagement Scale o Mayo Physician Well Being Index • Four behaviors of physician leaders that promote job satisfaction and well-being in the physicians they lead: o Transparency in communication o Humble inquiry (showing interest, curiosity, and vulnerability to build a collaborative relationship) o Aiding in professional development (coaching/ mentoring) o Acknowledging the contributions of each physician they lead • Institutional o Address workload and scheduling issues o Measure burnout across all medical staff and continuously work to improve it o Optimize physician interaction with technology and the electronic health record o Create a common work/rest space for all medical staff (burnout rates decrease when physicians feel they are being taken care of) o Reconsider incentivized compensation (some studies show these plans may accelerate burnout in physicians)

Physicians working in specialties at the front lines of care (e.g. emergency medicine, family medicine, general internal medicine, neurology) are at the highest risk for burnout.

Evidence suggests that male doctors have a 40 percent higher chance of committing suicide compared to the general population, but female doctors have a risk that is 2-3 times higher

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ACTIONABLE STEPS YOUR GROUP CAN TAKE

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• Measure the burnout baseline of your group and assess by gender.

• Investigate the relationship between clinical informatics and burnout rates, EHR optimization and burnout rates.

• Create an action plan to move that measure down.

• Investigate the demands faced by women (e.g. childcare and rearing, domestic responsibilities, financial responsibilities, etc.) that may be accelerating their burnout.

o Implement individual programs as described above. o Encourage physician leaders to use annual reviews, be transparent, ask how the group can meet individuals’ needs and promote meaning in their work, and improve their workload and schedules. o Participate in electronic health record (EHR) optimization and/or improving physician’s access to technological solutions to EHR pains.

• Examine the effects of organizational programs (e.g., changing incentive-based compensation to salary compensation) on burnout rates.

HOW TO MEASURE SUCCESS ON THIS TOPIC

Choose a burnout scale and survey at regular intervals to reduce burnout as described above.

To provide feedback and recommendations on these topics, email the authors at amy.josephine.zeidan@emory.edu and kgursahani@wustl.edu; Subject: AWAEM Toolkit: Gender Specific Needs and Wellness.

Resources Used for Discussing This Topic 1. K  levos GA, Nisreen SE. In Search of the Most Effective Interventions for Physician Burnout. 2. M  edscape National Report on Physician Burnout, Depression & Suicide 3. S  chernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment. American Journal of Psychiatry. 2004;161(12):2295-2302. 4. T  sugawa Y, Anupam JB, Figueroa JF. Comparison of hospital mortality & readmission rates for Medicare patients treated by male vs female physicians. JAMA Internal Medicine. 2017;177(2):206-213. 5. G  reenwood BN, Carnahan S, Huang L. Patient–physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci. 2018 6. H  oukes I, Winants Y, Twellaar M, Verdonk P. Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs.  A three-wave panel study. BMC Public Health. 2011;11(240):1-13 7. McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K, SGIM Career Satisfaction Study Group. Work lives of women physicians. Results from the physician work life study. Journal of General Internal Medicine. 2000;15(6):372-380. 8. P  hysician Burnout Presents Differently in Male and Female Doctors (The Happy MD) 9. S  hanafelt TD, Dyrbye LN and West CP. Addressing physician burnout: the way forward. JAMA. 2017;317(76):901-902. 10. G  autam Mamta. Women in medicine: stresses and solutions. West Journal of Medicine. 2001;174(1):37-41.

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Chapter 6

Mentoring

Kat Ogle, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine The George Washington University. Edited by Dina Himelfarb, MD.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[x] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[x] transitioning from community practice to academic emergency medicine

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CURRENT LITERATURE ON THIS TOPIC

Current literature highlights the importance of strong mentor-mentee relationships for several reasons, most notably, that gender disparities affect multiple aspects of our lives as women in academics. In 2016, JAMA published a study 1 which revealed a salary difference between men and women of $19,878. This study adjusted for a multitude of factors which include age, training, academic rank, medical specialty, research funding, publications, productivity and several other factors for physicians who were employed by public universities. In the 2018 Doximity Physician Compensation Report,2 women physicians were found to earn $105,00 less in salary per year on average. Further, there is no single medical specialty in which women earn more than their male colleagues. Proper mentorship has the potential to provide support and guidance to new women physicians and physicians changing practice environments when it comes to negotiating salary, protected time, administrative support, and systematic support for academic endeavors. When it comes to academic promotion, the AAMC highlights in their 2014 report3 the “leaky pipeline” which yields a paucity of women physicians remaining or advancing in academics. Women physicians make up 16 percent of medical school deans, 21 percent of full professors, and 38 percent of medical school faculty. Mentors can potentially combat this leaky pipeline through thoughtful engagement with their mentees on the key steps which need to be taken to advance one’s academic position and leverage the work they are doing into scholarship. Mentor roles should increasingly foster conversations in which mentees can critically examine

the work being done and parlay it into meaningful scholarship. Further, mentors can amplify and highlight the successes of their mentors and foster recognition on an institutional, regional, national, or even international platform. Of the more than 1000 leadership positions in the top 50 NIH funded medical schools, only 13 percent are filled by women physicians.4 Without more women physicians in leadership positions, there will be fewer role models for what is turning out to be, according to the AAMC in 20175 and 2018,6 the majority of medical school matriculants. Strong mentoring relationships and networks require the development and maintenance of environments in which women physicians garner support from their colleagues and institutions to foster their professional development, growth, and career satisfaction. Areas of interest for the woman physician in academics include but are not limited to: research and publication, obtaining research funding to further scholarly inquiry, developing educational programming, furthering advocacy in their areas of interest, seeking advanced degrees to broaden skill sets, academic advancement with promotion and tenure, appointment to leadership positions in local institution, and regional, national or international opportunities.7 Given the depth and breadth of career goals for women physicians, it is incumbent upon mentors to work in concert with their mentees, to review professional goals, highlight limitations, and discuss pitfalls encountered in their own experiences as well as those into which the less experienced academician may not have insight. This is a reciprocal relationship in which each party is responsible to the other and the needs may change over time, requiring flexibility and creativity as well as professional investment. According to the AAMC Mentoring Toolkit for Mentors, mutual roles and responsibilities of mentors and mentees can be found below:

Roles and Responsibilities in the Mentor/Mentee Relationship Mentor

Mentee

Mutual respect

Establish the goals of the relationship

Mutual commitment

Discuss the scope of the relationship (boundaries)

Maintain confidentiality

Frequency and format for meetings, including preferences for communication

Identification of shared goals

Demonstrate commitment

High standards

Maintain confidentiality

Realistic expectations

Seek mutual feedback, respect and trust

Effective communication Commitment to a regularity of interaction Adapted from AAMC Toolkit for Mentors7

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These measures of gender equity are at the heart of the importance of establishing strong and supportive mentorship networks for women physicians. Having supportive mentorship networks will ensure that women physicians have a clear understanding of their market worth in order to close the gender gap in pay, provide clear guidelines regarding the steps required and paths which may be taken to advance one’s academic career, and highlight the potential benefits of taking on leadership roles on a local, regional, national, or international platform. It is key to have more women physicians in leadership positions as coaching and sponsorship are slightly different methods by which we can further the advancement of women in medicine.8

STRATEGIES THAT ADDRESS THE DISPARITIES

• Start the difficult conversations in your institution about the gender pay gap, family leave, emergency medical leave for aging parents and family members, and flexible scheduling. • Highlight key guidelines for your institution regarding academic promotion and tenure tracks. • Encourage women faculty to step out of their comfort zones, take on leadership roles, and ensure there is a safety net to support them when challenges arise.

Current literature highlights the importance of strong mentor-mentee relationships for several reasons, most notably, that gender disparities affect multiple aspects of our lives as women in academics.

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• Foster a supportive environment which limits gender inequity and microaggressions between colleagues as well as patients and families. • Advocate for and protect women faculty from taskoriented opportunities and encourage engagement with leadership and administrative opportunities. • Regularly engage faculty, residents, and medical students in development sessions to address intrinsic bias. • Nominate your deserving women faculty, residents, and medical students for awards and recognition. • Amplify your women faculty, residents, and medical students for their successes, publications, and opportunities, as they are unlikely to amplify themselves. • Connect your women faculty with other colleagues who can support their academic goals and endeavors. • Develop your junior women faculty in networking skills and highlight the importance of this to their professional development and camaraderie. • Work within your institution and national organizations to write policies that acknowledge gender equity as a priority with a strategic plan which aligns with it. • Study it by performing a needs assessment, academic rank, academic promotion, social media impact, publications, alternative media development, and wellness metrics • Support/develop mentoring skills at all levels, including peer mentoring skills and micro-mentoring opportunities.

• Amplify women physician colleagues within your department during regional and national meetings, on social media, and within networks.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• Prior to implementation of any program, obtain baseline metrics on all the members of your faculty group, including salary, academic rank, grant funding, publications, and wellness metrics. • Analyze the metrics for areas of inequity. • Create a task force for each area of inequity in order to: a) educate and draw attention to any potential intrinsic or explicit biases which may be at play; b) compare metrics to national data in each of the focus areas; c) generate institutional support aligned with strategic plans/missions by contacting deans, chairs, and other leaders; d) seek funding to support your research and efforts. • Collect new data following implementation of the aforementioned strategies. • Publish. For areas in which there were minimal improvements in equity, perform root cause analysis to identify further barriers and generate new solutions. • Ensure involvement of medical students, residents, fellows, and faculty in each of these areas.

To provide feedback and recommendations on this topic, email the author at katogle@gwu.edu; Subject: AWAEM Toolkit: Mentoring Feedback

Resources Used for Discussing This Topic ONLINE RESOURCES • AAMC Mentoring Toolkit for Mentors • AAMC: GWIMS Mentoring Women Toolkit for Mentees • AAMC Group on Women in Medicine and Science Organizations • AWAEM: Academy for Women in Academic Emergency Medicine • AAWEP: American Association of Women Emergency Physicians • AAEM: American Academy of Emergency Medicine: Women in Emergency Medicine Section Literature 1. J ena AB, Olenski AR, Blumenthal DM. Sex Differences in Physician Salary in US Public Medical Schools. JAMA Intern Med. 2016;176(9):1294– 1304. doi:10.1001/jamainternmed.2016.3284 2. D  oximity Blog. 2018, March 27. 2018 Doximity Physician Compensation Report. Blogpost. Retrieved from https://blog.doximity.com/ articles/doximity-2018-physician-compensation-report 3. L autenberger DM, Dandar VM, Raezer CL and RA Sloan. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership. 2014. 4. W  ehner Mackenzie R, Nead Kevin T, Linos K, Linos E. Plenty of moustaches but not enough women: cross sectional study of medical leaders BMJ 2015; 351 :h6311 5. G  licksman E. 2017, December 19. A First: Women Outnumber Men in 2017 Entering Medical School Class. AAMC News. 6. A  AMC. 2018, December 4. Women Were Majority of U.S. Medical School Applicants in 2018. AAMC News. 7. L akoski J & Voytko ML. AAMC GWIMS Toolkit: Chapter 7: Mentoring Women- A Guide for Mentors. 8. T  ravis EL. 2018, January 16. Academic Medicine Needs More Women Leaders. AAMC News.

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Chapter 7

Grant Writing

Marina Del Rios Rivera, MD, MSc, Associate Professor, Department of Emergency Medicine College of Medicine, University of Illinois at Chicago. Edited by Tracy Madsen, MD, ScM.

THIS TOPIC MAY BE OF INTEREST TO YOU IF YOU ARE:

[x] a medical student interested in academic emergency medicine [x] a resident interested in academic emergency medicine [x] junior faculty in academic emergency medicine [x] mid-career faculty in academic emergency medicine [x] senior faculty in academic emergency medicine

[x] transitioning from community practice to academic emergency medicine

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CURRENT LITERATURE ON THIS TOPIC

E When considering the patient burden and influence of clinical emergency care, emergency care research is already vastly underfunded. This puts women in academic EM at a significant disadvantage compared to other specialties. Emergency medicine has the lowest percentage of NIH-funded principal investigators per full-time faculty (1.9 percent) of all clinical academic departments except family medicine.1 One study2 from 2016 noted that the clinical research investment of NIH on emergency care research is $61 million per year, which pales in comparison to the $233 million invested in sleep disorders and $494 million spent on rehabilitation research. Moreover, only one-third of emergency care research is conducted by principal investigators with primary appointments in emergency medicine2,3 and less than half of the training slots in National Heart, Lung, and Blood Institute K12 emergency care research training programs were filled by emergency medicine– trained investigators.1,4 As a result, 49 percent of academic emergency departments have no R01-funded researchers, and only 15 percent have three or more R01 funded researchers.5 The absence of successfullyfunded role models within academic EM is one of the most frequently reported challenges for junior faculty applying for grant funding.5 Because of the low proportion of NIH-funded research in emergency care, there is a paucity of literature addressing gender disparities in research funding for academic emergency medicine faculty. However, there is a wealth of evidence to suggest that there are significant gender gaps in grant funding in academic medicine overall. One study from Harvard6 noted that although women enter the academic pipeline in about equal numbers as men (46 percent of instructors), they are underrepresented in the more senior academic ranks. This gap can be explained in part by the lower proportion of women who pursue and secure research funding.7 Gender differences in grant application behavior at the lower academic ranks may contribute to the gender disparity in grant funding in academic medicine.8 Female physician-scientists are applying in equal numbers and are nearly equal in

their funding success rates in obtaining early career development grants such as training grants (e.g., T32) and early career development grants (e.g. K22/23) in human subjects research.9,10 However, nearly half of women who are eligible to pursue career development grants in basic science research (e.g., K08) are not applying, and there is a significant loss of eligible applicants at the transition from loan repayment programs to career development grants (e.g. K23) and independent funding.10 A large fraction of women leave the NIH-funded career pipeline at the transition to independence.10,11 One study of NIH investigators11 who received funding between 1991 and 2015 noted that only 31 percent of principal investigators were women. The study also noted that women who are successful at receiving a first major NIH award have similar longevity to men in research careers, highlighting the importance of retaining women when they are transitioning through career milestones. While men and women have near equal funding success when controlling for rank,10 significant disparities remain with regards to the dollar amounts and the number of years of funding awarded.8,9,12,13 Women are awarded significantly less money than men, although the percentage of funds requested are the same. In other words, grants submitted by women request lower funding amounts than grants submitted by men.8,14 Moreover, men apply more frequently to the NIH, which awards higher dollar amounts than other funding sources.7,8,9,11,13 This disparity in the number of grants submitted and dollar amounts requested may be a result of networking disparities. In the case of early career applicants, women tend to have female mentors at lower ranks than men.14 Among applicants of the more prestigious R01 funding mechanism, women have fewer publications, lower H-index, and smaller co-author networks.6 While much of the gender gaps in funding can be explained by differences in grant application behavior, there is also evidence of less favorable assessments of women as principal investigators. One study of applications14 to a mentored research grant noted that even after controlling for advanced degrees (the most important predictor of successful application), women receive lower grant scores compared to men. Selection processes that emphasize the scientist, as opposed to

When considering the patient burden and influence of clinical emergency care, emergency care research is already vastly underfunded. This puts women in academic EM at a significant disadvantage compared to other specialties.

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the science itself, could disadvantage women. A recent study 15 of grant applications to the Canadian Institutes of Health Research compared two grant programs: one with and one without an explicit review focus on the caliber of the principal investigator. When grant reviews focus on the proposed science, there is no significant gap in grant funding by gender. However, when the “caliber” of the investigator was considered, the gender gap widened. Changing the selection processes to describe the ideal candidate in nongendered terms may lead to an increase in the proportion of women who get funded. A study of applications16 to the Doris Duke Clinical Scientist Development Award noted that once recommenders were specifically asked to avoid referring to personal circumstances, such as marital status, age, work-life balance, and roles outside of the professional setting, there was an increase in the proportion of applicants that were female and increased successful funding of applications submitted by females.

STRATEGIES THAT ADDRESS THE DISPARITIES

• Increase opportunities for career guidance.

• Broadly disseminate funding opportunities to EM faculty. o Identify ways of reaching academics who are less likely to have access to traditional research networks. o Identify ways of reaching academics who are less likely to have access to informal networks and influential people. • Provide funding opportunities to prioritize specific groups who may be at a disadvantage due to family or employment circumstances. o This includes women physicians who are in part-time jobs, on non-tenure tracks, who are looking to move from community to academic centers, or who want to re-establish their reputation and activities after career breaks. o Increase awareness of the benefits of extension of Early Stage Investigator Status to compensate time used for family responsibilities/ having children (for applicable NIH grants). • Offer additional support for women in early career transitions to independence. This may include: o Bridge funding for preliminary research

o Grant writing workshops with successfully funded researchers from within EM and from other specialties

o Offer additional protected time or flexible work schedules for grant writing and publications

o Leverage mentoring schemes. Because EM is grossly underfunded compared to other specialties, this may require identifying influential role models and mentors outside of our specialty.

o Provide research support staff • Increase transparency of grant review processes. o Clearly define rating categories.

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o Disclose, publicly, the demographics of applicants and awardees (such as sex, gender, highest academic degree, and academic rank). • Influence the selection process of funding organizations: o To encourage the description of ideal candidates in non-gendered terms. o To consider blinding of names of candidates (based on data around gender-bias based on names).

ACTIONABLE STEPS YOUR GROUP CAN TAKE

• Appoint influential mentors to anyone who expresses an interest in pursuing a career in research. This may and often requires finding suitable mentors outside of EM. • Appoint a research coordinator for the department or identify institutional resources to assist with identifying suitable funding mechanisms (federal, institutional, professional society, or others).

• Encourage participation in research and grant writing workshops, within and outside of the institution.

HOW TO MEASURE SUCCESS ON THIS TOPIC

• Monitor the gender distribution of grant writing.

• Monitor the gender distribution of cross-sectional and longitudinal/sustained funding.

RESEARCH IDEAS FOR BUILDING UPON THIS TOPIC

• Collect mixed methods/ qualitative data on reasons for the gender gap in the transition from career development award to independent research funding. • Collect data on successful mentorship techniques/ mentor/mentee characteristics for female faculty on research tracks.

To provide feedback and recommendations on this topic, email the author at mdelrios@uic.edu; Subject: AWAEM Toolkit: Grant Funding

Resources Used for Discussing This Topic 1. Lewis RJ, Neumar RW. Research in Emergency Medicine: Building the Investigator Pipeline. Ann Emerg Med. 2018 Dec; 72(6):691-695 2. Baren JM, Cairns CB, Neumar RW. National Institutes of Health Funding of Emergency Care Research: Feast or Famine? Ann Emerg Med. 2016 Aug;68(2):172-3. 3. Jang DH1, Levy PD2, Shofer FS3, Sun B3, Brown J4. A comparative analysis of National Institutes of Health research support for emergency medicine - 2008 to 2017. Am J Emerg Med. 2018 Dec 26. (published online first) 4. Newgard CD, Morris CD, Smith L, Cook JNB, Yealy DM, Collins S, Holmes JF, Kuppermann N, Richardson LD, Kimmel S, Becker LB, Scott JD, Lowe RA, Callaway CW, Gowen LK, Baren J, Storrow AB, Vasilevsky N, White M, Zell A. The First National Institutes of Health Institutional Training Program in Emergency Care Research: Productivity and Outcomes. Ann Emerg Med. 2018 Dec; 72(6):679-690. 5. Mumma BE, Chang AM, Kea B, Ranney ML; Society for Academic Emergency Medicine Research Committee. Career Development Awards in Emergency Medicine: Resources and Challenges. Acad Emerg Med. 2017 Jul;24(7):855-863 6. Warner ET, Carapinha R, Weber GM, Hill EV, Reede JY. Gender Differences in Receipt of National Institutes of Health R01 Grants Among Junior Faculty at an Academic Medical Center: The Role of Connectivity, Rank, and Research Productivity. Journal of Women’s Health 2017 Oct 1;26(10):186-1093. 7. B  ailyn L. Comment on “gender differences in research grant applications and funding outcomes for medical school faculty”. Journal of women’s health (2002) 2008 Mar;17(2):303. 8. Waisbren SE, Bowles H, Hasan T, Zou KH, Emans SJ, Goldberg C, et al. Gender Differences in Research Grant Applications and Funding Outcomes for Medical School Faculty. Journal of Women’s Health 2008 Mar 1;17(2):27-214. (data 2001-2003) 9. Pohlhaus JR, Jiang H, Wagner RM, Schaffer WT, Pinn VW. Sex Differences in Application, Success, and Funding Rates for NIH Extramural Programs. Academic medicine : Journal of the Association of American Medical Colleges 2011 Jun;86(6):759-767. 10. Ley TJ, Hamilton BH. SOCIOLOGY: The Gender Gap in NIH Grant Applications. Science (New York, N.Y.) 2008 Dec 5;322(5907):1472-1474. 11. Hechtman LA, Moore N, Schulkey C, Miklos AC, Calcagno AM, Aragon R, et al. NIH funding longevity by gender. Proceedings of the National Academy of Sciences of the United States of America 2018 Jul 31,115(31):7943-7948. 12. Head MG, Fitchett JR, Cooke MK, Wurie FB, Atun R. Differences in research funding for women scientists: a systematic comparison of UK investments in global infectious disease research during 1997–2010. BMJ Open 2013 Dec;3(12):e003362. 13. Eloy JA, Svider PF, Kovalerchik O, Baredes S, Kalyoussef E, Chandrasekhar SS. Gender Differences in Successful NIH Grant Funding in Otolaryngology. Otolaryngology–Head and Neck Surgery 2013 Jul;149(1):77-83. 14. Gordon MB, Osganian SK, Emans SJ, Lovejoy FH, Jr. Gender Differences in Research Grant Applications for Pediatric Residents. Pediatrics 2009 Aug 1,124(2):e361. 15. Witteman HO, Hendricks M, Straus S, Tannenbaum C. Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency. The Lancet 2019 Feb 9,393(10171):531-540.

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Profile for Society for Academic Emergency Medicine

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