Best Practices to Reduce Gender based Disparities in Internal Medicine Trainees: Summary Recommendations from a Consensus Conference from the American College of Physicians’ Pennsylvania Chapter

Preface and Scope:

Systems-based inequities are highly prevalent in Internal Medicine (IM) training and education. These span across race, gender, sexual orientation and cultural background amongst other areas, and may influence the trajectory and outcomes of training in IM both in the short and long term, despite increasing representation of women in medical training. There are no current models for standardizing regional best practices to reduce and ultimately eliminate gender-based disparities in IM training.

To fill this gap, the American College of Physicians’ (ACP) Pennsylvania Chapter convened a leadership group in July 2019 with the goal of developing a regional consensus on best practices to reduce gender-based disparities in IM training.  This working group identified key focus areas of gender disparities: recruitment, career advancement, family leave/parental support, and sexual harassment. IM training program leadership were invited to attend a consensus conference on January 8th, 2020. This face-to-face conference included representation from academic IM training programs in the Philadelphia area and its proximity, including programs from Delaware, New York, and New Jersey. The conference group was given a timeline of one year from the starting point to produce a regional consensus agreement on best practice measures to reduce gender disparities in IM training.  The group continued to formally meet following the 2020 conference despite the challenges of the COVID-19 pandemic that occurred soon after the initial consensus conference.  This included four virtual webinars followed by open discussion.  On March 18, 2022, a follow up virtual consensus conference was convened which included representation from programs in the initial cohort as well as additional programs across the United States.

The following report summarizes the format and key items that participating programs agreed upon at the in-person consensus conference in January 2020 as well as the subsequent update and revision executed during the March 2022 virtual consensus conference. While the emphasis of this document is on reducing gender disparities in IM training as pre-determined by the scope of work and the timeline set by the ACP (2019-2020), the recognition of race-based inequalities that was laid bare during 2020 are closely linked to this group’s underlying commitment to identifying and addressing structural inequities across the system in IM training. To this end, the consensus conference attendees, conference leadership, as well as the ACP condemn events of race-based violence and discrimination in the strongest terms, and strongly support the policy statement issued by the ACP on racism and health in the United States (Serchen J et al., Annals of Internal Medicine, June 2020).

We believe that the output from this coalition of regional program leaders and the ACP represents a first step in a long journey towards ensuring equality across several domains in IM training, and we are confident that lessons learned from a consensus conference such as the present one will support, catalyze and amplify equity work in other areas to bring about a just, equitable, diverse, and inclusive environment for IM trainees. We are committed to supporting future work in a collaborative manner similar to the current gender equity conference format and sharing the knowledge gained from this project to ensure equality across domains in IM.


Format of the Consensus Conference:

Attendees at the 2020 conference included leadership from the ACP (national as well as Pennsylvania chapter), program directors, associate program directors, key clinical faculty members and chief residents from invited regional IM programs. Prior to the conference, four physician leaders conducted a literature review of gender disparities in graduate medical education as well as surveyed participants regarding the status of gender at their respective institutions.  Based on the results of their literature review and survey input, the leaders created key discussion points on four sub-topics: recruitment-based gender bias, sexual harassment, career advancement-related gender bias, and family friendly policies.  Each participant was pre-assigned to a specific topic in order to make the live discussion as robust as possible.  At the start of the summit, a review of each sub-topic was presented to the group at large followed by solicitation of any additional subthemes from participants.  Next, pre-assigned, theme-specific breakout groups convened and were asked to arrive at a consensus on acceptable best practices to reduce gender-based disparities in IM training.  In June 2020, the conference leaders disseminated a draft of these best practices to all participating programs for feedback.  On July 28th, 2020 the Memorandum of Understanding was finalized and 9 regional programs signed on to participate.

In March 2022, the initial program signatories as well as additional IM programs convened for the 2022 Virtual PAGE Conference. This conference focused on reporting out of the current status of gender equity at the programs, presentation of updated evidence to support best practices, and small group discussion for implementation and future directions of each subtopic. Based on this meeting, a revised list of best practices was developed.


Consensus-Based Best Practices to Reduce Gender Disparities in IM Training (Revised 2022)

A. Gender Bias in IM Trainee Recruitment:

  1. Programs will commit to prioritizing diversity and inclusion as part of their recruitment strategy and incorporate the principles of holistic review. Such commitment should be made explicit to all involved in the recruitment process including residents, faculty, and applicants.
  2. Programs will provide implicit bias training for all individuals involved in the recruitment process including faculty, residents, and core clinical faculty, with attention to newer forms of bias that may be introduced through virtual platforms.
  3. Programs will aim to formally track applicants by both self-identified gender as well as underrepresented-in-medicine status throughout the recruitment process
  4. Programs will aim to proactively engage under-represented IM faculty as part of the recruitment committee, interviewing faculty, and/or as experts during recruitment sessions. The program should account for faculty time dedicated to such recruitment activities.
  5. Programs will aim to proactively disseminate information to applicants regarding family-relevant policies and institutional resources for resident well-being and safety.

B. Career Development-Related Gender Bias for IM Trainees:

  1. Programs will recognize that explicit and implicit gender bias exists in IM training and has manifested in lack of adequate mentorship and sponsorship for women during IM training, decreased representation of scholarly work of female trainees at local and national conferences, decreased recognition of women trainees in the form of research awards and leadership role considerations as well as less representation in highly competitive subspecialties in IM.
  2. Programs will recognize the influence of gender bias in the educational environment and assessment of trainees.
  3. Participating IM programs will carefully evaluate their performance in assessing burden of gender bias in these critical areas and develop a strategy to identify and minimize gender bias in career development for IM trainees.

C. Family Friendly Policies:

  1. Programs will ensure that current and potential trainees are aware of the program’s parental leave policy and have access to a written copy.
  2. Programs will ensure safe, private, and clean lactation space that is easily accessible for trainee
  3. Programs will make efforts to accommodate needs of resident parents including family planning/ fertility needs, needs during pregnancy, and support upon return from parental leave.
  4. Programs will internally review these policies and solicit feedback in internal annual surveys on their performance in this area and scope for improvement.

D. Sexual Harassment:

  1. Programs will recognize the high burden of sexual harassment impacting medical students and IM trainees of all genders.
  2. Programs will ensure the existence of sexual harassment related policy for trainees and provide a written copy is provided at the time of commencement of training (and/or recruitment).
  3. Programs will organize face to face discussions at conferences and small groups at least on a semi-annual basis for trainees to be educated about how to recognize sexual harassment related behavior, micro-aggressions and what protocol to follow if they are a victim or bystander.
  4. Programs will educate trainees on the reporting policy, point personnel and process for reporting of sexual harassment.
  5. Programs will provide education to all faculty interacting with students and IM trainees on what constitutes sexual harassment (verbal and non-verbal) throughout the year and ensure that a strict no-tolerance policy is enforced.

Memorandum of Understanding:

To achieve implementation of these best practices regionally across IM training programs, the American College of Physicians encourages all programs to be part of a joint Memorandum of Understanding (MoU) that will provide a platform for programs to implement these strategies to reduce and eventually eliminate gender-based disparities in IM training.

The MoU is not a legally binding document; it reflects the commitment each program will make towards ensuring gender- based equality in IM training (The Philadelphia Agreement on Gender Equity in Medicine). The goal is to use this agreement as a model for other regions in the country to provide a successful and reproducible strategy for programs towards ensuring equal opportunity across gender for IM trainees.