Colloquially, the words “equality” and “equity” have been used interchangeably. However, the essence of each word is profoundly different. Author Caroline Belden wrote, “Equality is leaving the door open for anyone who has the means to approach it; equity is ensuring there is a pathway to that door for those who need it.”
Despite the push for equality in numbers, female anesthesiologists have historically faced challenges due to their gender. Some of these inequities include compensation differences, fewer leadership positions, gender-based discrimination, and lower rates of promotion (Anesthesiol Clin 2022;40:225-34). According to 2021 statistics by the Association of American Medical Colleges (AAMC), there are 42,220 total active anesthesiologists in the United States, of which 26.1% were women (asamonitor.pub/48KfUWS). The recent decline in women trainees from 36% in 2013 to 33% in 2019 (J Natl Med Assoc 2022;114:26-9) demonstrates the growing gender disparity. The numbers are only exacerbated, as a 2019 AAMC survey reported 40% of female physicians go part-time or leave medicine altogether within six years of completing their residency.
While pursuing all of one’s goals, a female anesthesiologist will experience a variety of personal and professional struggles during her career span. Young women face ongoing health challenges, as many battle with infertility or in finding a balance between raising young families while accelerating their career. As these women become mid-career anesthesiologists, they must balance motherhood while prioritizing their own health maintenance, experiencing symptoms of menopause, and often juggling leadership positions.
Women anesthesiologists face unique risks and adversities when compared to their male counterparts. Anesthesiology is a high-acuity field in which the working hours are long and stress levels can skyrocket in a matter of seconds. The minimum three years of advanced anesthesia training brings with it a constant exposure to toxic inhaled gas byproducts, airborne and blood-borne pathogens, and intermittent to constant full-body radiation. Anesthesiologists experience great fluctuations in cortisol levels, iatrogenic changes to their circadian rhythm, toxic and pathogenic exposures, and repetitive scattered radiation exposure, despite wearing pounds of heavy lead aprons. Females are also more susceptible to ionizing radiation and are therefore at a higher risk for radiation-induced carcinomas of the lungs, thyroid, and breast (Front Genet 2019;10:260). Ionizing radiation is both permanent and cumulative, resulting in a far higher occupational hazard risk for young women physicians entering our field (Front Genet 2019;10:260). It is no surprise that women anesthesiologists experience higher rates of infertility and miscarriages than the general population (Anesthesiology 2011;114:512-20; JAMA Netw Open 2023;6:e2326192).
When compared to men, studies have shown that women physicians with children spend on average 8.5 more hours a week on domestic responsibilities such as household and child care activities (Mayo Clin Proc 2018;93:1484-7). When women play vital roles in their family systems as mothers, wives, and daughters, where does that leave nonclinical time for their career-advancing pursuits of leadership and/or research? Furthermore, the decline of a physician’s health can be far more detrimental than for the average employee. A physician’s depression manifests as a six-fold increase in medication errors, which can result in poor patient outcomes as well as litigation and legal repercussions that would only worsen a physician’s entire well-being (Lancet 2021;398:920-30).
The internal struggles can be exacerbated by external factors. For example, when compared to multiple specialties, women anesthesiologists were significantly more likely to report maternal discrimination (J Educ Perioper Med 2021;23:E656; JAMA Intern Med 2017;177:1033-6). A 2021 study found that women who had children during training did not feel they had adequate time off after delivery (59.6%) and felt discouraged from taking additional time off (65.7%). Among female trainees wanting to start a family, 51.6% felt discouraged from having children during training, and 60.3% felt a stigma surrounding pregnancy during training (J Educ Perioper Med 2021;23:E656). Compounding upon the emotional toll of leaving a child after maternity leave, breastfeeding female anesthesiologists face even more work-related barriers. For example, many designated lactation spaces are not in close proximity to the ORs, and the women lack time to pump. The inflexible schedules can prohibit women from breastfeeding for their desired length of time (Anesthesiol Clin 2022;40:235-43).
The issue with lactation for women anesthesiologists in the perioperative setting was recognized by ASA in 2021. The society released a Statement on Lactation Among Anesthesia Clinicians, which supported breastfeeding anesthesia clinicians and recommended that employers create lactation policies (asamonitor.pub/3ZRmHdk). Future endeavors should be made to evaluate the efficacy of these policies.
The culture within our field must start to change to truly achieve gender equity. How do we, as a specialty, take those steps? In order to help women climb the academic ladder and gain leadership positions, institutions can adopt the work of Jennifer Martin, which was described in a 2017 article titled “Women, Minorities, and Leadership in Anesthesiology.” The article defines steps that can be taken by departments to increase awareness and combat issues faced by underrepresented individuals (Anesth Analg 2017;124:1394-96). The steps include: collecting data, developing a policy and distributing it, establishing an advisory group, building a database and reporting the data, responding to resistance, supporting women and minorities in positions of office, promoting a family-friendly environment, and pledging to handle diversity and equity diligently. Departments can also familiarize themselves with the American College of Physicians (ACP) recommendations on how to promote gender equity (asamonitor.pub/3FbShcg). Some of these steps include: advocating for family leave, amplifying women’s accomplishments, engaging leadership to prioritize gender equity, offering opportunities to more women, shedding light on pay or leadership inequity, and soliciting more female role models.
The data unequivocally demonstrates that the number of women anesthesiologists is decreasing. In addition, studies have shown that one in 10 female anesthesiologists would dissuade female medical students from pursuing a career in anesthesiology due to obstacles relating to motherhood (J Educ Perioper Med 2021;23:E656). The numerous personal challenges related to health issues, along with the professional hurdles, only demonstrate that change is needed. Resources from various societies, including the ACP and ASA, can be used to institute system-wide changes that will allow fair representation of women within our field. Further conversations are imperative in order to raise awareness on this issue so that equity can be achieved.