How ageism holds back women in medicine

Though women make up more than half of medical students, they remain underrepresented in health care leadership: Women comprise just 29% of full professors, 25% of department chairs, 27% of deans, and 25% of health care CEOs. Among the reasons for this imbalance are the systemic barriers that sideline women out of the workforce. In some specialties, women leave the profession up to 12 years earlier than men.

At professional meetings, the discussion often turns to the root causes for why women physicians leave medicine: salary inequities, decreased rates of promotion, fewer sponsorship opportunities, lack of psychological safety, for example. There is often mention of environments permissive of workplace violence, bullying, toxic colleagues and sexual harassment. The high rates of burnout, moral injury and death by suicide are increasingly discussed.

Yet amid these critical conversations, one issue is less commonly parsed out and named outright: gendered ageism.

Gendered ageism is a form of discrimination that combines ageism and sexism, disproportionately affecting people — especially women — as they age. We have each witnessed it in the workplace. When one of us, Adaira, was on a committee tasked with selecting a candidate for a historically senior-level position, she heard someone say about a senior-career candidate, “She’s qualified, but we’ve heard she’s difficult to work with.” The committee selected an early-career faculty woman, with significantly less experience.

In 2007, physicians Molly Carnes and JudyAnn Bigby described a workplace condition called “Jennifer fever,” in which older men physicians preferentially give attention to the professional development of younger early-career women, who they call “Jennifers.” The authors posit that men leaders may prefer the older man/younger woman dynamic over an age concordant dynamic. And when people ask “Where are all the women?” male leaders highlight gender representation by pointing to “students, residents, fellows, or very junior faculty.” This system renders mid-career or senior-career women invisible.

In a follow-up editorial, Anna Kaatz and Carnes describe three workplace personas: an early-career “Jennifer”; a mid-career “Jane”; and a senior-career “Janet.”

The persona of the early-career woman, “Jennifer,” remained unchanged. The second persona, “Jane,” the motivated and successful mid-career woman, is underrecognized by her colleagues and bosses and faces an erosion of opportunity.

Jane sits at an inflection point, struggling to remain professionally relevant and involved. Kaatz and Carnes described a slow, difficult-to-perceive shift that affects Jane’s reputation. Colleagues may describe her as lacking ambition or leadership skills, thereby gatekeeping access to opportunities. When Jane does achieve success, someone else may get the credit. The gender stereotypes accumulate, together creating a detrimental perception that undermines Jane’s leadership.

“Janet,” the senior-career woman, is confident and competent, with more professional experiences than the other personas. Her ambition and impact are not perceived positively. She is considered “polarizing” and “difficult.” Her desire to serve in leadership positions receives a lukewarm welcome. Senior women may be siloed into undervalued and service roles: institutional housekeeping activities and other historically non-promotable work. Think about the “Janet” who hosts women’s mixers and leads women’s mentoring programs.

When offered a leadership position, she commonly stands on a glass cliff — taking a role during times of crisis or instability, where the risks of failure and career derailment are high. Without allies and institutional support, her success and career longevity may be limited.

While the two of us resonate with aspects of the authors’ arguments, we acknowledge that the three personas cannot describe the experience of all women. The persona names themselves — Jennifer, Jane, and Janet — do not speak to the ethno-racial diversity of the workplace. People, who are marginalized based on identity such as race, religion, ethnicity, ability, gender identity, sexual orientation, may be excluded at an earlier stage or face more intense bias spread throughout their entire career. There may be no positive “early-career woman” experience for groups who are historically excluded and unwelcomed from the time they enter medicine.

For those women who do identify with the personas, gendered ageism may be elusive and difficult to measure, coming on slowly. One insidious manifestation of gendered ageism is the limited representation of mid- and senior-career women in leadership roles. We have witnessed leadership positions that were quietly opened — without a formal search or advertised call for applications — and filled by pre-selected senior men. This backchannel hiring sidelines qualified women and sends a demoralizing message: your experience and leadership are neither sought nor valued. Some women describe behavior shifts in the workplace: invitations to professional opportunities dwindle, career development programs accept only on younger professionals, professional lists focus on early-career professionals, like “Top 45 under 45.”

The systemic discrimination may be vague until one looks around to find that the number of mid-career and senior-career women is disproportionately small.

But there are ways to combat this phenomenon. When it comes to ageism, medicine should adopt term limits and proactive succession planning to protect and expect equal longevity and opportunity for women. Search committees should include members from diverse backgrounds, who have stated no interest in the opportunity themselves, and aim to reflect that diversity in their candidate pool, including age. All leadership positions should have an open call to applicants, minimizing the possibility of backchannel hiring. Departments and hospitals should be mindful of their local barriers for the promotion and retention of mid- and senior-career women physicians.

It’s discouraging to watch competent and ambitious women remain stagnant in their careers or leave altogether. But we remain hopeful that the leaders in medicine can correct the pattern and create a culture of holistic inclusion for women throughout their entire careers. 

Adaira Landry is an assistant professor of emergency medicine at Harvard Medical School. She is the co-author of “MicroSkills: Small Actions Big Impact.” Resa E. Lewiss, M.D. is an emergency medicine physician, TEDMED speaker, and host of the Visible Voices Podcast. She is co-author of “MicroSkills: Small Actions Big Impact.”