A survey from McKinsey and LeanIn.Org revealed the immense amount of invisible work taken on by women during the pandemic. Across more than 400 companies and 65,000 employees at all levels of management, women showed up as better leaders, championed DEI (diversity, equity, and inclusion) work, and disproportionately led mission-critical work of supporting employees’ well-being and promotion. Companies reaped great rewards from these efforts, however 75% of women said this extra work was not formally recognized, and almost 40% considered downshifting their careers or leaving the workforce altogether. Over 50% of women leaders stated over the last few months they had felt burned out at work often or almost always. The report concluded, “Women leaders are disproportionately doing the work to make their companies be better and do better. Their companies should do better by them.”
Unfortunately, healthcare is not immune to invisible work, inequities, and lack of recognition for women. Throughout this pandemic, women in medicine have risen above and beyond, often taking on essential work that is uncompensated and unrecognized, but vital to providing exceptional care to patients and keeping health systems afloat. Despite (or more likely because of) this phenomenon, this pandemic has seen women leaving the workforce in droves. This phenomenon is more pronounced for those with intersectional identities — women of color and LGBTQ+ individuals have shouldered much of the invisible work of the pandemic, such as addressing vaccine hesitancy.
Our healthcare systems, patients, and teams thrive because of the incredible amount of extra work women in medicine take on. The work is necessary, but does not provide the currency — financial or otherwise — needed for advancement. Women are more likely to participate in “citizenship tasks” that benefit the organization but not the women participating. This mission-critical work, completed often on nights and weekends, benefits others but is burning out women.
A 2021 report revealed 51% of women in medicine reported feeling burned out compared to 36% of men. Prior to the pandemic, we described the “third shift” — equity work completed during non-work hours after the first and second shift are over (regular job and home responsibilities). This third shift was already contributing to burnout pre-pandemic. Similar to the findings in the McKinsey survey, Julie Silver, MD, described a fourth shift, uncompensated COVID-19 work that has been disproportionately allocated to women. This work is often completed during non-work hours because it is essential — but at what cost?
These same women in medicine who continue to perform necessary uncompensated and unrecognized work are the same qualified women who continue to be overlooked for awards, grant funding, research, leadership, promotions, tenure, and continue to be paid less than their male colleagues. A recent report from the Association of American Medical Colleges (AAMC) showed the pay gap for women in medicine persists, a trend that mirrors the U.S. labor market, and was the worst for women of color. Amy Gottlieb, MD, stated that the “Traditional way of compensating physicians and faculty inadvertently devalues women’s contributions and monetizes men’s.” When women are consistently undervalued, it is no surprise that exceptional women continue to leave medicine. We have known these disparities have existed for years, yet they persist. And the pandemic has amplified them at every level. Steps to close this gap have stalled or regressed, with these disparities being more pronounced for those with intersectional identities.
The White House has initiated its first ever national gender strategy to advance gender equity and equality. If we are strategic and intentional in how we change the system and emerge from this pandemic, this could be a watershed moment in healthcare.
First, those not directly impacted must be convinced that these inequities affect everyone. Countless studies have found that equity in leadership benefits patients. When leadership is diverse and representative of the communities served, healthcare outcomes improve — this includes decreased mortality, increased efficiency in treating chronic conditions, and reduced hospital readmissions. Organizations with greater equity — such as equal pay — have improved overall performance and retention, and workers have greater trust in leadership, improved job satisfaction and productivity, and more innovation and creativity.
Second, there is no one-size-fits-all solution. The approach must be multi-pronged and requires intentional strategies that do not place the onus on those directly impacted. That is a recipe for burnout. The work must be championed by everyone. A comprehensive approach should include the following:
- Perform a culture audit. Make sure all voices have a seat at the table. Be intentional in ensuring there are individuals with intersectional identities, such as women of color, whose ideas are being heard.
- Distribute citizenship tasks equitably. Make sure women are not the only ones being assigned to citizen type work that will not provide a return on investment. Do not rely only on impacted marginalized communities to complete necessary “invisible” work. Provide compensation for this type of work.
- Pay transparency. This is one of the most challenging, but most necessary steps in moving toward systemic equity. Hire an objective auditor, identify the cause, and then implement a solution.
- Sponsorship and mentorship. Be intentional about who is being sponsored and advanced into leadership positions. Think outside of the normal social or professional circle. Equally qualified individuals are often overlooked because they are doing exceptional work on nights and weekends and not in plain sight. Look around and see who is not being offered opportunities and think critically and objectively regarding their attributes. The AAMC has a Women of Color Initiative with a toolkit to advocate for their advancement.
- Be an accomplice. The majority of those in leadership continue to be men. Without male leaders helping to lead the change, the system will continue on with business as usual. Provide leadership training for men interested in learning how to be more inclusive leaders. Men can also decline to participate in all-male speaking panels or “manels” as initiated by the NIH Director in 2019.
- Fix the system. Multiple barriers persist throughout healthcare, perpetuated by a hierarchical structure that does not consider that more than half of the healthcare workforce is comprised of women. Early-morning or late-evening meetings may not be feasible for everyone and should be adjusted according to the members of your team.
We have a recipe for burnout when women are: completing work during the third and fourth shift; taking on responsibilities benefiting others but not themselves; not being equitably recognized with awards, opportunities, and equitable pay; and working harder than their colleagues. We must stop the hemorrhaging of our best and brightest women from medicine. Our healthcare systems and patients will suffer without them. Let this be our watershed moment and let’s change the system. It will take all of us working together if we want to move forward.
Shikha Jain, MD, is an assistant professor of medicine in the Division of Hematology and Oncology at the University of Illinois in Chicago. She is also the CEO and president of the Women in Medicine non-profit organization and CEO of IMPACT. Monica Verduzco-Gutierrez, MD, is an accomplished academic physiatrist and professor and chair of the Department of Rehabilitation Medicine at the Long School of Medicine at UT Health San Antonio. Vineet Arora MD, MAPP, is the Herbert T. Abelson Professor of Medicine, a board-certified academic hospitalist, and the dean of medical education at University of Chicago Medicine. She is co-founder of IMPACT.