When I decided to pursue medicine as a career, I sensed I was not entering an even playing field for women. This was a gut feeling based upon the standard depictions of doctors and based upon conversations. The system had been designed by and organized for the success of men. What I could not have anticipated was that by mid-career, some women friends and colleagues would disappear due to disappointment and disillusion. For this and many other reasons, medicine is making mid-career academic women physicians invisible.

Studies show that diverse teams are more productive, have higher morale, a culture of innovation, and a greater return on investment. So, medicine should be motivated to keep top talent on the team. Medicine should be motivated to keep women in academics.

Women are greater than 50% of the health-care workforce; yet, they do not proportionately attain top leadership positions. For example, women hold only 22% of full professor appointments, 18% of department chair positions, and 17% of medical school dean positions. A multifactorial phenomenon occurs beginning in training and extending into early career and transitioning to mid-career. There are subtle and not-so-subtle forces that make some women leave academic medicine by mid-career.

Women face two well-documented macro-inequities: salary and promotions. Women earn less than men even when adjustments are made for race, specialty, and years out of training. There is no specialty for which women have a higher salary than men. And in instances where the salary seems fair, women are not promoted at the same rate. Because promotion may be tied to salary, this continues a cycle of salary disparity. Women are not invited as often to deliver keynote addresses or grand rounds lectures. They are less likely to receive academic recognition and awards. Without these two items on a curriculum vitae, women are less likely to be promoted.

Women face countless microaggressions. For example, a woman physician is more likely to be called by her first name, rather than by her professional title. Academic letters of recommendation for women tend to be shorter in length, more likely to comment on appearance and personality, and less likely to document competence. These insults and slights are seemingly benign comments or behaviors, which can cumulatively cause harm. If the microaggressions were few and far between, women would hardly take notice. However, the frequency and effect over time is why some women leave. The pipeline is leaky.

Finally, academic medicine may present one of the most challenging cultures for women when the environment, which is inherently steeped in tradition and conservatism, allows men to be verbally and behaviorally aggressive in blatant manners. Picture Brett Kavanaugh and his outburst on national television in our most recent Supreme Court appointment. Men experience a form of status anxiety, when they feel their roles threatened by women. They lash out verbally with threats, bully with behavior and with words, and use confronting body language. All told, this contributes to making women feel unsafe at work. Medicine has allowed these behaviors, protected these men, and in many cases promoted them.

Women stepping out of academic medicine can’t be chalked up to leaving for caregiving duties. Surveys and studies prove that women do not commonly step out of academic medicine for these reasons. Academic women physicians are equally interested in leadership positions and promotions. Women physicians want salary transparency.

We can change this. Although difficult, we must examine and implement culture change initiatives. We can call out, and stop rewarding and promoting status anxiety-fueled behaviors. We can all contribute to a safe, equitable, and dignified work environment that keeps the most talented physicians working in academic medicine.

Resa Lewiss is the director of the point-of-care ultrasound division at Jefferson Health and a professor of emergency medicine at Thomas Jefferson University. She is a founding member of TIMES UP Healthcare.