Article

A word for equity: the long road ahead

152 Correspondence / American Journal of Emergency Medicine 38 (2020) 151-161

References A word for equity: the long road ahead

Jung W, Kim J. Does physician gender have a significant impact on first-pass

success rate of emergency endotracheal intubation? Am J Emerg Med 2019.

https://doi.org/10.1016/j.ajem.2019.06.021. pii: S0735-6757(19)30398-5.

Han H, Kim Y, Kim S, Cho Y, Chae C. Looking into the labyrinth of gender inequality: women physicians in academic medicine. Med Educ 2018;52 (10):1083-95. https://doi.org/10.1111/medu.13682.
  • Bates C, Gordon L, Travis E, et al. Striving for gender equity in academic medicine careers: a call to action. Acad Med 2016;91(8):1050-2. https://doi. org/10.1097/ACM.0000000000001283. Aug.
  • Chandra NC, Ziegelstein RC, Rogers WJ, et al. Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of myocardial infarction-I. Arch Intern Med 1998;158
  • (9):981-8. https://doi.org/10.1001/archinte.158.9.981.

    K. Ogle, MD

    C. Roche, MD

    A. Pourmand, MD, MPH, RDMS * Emergency Medicine Department, George Washington University School of Medicine and Health Sciences, Washington, DC, United States

    * Corresponding author at: Department of Emergency Medicine,

    George Washington University School of Medicine and Health Sciences, 2120 L St., Washington, DC 20037, United States. E-mail address: [email protected] (A. Pourmand)

    https://doi.org/10.1016/j.ajem.2019.158437

    Dear Editor,

    It was with great interest that we read the article by Jung and Kim entitled ”Does physician gender have a significant impact on First-pass success rate of emergency endotracheal intubation?[1]. Although, the aim of the study was undoubtedly noble, a first consideration would be in relation to the hypothesis for the non-inferiority design.

    Demonstrating non-inferiority necessitates rejecting the null hypothesis [2] (H0: male gender > women gender) in favor of the alternative hypothesis (HA: men gender < women) with a sta- tistical test for the outcome measure ”first-pass success rate of emergency endotracheal intubation”. As authors conclude, female physicians’ performance was not significantly inferior (= not much worse) to that of male physicians’.

    It implies also that all ”participants” in this study matched sex and gender, since usually sex defines a biological components (karyotype), whereas gender includes identity, relations and norms that may influence self-identity [3].

    Both these assumptions are really discouraging and dishearten- ing. Are we still there? Do we still need to demonstrate that sex, gender, (why not?) ethnicity or other similar features could impact something that is entirely and only affected by experience, setting and training? Do we still need complex multiple logistic regression models?

    If we should investigate something that may impact the out- come, we should focus on the barriers to experience, setting and

    Fig. 1. Results from the survey promoted by YSICO and WIS Italia, November 2018. The survey was conducted on November 2018 by emailing all the Chairs of the Residency Schools in General Surgery with the aim to investigate the total number of residents and rate of women trainees currently enrolled in each school. In case of missing/ unavailable data the same question was extended to the residents enrolled in the School. Overall, data were obtained from 29 out of the 41 Italian Residency Schools in General Surgery (response rate 70.7%). Both Chairs and residents were categorized according to gender and results presented according to Italian regions. Norther Italian regions were considered the following: Liguria, Lombardia, Piemonte, Valle d’Aosta, Emilia Romagna, Friuli Venezia Giulia, Trentino Alto Adige and Veneto. Central Italian regions included: Lazio, Marche, Toscana and Umbria. Finally, Southern Italy and Islands encompassed: Abruzzo, Basilicata, Campania, Molise, Calabria, Puglia, Sardinia and Sicily. All categorical variables were analyzed using frequencies and percents and compared using Chi-square test; p value <0.05 was considered as statistically significant (MedCalc, MariaKerke, Belgium version 10.2.0.0).

    Correspondence / American Journal of Emergency Medicine 38 (2020) 151-161 153

    training which could be gender-related and more than other things on equity.

    Equity in Academic Medicine is a well know issue and Surgical Departments are largely affected by this. Concerns regarding the barriers, both structural and perceived, were more than once reported, but research in this field is mostly focused on US-based studies [4,5].

    Indeed, Columbia University – Irving Medical Center, estab- lished a taskforce about 15 years ago to identify the difficulties and improve equity in career tracks [6]. In our country, Institutions are still in the process of identifying the issue.

    In this field, a preliminary investigation was presented on Octo- ber 2018 during an Italian National congress with the aim to deter- mine the rate of women enrolled in a surgical training on the basis of the last official data that end in 2015 [7]. These results were implemented using a survey promoted by the Young Board of the Italian Society of Surgical Oncology (YSICO) and the Associa- tion Women in Surgery Italia (WIS Italia), conducted among Chairs of the General Surgery residency programs and Italian surgical res- idents in November 2018 . Response rate was 70.7% and the sam- ple included 1214 residents from 29 Residency Programs covering the entire country. Women represented about 50% of the surgical residents, with no substantial differences between Northern, Cen- tral and Southern Italian regions (Chi square p 0.25), in line with the recent reports [7]. Remarkably, despite the huge presence of women training in surgery, just 2 out of the 41 (4.9%) Residency Programs are currently chaired by women surgeons (Fig. 1). Even if data regarding women who achieved a Full Professorship in Gen- eral Surgery could be dissimilar, results are far inferior from the US rate of 9.8% [4].

    Quoting D’Armiento and collaborators, ”absence of women in leadership positions perpetuates inequity and is detrimental to trai- nees who continue to lack role models[4] is a reflection worth of endorsement. However, it does not affect just female trainees, but also the counter-part of the male colleagues. Promoting equity means to even up (hypothesis) bias and not just defend women rights. A task force to assess the limitations and define a measure of intervention would be advisable in many countries. Results would be quite expected, such as flexibility of career, transparency of hiring, mentorship programs, child day-care facilities, but at least it would be a first step.

    Still, we do not need hypotheses, we would need solutions.

    Disclosure

    Laura Lorenzon: Chair of the Young Board of the Italian Society of Surgical Oncology (YSICO) 2017-2019; Gaya Spolverato: co- founder and President of the Association Women in Surgery (WIS) Italia; Isabella Frigerio: co-founder and Past President of WIS Italia.

    Declaration of Competing Interest

    None of the authors has any potential financial conflict of interest related to this manuscript.

    References

    1. Jung W, Kim J. Does physician gender have a significant impact on first-pass success rate of emergency endotracheal intubation?. Am J Emerg Med 2019. https://doi.org/10.1016/j.ajem.2019.06.021 [Epub ahead of print].
    2. Lesaffre E. Superiority, equivalence, and non-inferiority trials. Bull NYU Hosp Jt Dis 2008;66(2):150-4.
    3. Clayton JA, Tannenbaum C. Reporting sex, gender, or both in clinical research?. JAMA 2016;316(18):1863-4.
    4. Abelson JS, Chartrand G, Moo TA, Moore M, Yeo H. The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical

      training and academic leadership from 1994 to 2015. Am J Surg 2016;212 (4):566-72.

      Cochran A, Hauschild T, Elder WB, Neumayer LA, Brasel KJ, Crandall ML. Perceived gender-based barriers to careers in academic surgery. Am J Surg 2013;206(2):263-8.

    5. D’Armiento J, Witte SS, Dutt K, Wall M, McAllister G. Achieving women’s equity in academic medicine: challenging the standards. The Lancet 2019;393(10171): e15-6. https://doi.org/10.1016/S0140-6736(19)30234-X.
    6. https://www.sicitalia.org/primo-rapporto-sic-sulle-donne-in-chirurgia/.

      Laura Lorenzon a,? Gaya Spolverato b Isabella Frigerio c Domenico D’Ugo a

      a General Surgery Unit, Fondazione Policlinico Universitario Agostino

      Gemelli IRCCS, Catholic University, Rome, Italy

      b Department of Surgical, Oncological and Gastroenterological Sciences,

      Section of Surgery, University of Padova, Padova, Italy

      c Department of Hepato-Pancreato-Biliary Surgery, Pederzoli Hospital,

      Peschiera del Garda, Italy

      * Corresponding author at: General Surgery Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University,

      Largo Francesco Vito 1, 00168 Rome, Italy

      E-mail address: [email protected] (L. Lorenzon)

      https://doi.org/10.1016/j.ajem.2019.158437

      Letter to the editor

      To the Editors,

      We were dismayed to read the on-line preprint of the paper by Whei Jung and Dr. Joonghee Kim, exploring the association of physician gender on first-pass success during emergency endotra- cheal intubation. We understand that the authors subsequently submitted a revision with a broader analysis and a more nuanced discussion of any gender variables. However, we still wish to voice our concerns about papers that seek to associate physician gender with patient relevant outcomes.

      We wholeheartedly believe the authors of this study were act- ing in good faith throughout this process, as they sought to address real and unfortunate gender inequities experienced and witnessed while working in emergency medicine in their cultural context. We wish to stand strongly beside them in their efforts to address this problem. However, we were concerned the original revision, with- out appropriate framing of a complex, nuanced issue may have precipitated quite the opposite effect, and may even have put the authors at undue personal risk given the significant backlash that has arisen.

      Studies that seek to attribute differences in quality of care, pro- cedural skill, or patient outcomes to innate and immutable traits like sex, gender, or race of physicians are often specious, and likely detrimental to the progress of medicine. Editorial boards that choose to publish such studies must be aware of this reality.

      Such works neither expose nor dismantle entrenched systems that promote discrimination and bias. Observational studies that ”prove” women deliver non-inferior, or even superior, care to men perpetuate the marginalisation of female physicians by emphasizing their ”otherness.” The use of quantitative methods in this manner legitimises outdated social stereotypes. When sci- entific journals publish such studies, they send a message to our profession and to the public that the competence of female doctors is still open for debate.

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