Authors: Meghan Etsey, Vashti Price, Pringl Miller MD FACS on behalf of AMWA Gender Equity Task Force
“Our Voices, Our Future” is a podcast by the Gender Equity Task Force of the American Medical Women’s Association that explores the challenges, stories, and successes of those working to advance gender equity in medicine. Through candid conversations with changemakers, advocates, and leaders, each episode dives into issues like pay gaps, leadership disparities, and inclusive workplace culture. Tune in to be inspired, informed, and empowered to take action. Full episode listening links are available below the transcription.
Meghan: Welcome to Our Voices, Our Future, a podcast where we amplify the voices driving change in equity within medicine and beyond. Brought to you by the Gender Equity Task Force, a committee of the American Medical Women’s Association. We’re here to challenge norms, break barriers, and ignite conversations that matter.
I’m Meghan Etsey, and in each episode, we bring you candid conversations with leaders, change makers, and advocates, working to create a more inclusive and just world. No more silence, no more waiting. It’s time to get Our Voices, Our Future.
Let’s get into it. Today, we’re welcoming Dr. Pringl Miller. Dr. Miller is board-certified in general surgery and hospice and palliative medicine, with fellowship training in clinical medical ethics.
She is a fierce advocate for justice in the medical profession and the founder and Executive Director of Physician Just Equity (PJE), a nonprofit organization dedicated to providing peer support to physicians and surgeons in training and practice experiencing workplace injustices.
Her advocacy and scholarship have shed light on critical issues in medicine, including the forced and involuntary attrition of women and under-represented women especially with intersectional identities in training and practice. In 2023, her work was published in the Journal of General Internal Medicine, highlighting PJE’s novel approach to peer support.
We’re excited to have her here today to share her expertise, advocacy, and vision for a more equitable future in medicine.
Dr. Miller, could you start by sharing a bit about your journey in medicine and what ultimately inspired you to found PJE?
Dr. Miller: Yes. Thank you, Meghan, for that lovely introduction. It’s nice to see and speak with you again. And let’s get into it. I like that expression.
What inspired me to found the organization, Physician Just Equity, was a growing recognition of the perpetuation of injustices against those under-represented in medicine. Those injustices can take different forms and unfortunately be experienced by a lot of different people. But in my network of women with intersectional identities, it seems like it is more prevalent among that population of clinicians, especially women in surgery, who are subjected to double standards and inequitable working conditions.
The double standards aren’t being recognized as a barrier to performing optimally. I’m not suggesting that women don’t perform as well as their male colleagues in a binary construct, because it’s been studied and published. The literature demonstrates that women in medicine and surgery have better outcomes than their male counterparts. It was the lack of equity and unchecked toxic work environments that impact people’s ability to feel comfortable in their workplace that motivated me to found a physician advocacy organization.
Meghan:
You’ve spoken about the issue of forced and involuntary attrition among women physicians. For those unfamiliar with the term, can you explain what this looks like in training and practice?
Dr. Miller: What I mean by involuntary attrition is that women will be performing their jobs at a high level and then, for some unknown or rational reason, find out that their position is in jeopardy or ending, so the end of their employment doesn’t happen on their terms. There are forces within the work environment that for untoward reasons target talented ethical physicians leading to job loss.
So the “forced” in the forced involuntary attrition of women means that women are leaving the workforce not because they want to, but because of unjust circumstances that have amassed against them leading to job loss and sometimes even loss of their career due to the whisper campaign and being black listed.
Meghan: So you’ve had a front-row view of these things that go on.
Can you talk about how widespread this is and what patterns you’ve observed through your work within PJE?
Dr. Miller: That’s a really good question. It’s hard to assess how widespread the problem is because we don’t have data. The incidence and prevalence of forced involuntary attrition are unknown because people don’t like to talk about it. There’s a stigma attached to job loss. It suggests that you’ve done something wrong and deserved to lose your job.
I just want to emphasize that it is usually not the case, especially in a female population of clinicians and especially those with intersectional identities that they did something wrong to lose their job. It’s usually the case that you actually did something right, something courageous, against the status quo and it rubbed someone with power and influence the wrong way. People are often reluctant to talk about workplace injustices and job loss because it’s traumatizing, painful, and there’s an attached stigma. Another reason forced involuntary attrition is kept under the radar is because separation agreements often include non-disclosure agreements (NDA’s), legally binding the clinician not to talk about what happened to them.
The combination of people not wanting to revisit that time in their life because of how hard it was, and being legally forbidden to talk about it because of signing an NDA, keeps the prevalence from being known. I think (hope) that as NDAs become outlawed there will be a growing acknowledgement and recognition that it’s unlawful to silence someone who is a survivor of injustice who wants to tell the truth about what happened to them. NDA’s provide immunity and protections for bad actors unethical and unlawful actions.
Meghan:
What personal and professional consequences do these women face when they experience this form of attrition in their workplace?
Dr. Miller: Another excellent question. There’s a litany of them. One of them is the loss of one’s professional identity.
Women have worked very hard to earn a medical degree, finish training, and get into practice. The investment they’ve made is huge. A lot of people entering medicine do it not just as a way of making an income, but because they have a calling or strong sense of duty and values that center doing what’s right for people seeking healthcare. That professional identity is challenged and sometimes lost for unjustified reasons. Additionally, moral injury occurs when one is doing the right thing clinically for patients only to suffer punitive consequences. A driver of burn out is unfair treatment and an example of unfair treatment is being punished for doing the right thing for patients.
When a physician loses their job and cannot communicate or show up for continuity patients that can lead to the feeling of patient abandonment.. A number of the people we’ve supported have spoken about this harm. They’ve reported showing up for work , one day and before they know it they are being walked out of the building for no clear reason. They had patients to see, pathology reports to follow up on, and patients to notify that they had malignancies, or other patients being seen for serious illnesses who were left without them. When you’ve been so central to your patients’ well-being and overall care, the feeling of patient abandonment is unethical and hard to accept, especially when you’re deeply committed to the physician-patient relationship and patient care.
There’s also the loss of productivity. If you’re not working as much as you were and to your potential, the loss of productivity coincides with professional identity loss, work dissatisfaction and lost income. In the worst-case scenario people can no longer work in their chosen profession in any capacity losing a sense of purpose. So professional consequences run the gamut, from the immediacy of not being able to fulfill your professional obligations to your patients if you suddenly lose your job, to not being able to get a job again as a clinician because your last employer reported you to the NPDB or state medical licensing board making it impossible to procure gainful employment as a clinician.
Meghan: Your whole answer, especially about the patient abandonment, takes me back to a few episodes ago when we interviewed Dr. Fouts Fowler and Dr. Bean from a hospital in Cleveland, Ohio, where they were let go. That’s exactly what they expressed to me, it feels so awful to have to leave your patients. They’re fighting so hard to get their jobs back because they just want to take care of their patients. It’s such a heartfelt response to being fired inequitably, and it’s so sad that these great doctors who just want to care for people are let go for such silly reasons.
Dr. Miller: You nailed it on the head. Clinical work is a calling for a lot of physicians, and the motivation to show up every day is in service to patients. I think it’s important that your podcast brings to light that when our profession and employers eliminate talent for unjust reasons patients are being harmed.
We know from the literature that the patient-physician relationship is very important in the delivery of therapeutic interventions within healthcare. When systems don’t recognize that patients have therapeutic relationships with their physicians, and that physicians can’t just be replaced like a cog in the wheel, it’s a disservice to patients and public health overall.
The other thing worth mentioning is that it’s well known there’s an impending workforce shortage. So it’s nonsensical to systematically target and eliminate educated, trained, talented and ethical clinicians from the workforce at a time when we need more physicians and surgeons.
Meghan: Very fair.
Can you tell us a little bit about how you created PJE? Can you share with us how PJE provides this peer support to the people who need it, and why the model you’ve created is important for physicians navigating these workplace injustices?
Dr. Miller: I’ll take the second part first, physicians and surgeons who find themselves suffering from workplace injustices like retaliation for speaking out about patient safety issues can feel like doing their job is causing moral injury. They might feel confused about why they are being targeted and feel isolated for simply doing their job as a patient advocate within best practice.
Those people are vulnerable and start to feel more and more isolated because others distance themselves out of fear of reprisal for being supportive. Interprofessional relationships change, and the workplace becomes less safe and respectable than it did before. It’s almost like the targeted clinician becomes radioactive.
In that situation, a person doesn’t know who they can trust and talk to to figure out what’s going on at work. A person might say “I’m noticing things. I’m feeling things. I don’t feel comfortable at work anymore. Things have changed. I said something I thought was relevant, but now I feel like I’m getting punished for it.”
Intra-institutionally, we look to our seniors, mentors, and those who have helped support us. Sometimes those people are helpful for academic or clinical matters, but they’re not necessarily the right people to talk to about more personal professional conflicts. So, we have to pick and trust the right people for the given circumstance. We’ve noticed that a lot of folks don’t have many people they trust in the workplace. And the institutional offices that exist as “resources”, like HR, Title IX, DEI, and Ombudspeople, are there at the behest of the institution. So they’re not usually safe places to get support as a target of injustices.
PJE has created a safe space. PJE does not have a conflict of interest with a peer like a representative of their employer might. We’re not getting paid by the institution where the conflict is occuring. We’ve created a safe space for people to share their experiences and get strategic help to navigate their workplace conflict.
We find that folks usually don’t know how to protect themselves. They don’t know what tools to employ to achieve their best outcome, whether that’s staying in their job, or staying employed in their specialty or subspecialty of choice.
Recently, we’ve re-designed peer support. We host separate one-hour monthly forums for people in training and practice by demand when they reach out for support. At a forum, participants can show up on video with their name or off video with an alias if they want to maintain their anonymity. The purpose of the forums is to answer commonly asked questions like: “I’m having this happen to me. I don’t know what to do. What are my options?” One nice thing about the forums is that people can learn from each other and they often feel less isolated hearing other people’s stories. The forum is a way for people to get their questions answered, and perhaps even learn something they didn’t even think about. In the forum setting, we usually have two to six PJE representatives to answer questions. The other peer support that’s written about in our research letter is an individualized peer support virtual meeting with three to six members of the PJE collective tailored to the peers specific needs.
Peer support is important for several reasons 1) because people don’t often know what their options are and they don’t know how to protect themselves and 2) because they don’t really know where else to turn for safe support, because unfortunately, our professional societies and organizations that we pay generous membership dues for don’t offer individualized support for people navigating workplace injustices.
Meghan: I feel like, for the forum, what I thought of when you were explaining it is that not only do they get to learn from other people, but when you’re in that situation, just learning that others are going through it would be a weight off your shoulders, to know that you’re not alone in what’s happening. Because, like you said, many times you don’t trust the people in your institution. Who are you talking to about this? It sounds like it would be a great support system as well.
Dr. Miller: Yes. To follow up on what you said, one of the common responses we get on the PJE outtake form to the question “How did PJE peer support help you?” is “[peer support] made me feel less isolated”. Peer support gave people hope and inspiration that there is something they can do, that people have their back and it affirmed that what’s happening to them is real and that they’re not crazy.
Meghan: You’ve already explained how you all approach supporting physicians this way.
Can you tell us what you’ve learned from implementing it, other than what you might already know? Is there any big thing that you’ve found that’s really working for these people?
Dr. Miller: I would definitely direct people to the research letter, but let me share Table 2 from the research letter because it summarizes peer feedback from our outtake forms.
We did a qualitative analysis to understand the benefits of receiving PJE peer support from the peers perspective. The four themes that came out were strategic support, emotional support, resource provision, and importance of the work. I can share with you the definition of each of those four themes and a few bullet points of what people said about each theme.
Meghan: Yeah, for sure. Go ahead.
Dr. Miller: For strategic support, “PJE assisted in establishing goals, providing practical tools, and offering strategic advice.” For emotional support, “PJE fostered a safe, nonjudgmental space to discuss the workplace injustice, validate the peer’s experience, and provided ongoing emotional support via a network of physicians.” That comment reinforces what we were just talking about. For resource provision, “PJE provided useful resources, including web-based information and practical, experiential information during peer support sessions for conflict navigation. For the importance of the work, “the work PJE is doing addresses a significant gap in support that workplace environments lack. Peers expressed appreciation for the impact PJE’s initiative had on their personal and professional lives.” One of the specific quotes was “it’s about time an organization like PJE’s comes to the forefront. Women, minorities, and other physicians in protected classes have been systematically discriminated against by their colleagues and organizations without significant protections or recourse. Physicians who are targeted and attacked need a team on their side to help navigate dangerous territory.”
Meghan: I love that. That’s great.
Dr. Miller: I did put together a few other testimonials that I thought would be helpful for people to hear. If you’re considering reaching out for support these are testimonials that might resonate:
“This is an excellent resource for those who have no idea where to go and how to go about it. For those who are so afraid to move anymore, this resource can help you take the first step and remind you that you’re not on your own.”
From a second peer:
“I’ve been through a dramatic, traumatic, and disappointing separation from my previous residency. It has been difficult trying to sort out what happened. PJE helped me understand what happened to me. Through that understanding, I can start the healing process and move forward. PJE helped me to put an action plan in place, and the future seems hopeful.”
Meghan: I got goosebumps when I read, “This has helped me start the healing process,” because that’s so true. This is traumatizing to go through these things, especially when you have no idea what happened. Yeah, wow, that’s amazing.
Can you tell us what changes you think are urgently needed at the institutional or policy level to address this attrition and to create more of an equitable workplace for, I guess, especially women in medicine? I know this is probably something we could talk about for days, but if you could just pick a big overarching thing.
Dr. Miller: I’ve broken it down into both structural ways of doing things and who governs those structural ways of doing things.
Number one, I think moral leadership is really important and unfortunately, I think moral leadership is lacking because, in today’s corporate medicine milieu, what tends to take precedence is the protection of the institution instead of doing what’s right.
The other bucket is really about institutions and individuals in power, there’s a lot of immunity that they have to do things that are either unethical or unlawful. That immunity needs to be addressed because there’s no accountability for harming someone. It takes people who are motivated by what’s right to do what’s right by individuals who are suffering from these injustices. It’s going to require effort from those who have a moral core and the courage to act on it. I know this will sound harsh because I think that, in many ways, people in leadership consider themselves to have an ethical framework with which they operate. In a number of cases that PJE has heard, and in my own experience, it seems that some people in leadership are following a path that doesn’t support what’s right for either the patient or the clinician in conflict. Which means there ought to be different leaders with different leadership priorities.
With regard to policy and law, I always come back to the fact that there are professional codes of conduct, policies, procedures, bylaws, state and federal laws and ACGME common rules that guard against injustices and unfair treatment. These existing documents should suffice. They’re just not enforced. There needs to be better adherence and more accountability to existing governing policies, procedures, and the law.
Existing laws addressing harassment, discrimination, and retaliation should be enforced as should due process rights.
Meghan:
Can you finally just tell us what advice you would give to women in training or practice facing challenges that threaten their place in medicine?
Dr. Miller: I think if you feel like something is happening to you in the workplace that doesn’t seem right, you should not be embarrassed to come forward and speak to someone you trust about it. Chances are your instincts are correct and something has probably gone haywire. It’s probably not something you did wrong, but something that an individual with power and influence took offense to. Get help sooner rather than later. PJE is available to support you. I think the biggest piece of advice I have to give is don’t brush off something that seems fundamentally wrong, don’t gaslight yourself into thinking you’re just making it up.
Meghan: Great. Thank you so much today for this talk. It’s been very fruitful.
Dr. Miller: You’re welcome. Thank you for having me.
Meghan: So that’s a wrap on this episode of Our Voices Our Future. We hope today’s conversation inspired, challenged, and reminded you of the power of raising your voice. The fight for equity doesn’t stop here. Join us in the movement. Subscribe wherever you get your podcast. If you love this episode, share it with someone who needs to hear it. Until next time, stay bold, stay vocal, and keep the conversation going. This is Our Voices, Our Future.
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About the Authors
Meghan Etsey, MS4
Meghan Etsey is a fourth year medical student from St. George’s University. She has a Bachelors of Arts in Biology and a Bachelors of Arts in Nutrition and Dietetics from Bluffton University in Bluffton, Ohio. She served as the President of the St. George’s University’s Women in Medicine chapter in St. George, Grenada where she expanded relationships with the community and worked towards educating women and helping the youth. She is also a member of the Gender Equity Task Force and Sex and Gender Health Collaborative Committees within the American Medical Women’s Association. When she is not pursuing medicine, you can find her with her friends and family on different road trips and adventures exploring the world.
Vashti Price, MS, MHS, MS4
Vashti Price is a fourth-year medical student at St. George’s University. She holds a Bachelor of Science in Biology from the University of Louisiana at Lafayette, a Master’s in Biological Sciences from Alcorn State University, and a Master’s in Health Sciences from Meharry Medical College. With a strong passion for public health and health equity, Vashti has dedicated much of her time over the years to volunteering with underserved populations, including individuals experiencing homelessness and children in need. Her commitment to service continues through her involvement with the American Medical Women’s Association, where she serves on the Gender Equity Task Force and the Sex & Gender Health Collaborative Committees. Vashti is particularly interested in the intersection of medicine, public health, and community outreach. Outside of her academic and clinical pursuits, she enjoys spending time with friends and family, attending festivals, exploring new cities, and winding down with a good Netflix series.
Formatting, publication management, and editorial support for the AMWA GETF Blog by Vaishnavi J. Patel, DO