Gender Equity in Pediatric Hospital Medicine: What History Tells Us.

Abstract

In 2018, the American Academy of Pediatrics (AAP) reaffirmed the value of diversity: “Maximizing the diversity of our members and leaders allows the AAP to benefit from the rich talents and different perspectives of these individuals.”1 Outside of medicine, it has been shown that companies with diverse leadership make better decisions, are more innovative, and ultimately perform better financially.2–4 In medicine, it has been shown that increased representation of women leads to better patient outcomes, more collaboration in research and education, and reduced health care costs.5–7 Without women at the highest levels, the field of pediatric hospital medicine (PHM) cannot reach its fullest potential.8It is clear from the literature that more women in a field does not necessarily translate to gender equity.9,10 Women predominate the field of general pediatrics, yet women are underrepresented in positions of leadership, speaking opportunities, editorial boards, authorship, compensation, and academic advancement.9–12 Although women constitute 70% of PHM, our understanding of what gender inequities may exist in PHM is still evolving.13 Allan et al13 recently examined leadership of university-based PHM programs and found that women are underrepresented as PHM division directors. Although we continue to gather data in PHM, it may be helpful to review what history tells us about the evolution of gender equity in our field.To understand our history, we examined PHM annual conference programs from 2005 to 2020 to determine the names of speakers and members of planning committees, communicated with past planning committee members to learn about changes in conference planning over time, and obtained the names of elected leaders and membership data through communication with society administrative leadership. Gender was determined by established methods, including examining first names and using pictures and pronouns through Internet searches. In Fig 1, we compare the annual percentage of women joining the AAP Section on Hospital Medicine (SOHM), the largest of the PHM sponsoring societies, to the percentage of women who were PHM society leaders, PHM national conference planning committee members, PHM conference speakers, and AAP SOHM Executive Committee members. Initially, there were fewer women as national society leaders, members of the conference planning committees, and national conference speakers. Only in the past 5 years have significant improvements in the representation of women in PHM been made. A closer look at the evolution of conference planning and leadership selection sheds light on this movement toward equity for women in our field.The PHM conference developed from a meeting with several hundred attendees in 2005 into a premier national event for our field, with >1600 registrants at the 2019 meeting.14 The magnitude of the conference led to the first major change we identified: the expansion of the planning committee membership. The early conferences were planned by leadership from all 3 sponsoring societies (the Academic Pediatric Association, the Society of Hospital Medicine [SHM], and the AAP); therefore, the gender distribution of the planning committees reflected the society leadership, which was predominantly men. Figure 1 reveals that the selected speakers were also largely men. As the conference grew, the planning committee expanded to include members outside of society leadership, ultimately increasing the representation of women on the committee. Starting in 2014, women outnumbered men on the PHM planning committee, and the following year, more women than men were selected as lead presenters of submitted content. Diversity of planning committee membership has been correlated to the gender distribution of selected speakers in other fields15,16 and could have contributed to improved representation of women speakers at the PHM national conferences.In addition to the expansion of the planning committees, the second major change in the conference was the process for selecting content. Early conference speakers were invited by members of the planning committee and would often be invited to return subsequent years to give similar presentations. Evolution from a small annual conference with invited speakers to a recognized national event for PHM necessitated the gradual shift during 2010–2014 from largely invited content to an open call for submitted content. In addition, a peer review process for selection of abstracts, submitted content, and conundrums was developed to mirror other major conferences. The establishment of a robust content selection process with peer review by the 2015 PHM planning committee set the stage to increase the diversity in our conference speakers.17 A similar increase in representation of women speakers was seen when the SHM established an open-call peer review process for its national conference.18 These 2 changes (peer review and open call) likely mitigated some of the barriers women faced in getting selected for speaking roles at the conference. Thus, changes implemented in the content selection process over the past 10 years by the PHM planning committee led the way to increase the gender diversity in our conferences.The representation of women in society leadership roles has followed a similar positive trajectory to that of PHM planning committees and PHM conference speakers (Fig 1). From 2000 to 2009, 24 of 104 (23%) society leadership positions per year were held by women. Over time, the percentage of women in society leadership roles has increased, and since 2016, more women than men have held PHM society leadership roles. With the maturation of the field, each society established transparent leadership succession processes and term limits; both have been demonstrated to increase representation.19,20 These changes, along with an increased focus on sponsorship, likely contributed to the increased representation of women in leadership. Sponsorship of women has been shown to increase the number of women in roles of influence and may have been another key to the success of gender representation in PHM over time.21 Finally, name recognition and national visibility are important for electoral success in society elections, and the increasing representation of women at national conferences could have played a role.As a young field with a majority of women, PHM is in a unique position to lead the way in gender equity in pediatrics.22 Examination of the history of our field reveals that deliberate changes in our processes likely influenced the increasing representation of women as planning committee members, conference speakers, and society leaders. For the first time since the birth of PHM, our society leadership is reflective of the proportion of women in our field at large, which is crucial to the development of the field and for the career advancement of women in PHM.8,9,23 Although this improvement in society leadership should be celebrated, there is work to do in other areas of leadership, most notably division directors,13 department chairs,24 and hospital executives,25 all of which may have a more direct impact on pediatric hospitalists’ practices, resources, and individual careers.Although the gender gap may be closing for women in society leadership and speaking opportunities, PHM must continue to prioritize diversity and inclusion in the broadest sense. There is limited information about the representation or experiences of underrepresented populations in our field. As our history reveals, when a group is not seated at the table, their representation does not change. If we aim to elevate our field as a whole, it is critical that we advance all of our colleagues, and it cannot wait for another 15 to 20 years. PHM is a new board-certified subspecialty with a diverse membership (including, but not limited to, race and ethnicity, sexual orientation, practitioner type, and practice setting), and we must be intentional about how we collectively move forward to ensure that PHM values and enhances its diversity through inclusion.More research is needed to understand what inequities exist in PHM and to benchmark our progress. We need to evaluate our systems for any barriers that may prevent qualified individuals from applying for leadership positions or submitting content. We need to sponsor women and other groups and increase the diversity in our leaders. All national conferences should establish processes for selecting representative planning committees and for choosing speakers who reflect the diversity in our membership. We can go further and ensure that all leadership roles have clear selection processes and term limits, which has been shown to increase representation.19 We must also be transparent about our progress by tracking metrics and making them available.We are heartened that progress has been made over the past 20 years in the development of our field, but we cannot relent. We must continue to ask what voices are present and what voices are missing. We have come a long way in the advancement of women in PHM; it is now time that our field leads the way to a more equitable state for all.