How to increase diversity: views from young physician leaders
Melanie Bechard, MD
Every physician leader has the power to increase the representation of early-career women physician leaders. Recommendations, based on interviews with young physician leaders — both women and men — as well as brief highlights from the literature, include dispelling myths such as women’s “disinterest” in leadership roles, eliminating bias and exposing unconscious ones, avoiding discriminatory language, and accommodating family demands.
KEY WORDS: diversity, physician leaders, women physician, young physicians, myths, bias, discriminatory language
As leaders, we women physicians transform and contort ourselves in countless ways, impossibly balancing perceptions of likeability with competency, authenticity with self-preservation. The situation is particularly sensitive for learners and early-career women physician leaders. Without the security of an established career, advocating leadership diversity and promoting oneself may result in significant personal and professional consequences.
The intent of this article is not to invoke blame or guilt. All people, physicians included, have biases. Some are overt and easily demonstrable. Most are subconscious. Yet the collective subconscious bias of the culture of medicine has very apparent effects.
Women clinical department leaders in the United States are outnumbered not only by men, but even by men with moustaches.1 It is a moral imperative that our medical leadership better reflect the general population. Gender is only one metric of diversity. Equally important is ensuring diversity in religion, racial background, socioeconomic background, sexual orientation and gender expression, family status, and appearance. These factors can interact to affect one’s social standing — a phenomenon known as intersectionality. Only 25 of 166 internal medicine chairs in the United States are women, but only three are women of colour.2 Although this article focuses on the experiences of residents and new-in-practice women physician leaders, we cannot forget these other dimensions of diversity. Top
The problem is bleak, but our solutions are many. Every physician leader has the power to increase representation from early-career women physician leaders. The recommendations listed below were compiled based on interviews with young physician leaders — both women and men — as well as brief highlights from the literature.
A new-in-practice physician, Dr. Natasha Snelgrove, mentioned that members of one of her organizations questioned efforts to increase women physicians in leadership positions, as women did not seem to be interested in these roles. A brief review of the literature reveals this to be patently untrue. Male and female faculty at USA medical colleges report similar leadership aspirations.3 If these aspirations dissipate with time, we must question whether this is truly women’s choice or whether repeated barriers to advancement dissuaded them from the leadership path. Hitting the glass ceiling too many times is sure to cause a headache.
The old adage, “men are from Mars, women are from Venus” deserves our skepticism. The differences between men and women are often exaggerated and ignore the wide inter-individual variation. Although men and women tend to use different leadership styles, there is no evidence that women physician leaders are less effective than their male counterparts.4 The colleagues I spoke with acknowledged that the individual personalities of their leaders, rather than gender, seemed to have the largest impact on leadership styles.
Seek and eliminate bias
All people have biases — even subconscious ones. These are necessary mental heuristics that allow us to rapidly appraise our world. Yet these cognitive shortcuts can lead to inequitable treatment of our colleagues.
Resident physician, Dr. Anthea Lafreniere, shared examples of her experiences. “There is the sexism at the board table. But there is all the subtle sexism that happens really regularly.” Dr. Lafreniere described a meet-and-greet event for a medical association board that she attended with her husband. Although she was the incoming board member, all of the current board members introduced themselves to her husband first, assuming he was the physician and board nominee.
Dr. Lafreniere also spoke about her experience attending a national medical organization meeting as a medical student. “I walk in, and I’m looking for my nametag and seat. I step up to the table and lean over to read the name labels. The man who was sitting nearby doesn’t even look at me, whips his hand up with a piece of paper, and says ‘I need a photocopy.’ I just laughed and said that I’m a member of this committee. He didn’t apologize. He seemed to still think I was a secretary. That was my first national meeting.”
I spoke with several young women physician leaders who shared similar incidents: for example, a resident physician received an email addressed to her as “Ms. [surname]” while her male resident physician colleague was addressed as “Dr. [surname]” in the same message. Board chairs and presidents who were asked to take notes during meetings. These instances may seem trivial, but when they occur so frequently, it sends an unspoken but strong message that discredits the legitimacy of women physician leaders. Top
These situations create more than socially awkward encounters. Biases can impact the lives and careers of women physician leaders. Two thirds of women clinician-investigators in a survey felt that gender bias affected their academic advancement.5 Indeed, studies show female grant applicants of equivalent experience and prior success rates are given lower application scores than male applicants.6
Bias is a pervasive problem. Fortunately, there are mitigating strategies we can employ. Morgan and colleagues7 produced recommendations for eliminating gender bias in academic medicine: acknowledge the systemic nature of bias, motivate those with influence to promote a culture of equity, implement evidence-based anti-sexism training, ensure transparent processes for career advancement and compensation, and research drivers of and solutions to gender bias within medicine.
Dr. Alim Pardhan, an early-career physician, further emphasized the importance of building diverse teams, “Diversity in leadership teams provides added context, a wealth of different opinions that ultimately make leadership teams stronger and more flexible. Fostering diverse teams should be one of the key performance indicators of leaders. Ensuring that women are encouraged and afforded the same opportunities to participate in leadership is a key part of that.”
Acknowledge the blind spots
Dr. Thomas McLaughlin, an early career physician, informed me of when he was tasked with introducing fellows for grand rounds presentations as part of his chief resident responsibilities. After the rounds presentations, a staff physician pointed out that he had introduced the male fellows as “Dr. [surname]” and the female fellows by their first names – a common phenomenon.8 He admitted to initial surprise, but then reflected and apologized to both the staff physician and the female fellows. “I don’t think people always notice their own internal biases… when you do get something pointed out, do be open to it.”
Responding with grace to this type of feedback is unquestionably difficult. Although it takes great strength of character, an openness to these conversations is the only way we can mitigate our individual and systemic biases. Of note, women are not immune to gender bias. It is incumbent on all of us to pause, reflect, and respond with kindness if a colleague finds our blind spot. Top
Choose words carefully
One tangible action we can all take to advance women physician leaders is to consider nominating deserving candidates for awards or leadership positions. Many of us may have experienced the challenge of trying to translate a candidate’s ample qualifications into a letter of nomination. Little did we know that some of our laudatory comments might actually have harmed, rather than helped, our nominee’s candidacy.
Words matter. Each word has particular connotations. The adjectives that we often use in letters of nomination can be categorized as “agentic” or “communal” traits. Agentic traits tend to be “competency-based” (e.g., strong, logical, decisive) and associated with masculinity, while communal traits are “warmth-based” (e.g., collaborative, kind, nurturing) and associated with femininity.9 Word choice can affect medical students’ perceived suitability for different specialties.4 There is also evidence that including “leader” in the selection criteria for tenured medical faculty positions decreases the success rate of women applicants.10 When preparing letters of nomination for our women physician colleagues, it is important to consider the connotations of the selection criteria and ensure that we include relevant agentic traits as appropriate.
During a coffee break at a national meeting of medical leaders, a student leader and her colleagues were admiring their friend’s cooing infant. An older male physician passing by chuckled and exclaimed, “Typical women! Distracted by babies.” Although the comment was likely intended to be good-natured, they were surprised (partly because two members of the group were men). It also seemed a very reductive label to apply to ambitious women leaders who had spent the conference engaging in difficult debates, ardently networking, and proposing creative solutions. The student described feeling as though her contributions to the meeting were discredited because of the momentary “distraction.” Top
We have seen generational shifts in attitudes toward work–life balance; both male and female physicians are becoming more likely to prioritize family life. Resident physician, Dr. Ali Damji, expressed a need for the leadership community to embrace this mindset: “Generally, I think our leadership community needs to be more sensitive towards family needs. These are not female-specific. They need to be more responsive to having more familial responsibilities… We need to shift our mindset to people holding these multiple responsibilities as an asset and not a hurdle.”
There is evidence that women physicians contribute approximately eight additional hours a week to parenting and domestic responsibilities compared with male physicians.11 For some, that represents an entire additional workday. I spoke with multiple young physician leaders, both men and women, who expressed a desire for childcare at meetings. It is a small but tangible step toward enabling women and family-focused physicians to adopt meaningful leadership roles.
Some of these experiences may seem trivial. They certainly pale in comparison to parts of the world with systemic violence and persecution of women, or the overt and widespread discrimination faced by our woman physician predecessors. Yet, it is a wonderful thing that there is not a finite amount of justice in the world. Every one of us can work toward improving the status of women in any corner of the world, while also promoting fairness and equity for women physician leaders within our hospitals and homes. Top
1.Wehner MR, Nead KT, Linos K, Linos E. Plenty of moustaches but not enough women: cross sectional study of medical leaders. BMJ 2015;351. doi: 10.1136/bmj.h6311
2.Albert MA. #Me_who: anatomy of scholastic, leadership, and social isolation of underrepresented minority women in academic medicine. Circulation 2018;22 May. doi: 10.1161/CIRCULATIONAHA.118.035057
3.Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. Experiencing the culture of academic medicine: gender matters, a national study. J Gen Intern Med 2013;28(2):201-7. doi: 10.1007/s11606-012-2207-1
4.Carnes M, Bartels CM, Kaatz A, Kolehmainen C. Why is John more likely to become department chair than Jennifer? Trans Am Clin Climatol Assoc 2015;126:197-214.
5.Jagsi R, Griffirth KA, Jones R, Perumalswami CR, Ubel P, Stewart S. Sexual harassment and discrimination experiences of academic medical faculty. JAMA 315(19):2120-1. doi: 10.1001/jama.2016.2188
6.Morgan R, Hawkins K, Lundine J. The foundation and consequences of gender bias in grant peer review processes. CMAJ 2018;190(16):E487-8. doi: 10.1503/cmaj.180188
7.Morgan AU, Chaiyachati KH, Weissman GE, Liao JM. Eliminating gender-based bias in academic medicine: more than naming the “elephant in the room.” J Gen Intern Med 2018;33(6):966-8. doi: 10.1007/s11606-018-4411-0
8.Files JA, Mayer AP, Ko MG, Friedrich P, Jenkins M, Bryan MJ, et al. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. J Womens Health (Larchmt) 2017;26(5):413-9. doi: 10.1089/jwh.2016.6044
9.Heilman ME. Gender stereotypes and workplace bias. Res Organ Behav 2012;32:113-35.
10.Marchant A, Bhattacharya A, Carnes M. Can the language of tenure criteria influence women’s academic advancement? J Women Health 2007;16(7):998-1003.
11.Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. Ann Intern Med 160(5):344-53. doi: 10.7326/M13-0974
Many thanks to Drs. Ali Damji, Anthea Lafreniere, Thomas McLaughlin, Alim Pardhan, Natasha Snelgrove, and anonymous contributors for sharing their experiences and insights.
Melanie Bechard is a PGY4 student in pediatric emergency medicine at the University of Ottawa. She is past-president of Resident Doctors of Canada and has served on the board of Canadian Doctors for Medicare.