What Would Patsy Mink Think?

In 1972, the Education Amendments of the Civil Rights Act of 1964 were passed.¹ Title IX of these amendments, among other things, prevented institutions of higher education from discriminating against women in admissions. Prior to Title IX, only about 10% of US medical students were women. Title IX had a personal impact on my life because I entered medical school in 1974. I recently asked separately several women students if they knew what Title IX was. None did.

Title IX is also called the Patsy Mink Amendment. Patsy Mink, a Hawaiian woman of Japanese descent, wanted to be a physician. When she finished college in 1942 with a stellar academic record, she applied to 20 medical schools, but none accepted women. Undaunted, Patsy Mink went to law school. She attended the University of Chicago, went back to Hawaii, set up a law practice, and was eventually elected to the House of Representatives, becoming the first woman of color to serve in the US Congress. To open the doors of our nation's medical schools to other women, she authored Title IX. The 40th anniversary of the passage of Title IX provides an opportunity to reflect on the progress made toward gender equity in medicine as well as the barriers that remain.

When I entered medical school two years after Title IX, women medical students in more than token numbers were a new phenomenon, and the change was not welcomed by all. I was asked point-blank during my medical school interview, “How do you think you are going to be a doctor if you have children?”—as if somehow the act of reproduction altered one's cognitive capacity or motor skills or wiped clean all knowledge gained from hours of studying physics, calculus, and organic chemistry. I am fairly certain that no applicants are asked such questions today.

When I was a third-year medical student, my surgery clerkship director told me on my first day, “It won't affect your grade, but I want you to know that I don't think women should be doctors.” If he were alive today, he would perhaps be interested in the results of studies that find essentially no difference in the competence of male and female physicians, including surgeons,² and that women now comprise 35% of residents in surgery.³

I was once told by the head of research that “Women just don't have what it takes to be researchers”—not a very evidence-based statement, but neither the term nor the constructs of evidence-based practice existed yet. I’m glad I didn't listen to him because I enjoy every aspect of research and have had continuous grant funding to support my work for almost 3 decades.

Finally, I remember my small-group discussion leader in psychiatry telling me that I was “too nice to go into academic medicine.” That really struck me as odd—don't we want nice people in academic medicine? I’d like to contact him today and let him know that it is possible to be nice and succeed in academic medicine—at least if you live in the Midwest.

What would Patsy Mink think if she could see the status of women in medicine today? She would undoubtedly be heartened that women now account for nearly 50% of medical students nationwide and are increasingly visible and effective in top leadership positions in all areas of medicine. Women physicians have made groundbreaking contributions to medical education, research, and practice. I am sure Patsy Mink would also be gratified, as am I, to see that the explicit prejudice against women in medicine that was so openly expressed and tolerated 40 years ago has been nearly eliminated.

While it is important to celebrate the tremendous gains in gender equity since its passage, we would have to admit to Patsy Mink that the promise of Title IX for full gender equity in medicine remains unfulfilled. For example:

1. A survey of more than 8000 physicians in New York State found that newly trained women physicians are paid on average $17000 less than their male counterparts after controlling for all conceivable confounders.⁴

2. Analyses of NIH data indicate that between 2003 and 2007, new female physician applicants and all experienced female investigators (MD, PhD, and MD/PhD) were significantly less likely than their male counterparts to have their R01 proposals funded⁵ and that in 2008 experienced female R01 renewal (Type 2) applicants had significantly lower proposal funding rates than experienced male applicants.⁶

3. While women have comprised nearly 50% of medical students for almost a decade and 30% of medical students for more than 25 years, only 18% of full professors and 12% of department chairs in academic medicine nationally are women.³

4. A detailed linguistic analysis of Medical Student Performance Evaluations suggested that women medical students may be subtly socialized toward family medicine and male students toward subspecialties.⁷

5. Several large faculty surveys at different academic medical centers have found that women faculty continue to experience largely covert discrimination based on gender.^{8 - 10}

If we are committed to egalitarian principles and if we believe studies confirming that nothing about being a man or woman confers intrinsic superiority in any position within medicine, how could we explain to Patsy Mink our inability to achieve gender equity in the past 40 years after she worked so hard to make it possible? Although the explicit prejudice that many women in my generation experienced has been almost (albeit not entirely) eradicated, we are still left with the impact of societal stereotypes about men and women. Stereotypes portray women as more likely than men to be nurturing, supportive, and sympathetic (“communal” behaviors) and men as more likely than women to be decisive, independent, and strong (“agentic” or action-oriented behaviors).¹¹ The mere existence of these stereotypes leads us, often unwittingly, to make assumptions about individual men and women and what their desires and talents may be. These implicit biases may underpin the overrepresentation of women physicians in the more “communal” and lower-status specialties of pediatrics, family medicine, and general internal medicine and the overrepresentation of men in the more “agentic” and higher-status specialties such as orthopedic surgery and neurosurgery. Even within these agentic specialties, when women enter, they find themselves subtly tracked into any aspect of the specialty perceived as more communal. For example, in cardiology women are more likely to be echocardiographers and men are more likely to be interventionalists, and I am told that within orthopedic surgery, male surgeons are more likely to do the agentic hips and knees and women the more delicate bones of the hands and feet.

The pervasiveness of implicit, stereotype-based bias and the way it infiltrates our decision-making processes even when we disavow prejudice¹² may constitute the biggest impediment to realizing the full potential of Title IX. I hope that it will not take another 40 years for the leaders of academic medicine to look like the patients we serve and increasingly like the students we teach and that someday 50% of our professors and department chairs will be women and at least 30% of these institutional leaders will be from ethnic and racial groups currently woefully underrepresented in academic medicine.

So, Patsy Mink, here is a thanks and an apology on this 40th anniversary of your transformative legislation. We have made much progress since you opened the doors of the nation's medical schools to women. However, I regret to tell you that your vision of equal opportunity for men and women in all aspects of medicine has not yet been fully realized. In order to achieve gender equity in medicine, we must address implicit bias that derives from gender stereotypes. The impact of these cognitive biases on decision-making continues to constrain the opportunities of women physicians and leaves unrealized the full potential of their vital contributions to the profession of medicine.