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. Gender-based disparities in IM training have historically been highly prevalent and continue to be so despite increasing representation of women in medical training. These disparities extend across several domains including recruitment, career advancement, family leave/parental support policies as well as sexual harassment. 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 and invited IM training program leadership from across the Philadelphia region 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 (Table 1). The conference group was given a timeline of 1 year from the starting point to produce a regional consensus agreement on best practice measures to reduce gender disparities in IM training.

The following report summarizes the format and key items that participating programs agreed upon at the face to face consensus conference in January 2020. 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 current climate of race-based inequalities and violence across the country 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 the current events of race-based violence and discrimination in the strongest terms, and strongly support the recent 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 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 programs. Prior to the conference, four physician leaders conducted literature searches on 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 category in order to make the live discussion as robust as possible.  Key questions for the subgroup discussions are shown in Table 2.  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.  A summary of these consensus based best practices is described below.

A. Gender Bias in IM Trainee Recruitment:

  1. Programs will commit to prioritizing diversity and inclusion as part of their recruitment strategy.  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.
  3. Programs will aim to formally track, and account for, a variety of gender equity metrics during their recruitment process including but not limited to:
    • current number of male/female residents in the program
    • the number of male/female applicants invited to interview
    • the number of male/female faculty on the recruitment committee
    • representation of female faculty and female residents highlighted in recruitment material.
  1. Programs will aim to proactively engage under-represented IM faculty, including women, to serve as members of the recruitment committee, as applicant interviewers, and as experts during recruitment sessions. The program should make efforts to track individual faculty time dedicated to such recruitment activities.
  2. 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. 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 mothers.
  3. 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 in Philadelphia region 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 in the Philadelphia region (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.