May 2024

Reshma Jagsi on Upstream and Downstream Disparities in Health and Medicine | Part Two

Reshma Jagsi, MD, DPhil

In the first installment of this two-part blog series, the Foundation spoke with Faculty Scholars Program Committee Member Reshma Jagsi, MD, DPhil, on her recent scholarship exploring disparate outcomes for breast cancer patients and work that can be done to close those gaps. Here in part two, we talk about inequities within the profession of medicine itself—which, as Dr. Jagsi notes, are connected to outcome disparities as well. The interview has been edited for clarity and brevity. 

Your work – including two papers this year in JAMA Network Open (in February and April) – has also heavily focused on equity within the medical workforce and workplace. Can you tell us about this research?

First of all, positions within medicine are positions of influence and authority. They’re highly sought after. Fair equality of opportunity to these positions is a fundamental part of demonstrating respect for persons qua persons. Many of the mechanisms that disadvantage women and people of color derive from unconscious bias and more overt forms of sexism and racism: at their heart, these become a matter of professional ethics to combat, as my Greenwall colleague Michelle Mello and I wrote

Moreover, it’s incredibly important for us to have a diverse workforce representative of the patient population we serves in order to adequately serve the needs of that full population. [There was just another study that came out] looking at mortality outcomes of patients, showing that female hospitalists had better mortality outcomes [than male ones], which has been shown before, but now also suggesting a new observation that the benefit was greatest in female patients. 

Does that mean we need a one-to-one match of identity characteristics for every dyad of patient and physician? Absolutely not. [A recent study shows] that even the female patients of male providers who worked in groups with more female colleagues had better outcomes, suggesting what we need is diversification of the whole profession. 

How is your research working to unpack these dynamics?

I first started doing research on this when I was a resident, because it became very apparent to me back then. All of the papers in the New England Journal of Medicine were written by a Henry or John or Frank – there’s a certain generation of name, and it was typically male-gendered. I mean, I wasn’t looking for Reshma – [I] was just looking for a Mary or Nancy or Helen, and that was not common. That observation actually led to my first publication in the New England Journal of Medicine.

I thought maybe this was just a pipeline effect. Is this going to just work itself out with time? Title IX was only in 1972. Women didn’t really break past 40% of the medical student body until the 1990s. Maybe we just needed to wait a little while, and it would work itself out. 

And so I started studying a unique cohort of faculty in academic medicine: recipients of K08 and K23 awards. [These awardees] are getting career development awards, they’ve articulated a commitment to the research mission, they were selected through a nationally competitive process, they’ve had supportive resources given to them. Surely you wouldn’t see [racial and gender disparities] in that group?

What we found was that actually R01 attainment—the articulated goal of the K award program—was lower for the women [than the men in the initial set of publicly available data we analyzed]. So then we started studying cohorts of K-awardees using mixed methods approaches.  We studied [one cohort] while they were on their K awards. We studied them five years later. We’ve now studied them much more recently, when they’re well beyond a decade out from those early-career grants and should be in senior, established positions. The women in this sample are less likely to have achieved a composite measure of success [that we designed], and we also learned more about what those mechanisms driving that difference might be.

The women are more likely to be burned out, the women are paid less for the same work, the women are more likely to have experienced sexual harassment, the women spend more time on domestic labor, the women are less likely to have experienced sponsorship. The women have less access to shared resources like personnel. The women describe different experiences with negotiation. They describe different experiences with mentorship, with cultivation of resilience and persistence.

It’s incredibly important for us to understand what the causal mechanisms are so that we can develop targeted interventions. It’s not about fixing women or fixing others from marginalized groups. It is about actually raising the awareness of how to transform the system, how to transform that culture, to make it more hospitable for people who have been marginalized and whose participation in medicine is so essential, if we really are going to serve the entirety of the population we are obligated to serve.