Introduction

Women and gender minorities have experienced a legacy of gender-related inequities that result in far-reaching health and social consequences. These pervasive inequities are maintained through gendered norms that often reinforce the social powers and privileges of cis-gendered men and typically favour characteristics ascribed to men and maleness [1].

For physicians, gender bias can minimize the important strengths of those identifying as female and has an impact on their well-being, career satisfaction and longevity [2, 3]. Research shows there are benefits to patients who are cared for by female physicians with regard to both outcome and satisfaction [2], most pronounced when patients themselves are female [4]. Rather than being celebrated however, female physicians’ practices and communication styles are often undermined in clinical practice through microaggressions and at times, overt harassment [5].

Gender-related health inequities for patients are pervasive and multi-factorial resulting from differences in disease exposure, health behaviours, access to medical care and lack of gender-specific research [6, 7]. While certain factors that result in this inequity are difficult to address, one actionable approach is to address gender-related inequities in medical education and staffing [8]. By supporting healthcare providers who identify as women to progress in their careers and take on leadership roles, we expect that gender-related inequities in patient care will be seen and addressed.

A recent position statement asserted the existence and impact of gender bias and discrimination on those training and working in emergency medicine (EM) in Canada [9]. This position statement [9] and other previous reports [10, 11] suggests that many policies and systems fail to reflect certain women’s needs or to adequately compensate them for their work [10, 11]. These barriers disincentivize those identifying as female to choose a career in EM. A 2019 Canadian survey looking at the overall pool of Canadian physicians under 40, showed that more than half identified as female [10]. However, only 31% of emergency physicians identify as women [12]. Signs suggest these trends will persist as gender parity has not yet been achieved with applications for EM residency spots [13].

Internationally, it seems that our American colleagues may be closing the gap in some regards. Women in at least two American EM societies (Society of Academic Emergency Medicine and American College of Emergency Physicians) appear to receive a similar proportion of awards to their male colleagues as opposed to our own Canadian Association of Emergency Physicians (CAEP) [14]. Even in the United States, however, where gender equity has been a priority for several national societies for approximately a decade, women are persistently under-represented in advanced leadership positions and academic positions [15, 16]. Addressing these issues to support equal representation and recognize and celebrate diversity within our workforce is essential.

To facilitate our continued journey to achieve gender equity in EM within Canada, we undertook a multistep, stakeholder-engaged, evidence-based review to develop recommendations for CAEP’s 2021 Academic Symposium.

Methods

Design and conceptual framework

The CAEP Gender Equity Working Group was developed to identify barriers to gender equity amongst emergency physicians working in Canada. The work was developed under the umbrella of the CAEP 2021 Academic Symposium on Equity, Diversity and Inclusion. Monthly meetings took place with chairs of the leadership committee and leads of two other working groups (addressing anti-colonialism and anti-racism in EM, and EM residency training about sexual and gender minorities). These meetings were essential for symposium cohesion and to recognize the intersectionality common to our equity-seeking groups.

Throughout this work we acknowledge that gender is a spectrum. When we refer to “women” and female perspectives we include all who identify as women or have had experience as women and/or on the feminine side of the gender spectrum. When we refer to men and male perspectives we are referring to cis-male perspectives (e.g. those who have only lived on the masculine side of the gender spectrum). See Online Appendix A for a complete glossary of terms used in this publication.

Study setting and procedure

This work was undertaken by a CAEP working group with the intent of establishing guidelines for its members and was designated as a quality improvement project. It was reviewed and granted a program development exemption from the Hamilton Integrated Research Ethics Board, Hamilton, Ontario according to Tri-Council Policy Statement 2 [2018], under Article 2.5.

We conducted a multi-phase study to elicit and then refine the consensus recommendations. The process included the following ten steps: (1) recruiting collaborators (2) internal discussions within the symposium group; (3) analysis of discussions to isolate problem statements; (4) creation of survey tool with all problem statements; (5) survey of emergency physicians and trainees to prioritize problem statements; (6) selection of top problem statements based on survey data; (7) literature review and expert consultation to construct solutions from the medical literature and beyond; (8) assembly of identifiable gaps in the EM literature; (9) presentation at 2021 CAEP Academic Symposium for Consensus; (10) final recommendations generated. Table 1 depicts the details of these procedures.

Table 1 2021 CAEP Academic Symposium gender equity panel methods
Full size table

Data collection tools

Focus group guide

A structured, focus group guide (see Online Appendix B) was developed based on review of a recent Canadian position statement identifying core barriers in Gender Equity in EM from the literature [9]. The focus group guide was also reviewed by an expert (AB) who has a background in organizational behaviour with a focus on women’s career and leadership trajectories. This interview guide was used to prompt discussion in virtual focus groups via Telus web-conferencing software (Telus, Inc., Toronto, ON, Canada) and ensure that key points in the literature were addressed.

Survey

Survey development

Once the focus groups were completed, a thematic analysis of the issues which emerged from the focus group data were used to construct our stakeholder consultation survey. The survey was developed by the authorship team leads (EMB, JM) with pilot testing and consultation from the rest of the authors.

Survey content

After gathering demographics, participants in the survey were presented using two, five-point Likert scales. Survey respondents were asked “To what extent do you agree or disagree with the statement according to your personal experience?” and second “If this is a true problem in Canada, how important is it to address?”. The first item aimed to assess the prevalence of a given problem statement and the second item aimed to address the importance of the issue regardless of prevalence. See Online Appendix C for complete survey.

Results

Qualitative problem statements

Authors EMB, JM and TC analyzed notes from virtual focus groups (see Table 1, Step 2) to bring together related themes to describe specific problems with gender equity in EM in Canada. These problem statements were further developed and revised with the involvement of a larger group of collaborators (see Table 1, Step 3). For a full list of problem statements please see Online Appendix D.

Survey results for problem statement prioritization

All problem statements were then presented in a national survey of Canadian Emergency Physicians. Respondents were asked to rate, on a five-point Likert scale, the degree to which they agreed with a given statement in their own workplaces, and then the degree to which they thought the issue was important, regardless of prevalence in their workplace. The survey was completed by 710 respondents with 607 (85%) completing at least the first statement rating scale. 382 (54%) were CAEP members. We had a reasonable distribution of gender, geographic location and practice experience. Priority problem statements were chosen according to top ratings for each domain (Gender Bias, Trainee concerns, Leadership advancement, and Organizational Policies and Procedures) as well as authorship group consensus. Given that the problem statement #12 on allyship appeared to cover a unique domain, and was very highly rated, it was also prioritized.

Problem statements

Literature review provides further context and supporting qualitative problems with gender equity in EM. While literature is sparse, we found supporting evidence for qualitative concerns which were described in our priority problem statements. Table 2 describes our priority problem statements with relevant context and background evidence discussed.

Table 2 Priority problem statements and background
Full size table

Summary of Recommendations

From our literature review and based on expert opinion, targeted recommendations to address the priority problem statements were developed. During the Academic Symposium, participants were asked to rank their top three recommendations for each of the problem statements using an online audience engagement platform, Slido (Cisco Systems, Inc., San Jose, CA, USA). The Slido tool generated an averaged, ranked score which was used to prioritize recommendations. Study authors reviewed the recommendation rankings and determined that they were consistent with general authorship consensus. We also used virtual breakout rooms to discuss and improve recommendations. Participants were asked for concerns and improvements on each recommendation as well as for feedback on how to best hold institutions accountable and implement these recommendations. This qualitative feedback was also integrated into our final recommendations.

We present in Box 1 the final recommendations from this academic consensus process in order of ranking during the symposium session. These final recommendations are the result of a national consensus process and represent the priorities CAEP members would like to see met initially. For those interested in further research, please see Online Appendix E which proposes future research questions based on our analysis of priority themes.

Limitations

Due to the nature of volunteer participation, we anticipate that there may have been a sampling bias in our study that skewed towards those individuals with an interest in gender equity who may have self-selected to be involved in our discussions. It is also possible that our survey may have been preferentially completed by those with interests in gender equity or that those attending the larger academic symposium would have special interests in promoting equity diversity and inclusivity in EM.

Our survey suggests that diverse gender representation is present in EM and that further research is required to better understand the experience of those who identify as part of a gender minority group. While this work was reviewed and informed by expert consultation from a stakeholder with gender-diverse lived experience, more research is needed to better understand the experience of gender diverse emergency physicians. Our work is also limited by the fact that it is unable to fully capture intersectional experiences. Almost a fifth of our respondents identified with an additional equity-seeking group beyond gender. Further work in this area is essential and requires dedicated focus.

Next steps

Our qualitative problem statements (see Online Appendix C for complete list) were derived from a broad cross-section of the EM physician population and may act as a starting point for those seeking to engage in research and/or scholarship in the domain of gender equity within EM. While we have identified key challenges to achieving gender equity, much more research is needed in understanding why these challenges exist and how to change the systems we work within to better improve equity in our field. We invite members of the CAEP community and beyond to consider engaging in this domain of scholarly work to help us in achieving gender parity within our specialty.

Conclusions

Gender inequity is a national problem for Canadian emergency medicine providers. We have clear evidence that gender inequities in emergency medicine can result in diminishment of the strengths that physicians identifying as women bring to their work [3, 18]. Further we know from past research that this impacts career satisfaction and longevity for female emergency physicians. Ultimately these factors can negatively impact healthcare satisfaction and outcomes for our patients [2, 4, 40]. We have not yet reached gender parity in many aspects of Canadian emergency medicine and this is likely, at least in part, due to persisting gender inequities and bias [9, 13, 14].

This academic symposium panel has described both important problems related to gender equity and has provided actionable recommendations for all emergency physicians to consider. We hope that these recommendations can be implemented in emergency departments across the country and that this research sparks further investigations into the important challenges with gender equity in emergency medicine in Canada that we have identified.