History of Challenges and Contributions of Physicians, Medical Schools, and Hospitals in Healthcare: A Global Context
I. Ancient Foundations of Medical Practice (15 minutes)
Early Healers and Medical Traditions
Women have served as healers since ancient civilizations, establishing the earliest foundations of medical practice. In Ancient Egypt, Isis was worshipped as the goddess of medicine, with her priestesses accepted as physician-healers 1. Ancient Greece similarly recognized Hygeia and Panacea, daughters of Aesculapius, as "sainted mortals" who likely practiced as independent physicians 1. Both Ancient Egypt and Ancient Greece demonstrated widespread acceptance of women as physicians and surgeons 1.
Origins of Academic Medicine
The birth of modern academic medicine originated from the convergence of multiple civilizations in Gondi-Shapur during the Sasanian empire in Persia, and later in Baghdad during the Golden Age of Islam. This multicultural assembly included Greeks, Indians, Syriacs, Persians, and Jews, who collectively established the foundations for teaching hospitals, medical schools, and biomedical research 2.
II. Medieval to Colonial Period: Domestic Medicine (10 minutes)
Transition from Professional to Domestic Care
From the Middle Ages through Colonial America, women bore primary responsibility for medical care in the home, serving in traditional domestic roles and as lay practitioners, though they were not typically recognized as professionals 1. This period represented a significant shift from the professional recognition women physicians enjoyed in ancient civilizations 1.
III. The 19th Century: Medical Education Revolution (15 minutes)
Breakthrough in Women's Medical Education
Elizabeth Blackwell's admission to Geneva College in New York in 1849 marked a pivotal milestone, though her acceptance was initially intended as a practical joke. She persevered to become the first woman to receive a medical degree in the United States, graduating first in her class 1. After working in children's hospitals in London and Scotland, she opened the New York Infirmary for Women and Children in 1857 1.
Expansion of Medical Schools
The late 1800s witnessed a surge in medical school establishment, including prestigious institutions like Johns Hopkins (opened 1893) and numerous proprietary and commercial medical schools 1. This expansion opened doors for women to assume professional physician roles 1. By the end of the nineteenth century, 17 medical colleges for women existed in the United States 1. In the 1890s, women comprised as many as 30% of graduates from some medical schools 1.
The Double-Edged Sword of Integration
Traditionally male-only medical schools began accepting women, initially lauded as progress toward gender equity 1. However, this shift resulted in many women's medical schools closing or merging with existing institutions 1.
IV. The Flexner Report Era: Standardization and Exclusion (10 minutes)
Impact on Medical Education Standards
The Flexner report, supported by the Carnegie Foundation for the Advancement of Teaching and authored by Abraham Flexner, accelerated the decline in medical school numbers through requirements for longer training periods and higher tuitions. Although Flexner stated that "privileges must be granted to women … on the same terms as men," the more stringent educational requirements morphed the profession into one that was more socially uniform, with declining access for women to medical education 1.
Consequences for Diversity
Women accounted for only 6% of US physicians in 1910, a percentage that remained unchanged for 50 years 1. The aftermath of the Flexner report created barriers for immigrants, lower and working-class Americans, Jewish Americans, and Black Americans, who, along with women, were discriminated against or "priced out" with rising tuitions and increasing opportunity costs 1.
V. The 20th Century: Feminist Movement and Renewed Progress (10 minutes)
The 1970s Resurgence
As the feminist movement burgeoned in the United States in the 1970s, renewed attention focused on women's role in medicine, particularly addressing the paternalistic culture of American medicine where women patients and nurses were routinely denied participation in medical decisions 1. The proportion of women medical students increased substantially during the 1970s, representing more than 25% of US medical students by decade's end 1.
Contemporary Statistics
By 2018-2019, women represented just over 50% of medical school applicants and matriculates, yet only 47.9% of medical school graduates 1. Women have never represented 50% of medical school graduates 1. Women represent only 45.6% of total US medical residents 1.
VI. Persistent Challenges Across the Career Continuum (15 minutes)
Early Career Obstacles
Gender bias, sexual harassment, lack of recognition, slower career advancement, salary inequities, and lack of career-long family leave policies create major drivers for burnout and may lead women to leave medicine. Although episodes of sexual harassment decline with physician age, 10% of women physicians over age 60 still occasionally experience sexual harassment, with slightly higher percentages noting verbal abuse or bullying based on age 1.
Mid and Late Career Discrimination
Seniority and accomplishments in medicine alone do not protect women from gender-based bias and discrimination. One-third of women physicians over age 60 still experience gender-based discrimination 1. Women physicians in middle age and older often serve as caretakers for grandchildren, elderly parents and/or partners, and other family members, yet policies and resources focus almost exclusively on early-career physicians 1.
Leadership and Recognition Gaps
Formal recognition of professional accomplishments, such as awards from medical societies and invitations to speak at conferences and grand rounds, are less likely to be conferred on women than men 1. When speaking at grand rounds, women are less likely to be introduced by their professional titles 1. The slower advancement of women's careers persists throughout the career continuum, evidenced by low numbers of women tenured professors, department chairs, and deans of medical schools, as well as leadership positions in hospitals and medical practices 1.
Faculty Representation and Funding Disparities
The proportion of women in all faculty ranks has increased since 2009, but women continue to represent a minority except at the instructor level 1. Women faculty from underrepresented-in-medicine race or ethnicity increased only from 12% in 2009 to 13% in 2018, with women at the full professor rank being 74.6% white 1.
Women received 23% of NIH awards in 1998, slowly increasing to 35% by 2020. A major factor in funding disparity by gender is the low number of grant applications submitted by women relative to men 1. Disparities in funding are even greater for women who are also underrepresented in medicine 1.
Institutional Barriers
Women faculty in leadership positions are more commonly in offices perceived as communal and less influential, such as offices for diversity, equity, and inclusion; faculty affairs and/or development; and student affairs and/or admissions 1. The smallest proportions of women leaders are in offices for research and clinical and/or health affairs, highlighting that women leaders are not in roles that exhibit final decision-making and budgetary power 1.
VII. Benefits of Diversity in Medicine: Patient Outcomes (10 minutes)
Gender Concordance and Clinical Outcomes
Patients treated by women physicians had significantly lower mortality rates and readmission rates compared with those cared for by male physicians within the same hospital, according to nationally representative data of hospitalized Medicare beneficiaries. In surgical procedures involving over 100,000 patients, fewer patients treated by female surgeons died, were readmitted to the hospital, or experienced complications in the 30 days after surgery than those treated by male surgeons 1.
Addressing Health Disparities
Racial and ethnic or linguistic concordance have been identified as key to improving communication and trust in mental health, essential in developing therapeutic alliances for those needing access to care. Physicians from historically marginalized and excluded groups are more likely to provide care to those living in underserved areas 1. Increasing physicians and learners with lived experiences of disability into the workforce can help address health disparities in patients with disabilities 1.
VIII. The Role of History in Medical Education (5 minutes)
Essential Historical Perspective
History offers essential insights about the causes of disease, the nature of efficacy, and the contingency of medical knowledge and practice amid social, economic, and political contexts—all things physicians must know to be effective diagnosticians and caregivers. History provides non-reductionistic mechanisms needed to account for changes in the burden of disease over time and explains why doctors think their treatments work and how their assessments have changed 3.
Historians serve three crucial roles: keepers of memories, conversation partners, and futurist thinkers, bringing historical context that enables better understanding of medical collecting, new imaginative futures, profound critiques of key medical concepts, and understandings of the body through time 4.
IX. Strategies for Institutional Change (10 minutes)
Systematic Interventions
Medical schools and teaching hospitals must partner to improve gender climate and culture through regular environmental assessments and equity trainings, such as implicit bias training. However, implicit bias training tends to be passive; having faculty, especially those on search or promotion committees, identify their own biases through assessments such as the Implicit Association Test may help inform their decisions 1.
Structural Recommendations
There should be mandated gender and race diversity within search, hiring, and promotion committees to bring in new perspectives 1. Limits on terms of leadership within academia should be implemented so that women interested in leadership are recognized and allowed to fulfill their potential 1. Organizations should recruit and promote women physicians from a variety of groups to better reflect the diversity of the US patient population and improve patient outcomes 1.
Career-Long Support
The mental image of the "pipeline" of women in medicine must change from one of getting women into the pipeline to one in which women become successful while advancing throughout their rewarding career. Supports for women physicians must be designed across the career continuum, not just for early-career physicians 1.
X. Contemporary Challenges and Future Directions (5 minutes)
Social Accountability in Medical Education
Medical schools in this century will be gauged by their capacity to anticipate the kind of doctors required by evolving health systems and consider the challenges these systems face as they grapple with critical health concerns in society. The roots of ill health lie in poverty, discrimination, lack of education, maldistribution, and misuse of often scarce resources 5. Fragmentation is a serious threat to the efficiency and effectiveness of health systems everywhere 5.
Narrative Medicine and Humanistic Practice
Stories have always been central to medicine, but during the twentieth century bioscience all but eclipsed narrative's presence in medical practice 6. Physicians who write even short, 55-word reflective stories can hold to humanistic and ethical understandings of patient care and of themselves as healers even as they practice in systematized settings and employ evidence-based expertise 6.