Gender diversity in academic medical leadership: are we moving the needle?
Megan Delisle, MD, and
Debrah Wirtzfeld, MD
The gap between men and women in academic medical leadership is larger today than it has ever been, and we must all work together to effect the necessary change. In this article, we look at the promotion of diversity in Canadian medical schools, explore implicit biases, and offer practical suggestions to help Canadian health care organizations establish gender equity in leadership positions. Individuals, both men and women, have a role to play in ensuring gender diversity.
KEY WORDS: gender diversity, equity, equality, inclusion, women’s leadership
Leadership is not new to women. Some of the most important scientific discoveries were led by women, but men often received the acknowledgements and rewards, a phenomenon known as the Matilda effect.1 For example, Rosalind Franklin made a major contribution to the discovery of the structure of DNA, for which Francis Crick and James Watson received the 1962 Nobel Prize. In 1903, Marie Curie was awarded the Nobel Prize with her husband for her work on the discovery of radioactivity, but she was only added as a recipient of the award because a committee member advocated the recognition of women in science. The reason women continue to have minority representation in the top leadership roles of almost all modern organizations is not because they do not possess the necessary leadership skills.2 The reason is deeply rooted in complex systemic issues.
Why do we lack gender diversity in academic medical leadership?
The number of women in medicine has increased dramatically since the 1960s.3 To many this is a sign that society has made progress toward diversity and inclusion; however, the presence of women in the upper echelons of medicine lags behind this trend. In fact, the gap between women’s representation in medicine and their participation in top leadership positions is even greater today than it was a generation ago. Top
No one is to blame for the lack of diversity and inclusion of women in health care leadership. It is our innate instinct to surround ourselves with people who share similar psychological and physical traits. Human biologist, E.O. Wilson,4 explains that, historically, our tribal behaviour is what kept us safe. It gave us a sense of belonging that drove us to perform altruistic acts for the tribe and put its members before ourselves. This tribal instinct has likely played a large role in succession planning in academic medical leadership, which was dominated by Caucasian men until the 1960s.4 Humans are wired to feel uncomfortable when there is diversity, as this increases the risk of adversity resulting from differing values and beliefs. However, we cannot solve today’s complex problems with the same thinking that got us here.
The current health care system is in dire shape, with high rates of preventable adverse events and wasteful medical expenditures.5,6 Future innovations and progress in medicine will come from leaders who look at things differently and from a society that embraces these alternative views. If we do not intervene, it will take over 200 years for women to naturally migrate into positions of top leadership.7 In this article, we discuss the benefits of and obstacles to including women in academic health care leadership, and we offer practical suggestions to help Canadian health care organizations establish gender equity in these positions.8
The benefits of gender diversity in leadership
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It is tempting to believe that this means women have better leadership abilities, as concluded by Catalyst; however, it may also be related to the fact that only the top performing women are able to obtain leadership positions in today’s organizations. This outperformance is a secondary effect of the higher standards to which all women are held.10
The third pillar is improved employee, consumer, and investor commitment as well as increased social responsibility on behalf of the organization.9 The variety of perspectives found in more diverse organizations creates a safe space for self-expression and allows more consumers and investors to identify with the values of the organization. Companies that value gender diversity are considered forward thinking and acting in the best interests of their clients and employees. Some countries have even started to implement legal requirements for diversity.
The final pillar is improved innovation and group performance seen with increasing numbers of female leaders. This is believed to result from the more astute social sensitivity of women leading to improved internal dynamics and collective intelligence. Although there exists limited direct evidence demonstrating that these benefits of gender diversity in leadership will translate into similar benefits for the health care setting, there is no reason to believe that they would not.
The role of equity
There are no two words that look as similar, but represent such opposite ideas as “equality” and “equity.” Equality is about giving everyone the same opportunities to be successful (i.e., the same starting line). In contrast, equity is about understanding what people need and providing this so that they might be successful (i.e., the same finish line). This does not necessarily mean that everyone will receive the same thing
(Figure 1).11
Until now, equality has been our approach to improving leadership diversity in academic medicine. The hallmark features of this strategy include trying to make women more competitive in taking opportunities that have traditionally been awarded to men: for example, through courses that develop negotiation skills and more assertive leadership styles.12 It is natural for this to be our approach, as we are socialized to think good leaders are synonymous with the male gender schema: agentic, assertive, competitive.13
This approach tries to “fix” women, but teaching women to lead like men may actually set them back. For example, when they exert their newly learned skills, they violate the traditional gender schema they are held to — namely nurturant, sensitive, warm, and communal — resulting in negative labels, such as bossy or rude.13 Although these leadership initiatives are well-intentioned, they do not support the necessary change in a sustainable manner. A better approach would be to encourage women to lead like women and support this by allowing the system to accept this different style using initiatives that foster equity. Top
The role of implicit bias
14
For example, a test developed by a collaboration of psychologists at Harvard University, University of Virginia, and University of Washington quantitatively measures an individual’s level of implicit gender bias to make them more aware of the role it may play in their actions and decisions.15 Over 72% of Canadians who have taken the test have some degree of gender bias.15 Among women, 70% report facing gender-specific bias in academic medicine and 30% report personally experiencing harassment compared with only 4% of men.14 This seems like a high proportion, but studies have shown that only 20% of such experiences are reported, so this is likely only the tip of the iceberg.16
Implicit biases have serious negative consequences at the individual and societal levels.17 For example, in a randomized double-blind study, Moss-Racusin et al.18 demonstrated that science faculty rated the same application from two students, who were randomly assigned either a male or female name, differently. The male applicant was rated as significantly more competent and hireable than the identical female applicant.18 Studies have also demonstrated similar mechanisms resulting in women being significantly less likely to get grants and promotions compared with their male colleagues.19–21 Maternal bias, a more specific type of gender bias, results in physician mothers being perceived as having competing time demands and priorities that make them less ideal candidates for leadership positions.22 Implicit bias has been shown to have at least as bad, if not worse, consequences in terms of individual well-being than the historical forms of more blatant discrimination.14,23
At the societal level, implicit bias is the first step toward and an important enabler of more dramatic acts, as conceptualized by the pyramid of hate (Figure 2).24 If we do not intervene now, the prevalence of acts at the upper tiers of the pyramid will only become more prevalent. We need a zero-tolerance policy for these behaviours. The combination of these negative experiences and male-normed assumptions about who can lead contribute to the higher rates of burnout and drop-out seen among women in medicine overall.25,26 With all these obstacles to overcome and factors pushing women away from leadership positions, we see more clearly why only the top 1% can succeed in this environment.27
Achieving equity in academic medical leadership
Equity in health care leadership can be achieved through policies targeted at stopping the Matthew effect.1 This term refers to the phenomenon, based on the Matilda effect, where a self-perpetuating cycle exists as men are more likely to get recognized leading to more opportunities for accomplishments.1
Policies must provide women with the resources and support they need to gain access to the same opportunities as men. These initiatives will require affirmative action through the implementation of best practices along the entire continuum of a medical career, starting with training, through to hiring, retention, and promotion, as it is not a single event that determines an individual’s leadership potential.27 Rather, it is the culmination of experiences over a lifetime that determines one’s commitment to the medical profession and one’s desire to lead. Top
Medical schools and residency programs
Medical school admissions currently have equal representation of men and women, but a “leaky pipeline” exists, as there is no longer an equal distribution in the upper tiers among academic medical leadership. A study by Roth et al.28 found that female physicians feel that medical leadership would distract them from their personal and family responsibilities and believe that these are incompatible priorities. These women also view leadership recruitment processes to be unfair, lacking transparency, and highly politicized.
Women need to be socialized to believe that they can become leaders in academic medicine and that these positions are equally available to them. Mentorship is needed to support women in entering traditionally male-dominated leadership positions. This starts by encouraging men to feel comfortable mentoring women by educating them on their own implicit biases. Reference letters should be standardized to avoid generalizations based on preconceived notions of gender schemas.29 These early career experiences are critical in influencing women’s desire and ability to enter academic medical leadership positions later in their career trajectory.
Practising physicians and health care organizations
Diversity and inclusion must be incorporated into the hiring, retention, and promotion of individuals. These are the strategies that top businesses have successfully used to become leaders in diversity and inclusion, including Google, Facebook, Apple, Boston Consulting Group, and McKinsey & Company. The following are suggestions for the development of academic leadership potential in women.
1. Ensure the values of our health care organizations are consistent with diversity and inclusion
Companies can distinguish themselves and attract a larger pool of talented prospective employees by explicitly stating that diversity is a part of their vision, mission, and values. A strategic plan and publicly available, up-to-date reports detailing the existing diversity among employees at all ranks establishes transparency.30 Better reporting systems are needed to allow people to speak up without fear of retaliation or stigmatization. One example is Callisto, a third-party, online system that reports perpetrators to participating organizations if they are subject of at least two complaints.31 A commitment to diversity needs to be woven into every aspect of a health care system, starting at the top.
2. Establish a diversity committee
A diversity committee is necessary to hold organizations accountable to their mission. Diversity should not be a tokenistic empty promise or an afterthought. Supporting and maintaining gender-equitable health care organizations is a full-time job, and the necessary resources should be allocated to it. An important role of a diversity committee is to provide implicit bias training, particularly to members of recruitment committees. American-based companies, such as Bias Interrupters for Managers, have been successfully employed by health care organizations for this specific purpose.31 In May 2018, Starbucks closed all 8000 stores throughout the United States and Canada to provide employees with implicit bias training. The Government of Canada provides Canadian research chairs with a module on the role of implicit bias in the peer review process.32 These are some examples that can be used to inspire the development of grassroots initiatives in Canadian health care organizations. Top
3. Blinded reviewing, standardized interviews, and objective promotions criteria
Among other inequities, women are assessed based on their accomplishments and men in terms of their potential.33 Women are punished more harshly for their failures.29 Recruitment teams have started to institute blinded hiring processes to overcome these imbalances. This can range from candidates being judged exclusively on their skills, based on a series of objective aptitude tests, anonymized résumés, and chat-room led interviews that employ voice-masking technology. It is also important for organizations to be transparent about the weight they will attribute to prespecified promotions criteria and to prioritize developing and promoting internally through talent development initiatives specifically for women.
4. Support through mentorship, sponsorship, and targeted opportunities for women
Mentorship is critical to the development of leadership skills, and sponsorship is necessary to enter into leadership positions. Women report difficulty finding mentors and are significantly less likely to receive sponsorship. Mentors provide advice and guidance whereas sponsors advocate for you in the workplace when you need to be more visible, such as being recommended as a panelist, to write an editorial, or to serve on an editorial board or a national committee.34,35 Although mentors and sponsors serve different purposes, their end goal is the same: to support you in achieving your goals. The equity gap can be closed through formal mentorship programs and encouraging peer mentorship programs. Training sessions to ensure senior leadership members feel comfortable mentoring and sponsoring women should be available. Top
5. Transparent, objective compensation plans
Roth et al.28 found that women do not perceive academic leadership to be worth the effort, that they perceive the sacrifice to be greater than the benefits. The gender pay gap may be contributing to these feelings, as women are paid as little as 46% of their male colleagues’ salaries for the same job.36 Objective compensation plans have been instituted at Oregon Health and Sciences University and the University of Alabama at Birmingham. These initiatives have helped bring women’s salaries up to 72% of their male colleagues’ salaries over the course of just a few years. Another strategy shown to reduce the gender pay gap includes annual salary reviews, successfully implemented by Columbia University and the University of California in San Francisco.31 Better and equitable remuneration may help attract more women to demanding leadership positions.
6. Flexible and equitable family-friendly policies
The significantly higher rates of emotional exhaustion seen among women compared with men after having children must be addressed if we are to give women a chance at remaining competitive for top leadership positions.37 At least 12 weeks of paid childbearing leave with an additional 4–12 weeks for new parents should be available to help address the physical and emotional needs of having a child.31,38,39 These policies should be clear and not at the discretion of supervisors. There should be lactation rooms and protected time for breast milk pumping, such as relieving women for at least two 30-minute periods every eight hours. Increased breastfeeding has been shown to have a strong return on investment in terms of reduced sick leave and improved retention and productivity.40 On-site childcare services and emergency back-up care for sick children at home are available at the University of California in San Francisco at a cost 10% below market rates.31 Women are also more likely to have to care for their sick relatives, and paid catastrophic leave can help alleviate the stress associated with this societal duty.31 Finally, women should not be penalized for deciding to teleconference into meetings. Efforts should be made to minimize the burden of evening meetings, allowing women to reclaim this time away from their families without penalty. Top
It is important to note that the focus of these six initiatives is mainly on increasing diversity. Progress in diversity is easier to measure than its counterpart, inclusion. Diversity is determined by the overt variability in things like gender, ethnicity, religion, sexual orientation, language, etc. Inclusion represents the actual behaviours that welcome and embrace the views these people bring, even if they do not represent mainstream beliefs and attitudes. As diversity becomes more commonplace, it is the hope that people will more readily accept and incorporate the new ways of thinking. However, the outcome is not guaranteed, and we must continuously ask ourselves if we are truly achieving inclusion rather than diversity alone.
What are we doing to promote diversity and inclusion in academic medicine in Canada?
A search using the words diversity and inclusion on the websites of the Association of Medical Faculties of Canada, the Royal College of Physicians and Surgeons of Canada, and the College of Family Physicians of Canada returns only one equity, diversity, and inclusion committee with no information on its mission or ongoing projects.41
The 17 Canadian medical schools vary in what is currently being done to foster diversity and inclusion (Table 1). Most have a mission statement, policies, or an advisory committee. The focus on diversity is mostly at the undergraduate level, which may explain why we have seen such a dramatic shift in the demographic profile of medical school admissions resulting in equal distributions of men and women. However, there is clear evidence that this is not enough to achieve gender diversity in academic medical leadership because of the “leaky pipeline.”42
Equal efforts are needed at the graduate level and in practice. The University of Ottawa’s faculty of medicine deserves mention, as it the only medical school with diversity resources specifically targeted at leadership. For example, it provides training on unconscious bias for search committees as well as a mentoring program for women faculty. Diversity and inclusion initiatives need to be regulated through accreditation standards to ensure minimum standards. Top
Canada is significantly behind the United States with regard to strategies to improve leadership diversity in academic medicine. The Association of American Medical Colleges has an active diversity and inclusion program with diversity profiles available for the physician workforce (2014)43 and medical education (2016).44 It also has publicly available resources to guide the establishment of best practices for diversity and inclusion across institutions. Top
The American College of Healthcare Executives (ACHE) has produced several white papers addressing this topic and assessing the impact of strategies used to improve diversity and inclusion in health care leadership. In 2017, the ACHE launched the Institute for Diversity and Health Equity to meet the broader demands to increase leadership diversity and with the mandate of working with institutions to expand leadership opportunities for minorities and women.45 Initiatives included under their umbrella are educational sessions on equity with the opportunity to obtain a certificate in Diversity in Health Management, bi-annual benchmark surveys assessing leadership diversity in health care, mentorship opportunities, and conferences. Equivalent initiatives are needed in Canada.
The role of the individual
Many of the strategies suggested above will take systemic efforts to successfully implement and will require a culture shift before we begin to reap the benefits. In the meantime, there are things that we can do as individuals to begin to make improvements. These will also serve as the “on ramp” to facilitate the bigger initiatives coming down the pipeline.
First, both men and women can find tactful ways of speaking up when we experience or observe inappropriate behaviour resulting from implicit bias. We can do this using real-time interventions as many of these offenses are unintentional. Examples include asking “what did you mean by that?” or “what you are saying/doing is making me uncomfortable.” Top
Second, we can make sure credit is given to the women who deserve it, as their voices are often ignored. For example, President Obama’s cabinet members were two-thirds men, and women often felt their ideas were being attributed to this dominant, more assertive group. They started to use a strategy called amplification, which involved repeating a key point made by a women and acknowledging the author to make sure they got credit.46
Third, we can make sure women are introduced and addressed by their professional titles. Studies have demonstrated that men are referred to as doctor 72% of the time and women only 49%.47
Finally, whenwomenunderestimate their potential and negotiate lower starting salaries, we can redirect them to a more suitable starting number.48 These actions will help normalize equity initiatives and behaviours and contribute to a more fair work environment.
Men as allies
Finally, we have to make sure men are allies and equally a part of this movement to avoid inadvertent consequences and harm.49 For example, campaigns, such as #MeToo, can result in gender-neglect as well-intentioned men become reluctant to mentor and sponsor women out of fear of being accused of mistreatment. Framing gender bias as a human rights issue rather than a women’s issue will allow people to stand in solidarity.50 It is not one single action that will result in gender diversity in leadership, but rather the energy that results from the work we do as a community, creating and generating new ideas and solutions, will begin to move the needle. Gender diversity in academic medical leadership will only be achieved if we work together.51
Conclusion
The gap between men and women in academic medical leadership is larger today than it has ever been, and we must all work together to effect the necessary change. We need to build on the evidence in other professions that demonstrates the benefits of gender diversity in health leadership to strengthen the support and motivation that is driving this change.
At the core of this movement is educating the health care workforce on the role of implicit bias and the need for access to equitable opportunities. We need to define what a gender-equitable organization looks like and who should be responsible for ensuring that a minimum standard is adhered to.
We can no longer believe that change will happen organically. Affirmative action will have to be undertaken to allow women to move into positions of influential leadership. Health care organizations must be held accountable and change must be visible. Finally, we need to remain cognizant of how we frame our efforts to ensure that we generate support and unity, not opposition and division, for this important initiative. Top
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Attestation
Both authors declare that they contributed substantially to this work, revised it critically, approved the final version, and agree to be accountable for all aspects of the work. Top
Author
Megan Delisle, MD, is a master of public health candidate at Harvard University and a general surgery resident in the section of general surgery, University of Manitoba.
Debrah Wirtzfeld, MD, FRCSC, CEC, CCPE, ICD.D, is a professor of surgery in the section of general surgery and director of leadership development, Max Rady College of Medicine, University of Manitoba.
Correspondence to:
This article has been peer reviewed.