A Woman in Intensive Care Medicine Reflects…

My father was an Intensive care doctor. My younger sister and I both became intensivists. If this is in fact hereditary, we may soon be joined by my three nieces. I, for one, would enthusiastically welcome them, as women remain grossly underrepresented in intensive and critical care medicine despite accounting for the majority of incoming medical students. This blog will hopefully trigger reflections on the experience of women working in the ICUs around the world and inspire many interesting debates regarding the future of the field.

The COVID-19 pandemic has brought to light existing gender inequities in healthcare and leadership positions around the globe. While only 6.6% of world’s Prime Ministers are women, the female leaders of Germany, Norway, Iceland, New Zealand, Finland, Hong Kong, and Denmark have been widely recognized for their excellent responses to the coronavirus pandemic.

I am thoroughly impressed with this group of strong and competent leaders—they have made photos like the one below all the more glaring.

The rapid utilization and relative scarcity of PPE in the era of COVID-19 have highlighted how insidious gender disparities can be. Zoe Kleinman of BBC News reported on the struggles female healthcare workers have had attempting to source properly-fitting PPE to protect themselves on the frontlines of this pandemic. Though approximately 77% of the NHS’s healthcare workers are women, personal protective equipment (PPE) tends to be designed to be unisex. N95 masks have just two sizes: regular or small. Caroline Criado-Perez, the author of Invisible Women, notes that “the vast majority of personal protective equipment has been designed to fit the male body, so when you have for example ‘small’ – that’s actually small for men rather than small for women, or just average for women.” A 2017 report from TUC, a trade union association, noted that “most women, and also many men, experience problems finding suitable and comfortable PPE because they do not conform to [the] standard male worker model” which is based upon a select group of European and American men.

This problem extends to many other facets of medicine. Merman et al showed that there is a significant difference in the authorship of clinical practice guidelines by gender, causing an impact on how problems are approached at the bedside. Similarly, women are under-represented on task forces and this is particularly relevant in the care of critically ill patients. Intensive and critical care medicine is a field well-known for its progressively evolving technology. Unfortunately, there is a significant mismatch between the disproportionate number of male engineers developing medical devices and bedside users, which are mostly women.  If the workplace or its instruments are not created with female users in mind, their comfort and efficiency could suffer which is not ideal for the patient.

It would be a mistake to ignore the impact gender has on disease outcomes, healthcare delivery, and the people working in medicine. In a recent publication, severe COVID-19 patients requiring ICU admission in Italy were 82% male and 18% female. We must commit to understanding the underlying factors which appear to make men more susceptible to severe and deadly bouts of COVID-19, just as we must commit to redesigning PPE to accommodate the female form and welcoming female voices when drafting guidelines and creating task forces. Diversity improves outcomes.

Here are 10 reasons why men should support women in critical care medicine for mutual benefit:

1. Encouraging female medical students and junior doctors to consider intensive/critical care medicine as a career. We want to ensure the sustainability of the field, especially considering the majority of students in medical school are female. (Avoid segregation)
2. Increase access to flexible working hours–ICM has high rates of burnout and being with family can aid well-being.
3. Shared leadership models—which will improve management strategies and work-life balance for men and women.
4. Balancing the traditionally female risk-averse approach with the traditionally male risk-seeking approach could equalize many leadership decisions.
5. Eliminate unconscious biases and work to trigger a change of culture in the workplace. We have endless examples!
6. Eliminate stereotypes in the workplace. Male nurses frequently share this burden along with female physicians.
7. Increase transparency in hiring, compensation, etc. 
8. Strive to overcome gender disparities in patients (e.g., not considering osteoporosis in men, not considering ACS in female patients with “atypical” symptoms)
9. Meeting the end user to improve outcomes. This is particularly relevant for companies and developers. Involving women in the design process upfront should increase their practical use at the bedside.
10. Listen more: frontline workers do not always have a forum to talk and this is a missed opportunity.

I have met amazing women in medicine from around the world in my travels over the last 20 years. In this time, three observations have stood out to me: women tend to struggle with networking, they don’t talk about their success, and the trajectory of their career is often tied to their family life due to the rigid realities of modern medicine. This is a shame!  Women around the world are achieving superb results and they are not being recognized–the reality of STEM as a male-dominated field extends to recognition with awards. I have become increasingly vocal about these observations over the last few years. The International Women in Intensive and Critical Care Network (iWIN) was born when I found several colleagues who shared my concerns and saw the opportunity to create a vehicle for change. Women are not lacking initiative or creativity—they are lacking opportunities to express their innovative thinking. The current reality is that young women cannot network or sustain a hub to share their findings and projects as easily as men do! Our IWIN vision intends to challenge that.

The International Women in Intensive and Critical Care Network is a hub for worldwide initiatives addressing the issues surrounding gender equality. iWIN aims to harness the efforts of all international groups facing the same challenges. Our iWIN members interact via a variety of different approaches including survey techniques, consensus, workshops, video conferencing, webinars, blogs, and ultimately a yearly face-to-face meeting which will allow team building and networking. 

The iWIN core values are IDEAL:

Innovation 

Diversity 

Equality (equal opportunities in career progression, research, grants, awards, and conferences)

Advocacy (including education)

Leadership (coaching new generations, highlighting role models, experience sharing, and mentoring)

iWIN aims to create a positive and inclusive culture and allowing its members to feel welcome, safe, supported, and respected. We aim to serve as role models for young girls who aspire to careers in science and medicine. We are weary of initiatives that view women or minorities as the problem, in lieu of viewing the system as the problem—one which should be redesigned to benefit everyone. iWIN will study common drivers, problems, and plan global actions to find ultimate globally applicable solutions.

Though the coronavirus pandemic has disrupted the #iWIN2020 conference, we want to continue the momentum behind the iWIN movement and will be hosting a 90-minute live webinar on June 27^th, 2020.  This webinar will focus on Leadership, Innovation, and Support in the era of COVID-19. We will also highlight the beauty and culture of Catania, which will remain the site of our inaugural iWIN conference tentatively planned for June 2021. 

Please visit www.iwinideal.org for more details and follow us on twitter (@iWIN_2020).

Let everything happen to you

beauty and terror just keep going

No feeling is final

Rainer Maria Rilke

Francesca Rubulotta, MD, PhD, MBA, FRCA, FFICM
Interim Chairwoman, iWIN
Consultant and Honorary Lecturer Imperial College London
Consultant in Anaesthesia and Intensive Care Medicine

References:

1. Lambert TW, Goldacre MJ, Turner G. Career choices of United Kingdom medical graduates 1999 and 2000: questionnaire surveys. BMJ 2003;326:194-5.
2. Goldacre MJ, Turner G, Fazel S, Lambert T. Career choices for psychiatry: national surveys of graduates of 1974-2000 from UK medical schools. Br J Psychiatry 2005;186:158-64.
3. Dacre J. Are there too many female medical graduates? No. BMJ2008;336;749.
4. Canadian Medical Association: Number of Physicians by Province/ Territory and Specialty, Canada, 2018. Available at: https://www. cma.ca/Assets/assets-library/document/en/advocacy/01-physicians- byspecialty-province-e.pdf. Accessed May 20, 2018.
5. Bellini MI, Graham Y, Hayes C, et al. A woman’s place is in theatre: women’s perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group. BMJ Open 2019;e024349. doi: 10.1136/bmjopen-2018-024349