How full is the glass? A perspective on women in medical leadership in Canada
F. Gigi Osler, MD
What do we really know about the representation of female physicians in medical leadership in Canada? Female representation on the current boards of the Canadian Medical Association and provincial/territorial medical associations is 23% and 40%, respectively. Identified barriers to female medical leadership include gendered organizational and workplace culture, gender bias, inflexible work practices, unequal childcare and domestic responsibilities, and biased performance assessment criteria and recruitment practices. Identified enablers include flexible tenure policies, systematic parental leave policies, greater inclusivity in the workplace, and formal mentorship structures. More has been written about the costs of leadership for female physicians rather than the benefits. Reinforcement of the positive aspects of leadership may serve as a motivator, particularly if the message is delivered by other female physician leaders. The negative consequences of the existing gender gap in medical leadership may have implications not only for physicians, but also for patients and the health care system. Further study on diversity and equity in medical leadership in Canada is needed to identify areas for improvement and ongoing work to address and correct gaps.
KEY WORDS: female physician leadership, barriers to leadership, enablers, benefits and costs of leadership, tracking women’s leadership
“If you can’t measure it, you can’t improve it,” or some variation thereof, is a frequently cited quotation of the late legendary management scholar, Peter Drucker. What do we really know about the representation of female physicians in medical leadership in Canada? What do we know about the barriers and enablers that female physicians experience in pursuing medical leadership positions? And what do we know about the benefits and costs to female physicians of taking on medical leadership positions? The short answer to all three questions is simply not enough. And if we are not measuring and tracking female physician leadership, how can we improve it or even recognize where it needs to improve?
How represented are female physicians in medical leadership in Canada?
Despite the lack of commonly accepted typology of medical leadership positions in Canada, I suggest three large categories: elected positions in organized medicine, clinical/administrative positions in hospitals, and faculty appointments in academic health sciences centres. Organized medicine includes the national medical organizations, national specialty and special interest societies, and the provincial/territorial and local medical associations. In the absence of systematic data collection, I will review selected examples in each category based on data availability. Although there are hundreds of medical organizations in Canada, I only have ready access to current data for the Canadian Medical Association (CMA) and the provincial/territorial medical associations (PTMAs).
As of January 2018, 42% of the 84 260 practising physicians in Canada were women.1 This percentage is projected to reach 50.1% in 2030.2 The 42% figure will serve as the benchmark of comparison for each of the categories that follow. Top
In August 2018, I was installed as the eighth female president of the CMA. I am also the first woman of colour and the first female surgeon to serve as CMA president. It took more than 100 years after the CMA was established in 1867 for the first female president, Dr. Bette Stephenson, to be installed in 1974. She went on to have a distinguished political career in the Ontario government and cabinet. Although eight female presidents might not seem like many over a 151-year history, I will be the fourth female CMA president in less than a decade; clearly the pace is picking up. The rapidly increasing number of women in the Canadian medical profession is a contributing factor. At the time of Dr. Stephenson’s installation, just a fifth of the MD degrees awarded in Canada were received by female graduates; by 2017, this proportion had nearly tripled to reach 57%.3
A more robust indicator of the changing representation of female physicians in organized medicine leadership can be seen in the gender composition of CMA/PTMA boards of directors. Although female representation on the CMA board is just 23% of the 26 directors, as of June 2018, females represent 40% of the 179 physician directors serving on the PTMA boards. In New Brunswick and Newfoundland and Labrador, female physicians outnumber the male board members. This compares favourably with the 42% representation in the practising profession and highly favourably with the data for corporate Canada, which show that women occupied just 14% of board seats in 2017.4
This did not happen by accident. Since the 1990s, the CMA and the PTMAs have all drawn attention to the issue and promoted better representation of female physicians. In 1990, the CMA Board of Directors appointed an ad hoc Committee on Women’s Issues, chaired by Dr. May Cohen from McMaster University. This became formalized as the Gender Issues Committee and met throughout the 1990s to advise the board. On the recommendation of this committee, the CMA established a Leadership Workshop for Medical Women that was offered for several years. In 2001, Dr. Cohen became the inaugural recipient of the CMA’s May Cohen Award for Women Mentors, which continues to be presented annually to a female physician mentor who has demonstrated outstanding leadership abilities in enhancing mentorship opportunities for female physicians.5 In 2015, Joule’s Physician Leadership Institute (PLI) began offering a two-day course: Leadership for Medical Women.6 Female physicians are participating in leadership development and represented 48% of the physicians who enrolled in one or more of the PLI’s offerings in 2017.
Aside from recognizing the importance of gender composition, the CMA/PTMAs have taken measures to encourage and facilitate the participation of female physicians in leadership positions. The New Brunswick Medical Society has adopted a specific intent to make its board and committee structure more reflective of the future composition of its membership and has made gender a specific consideration in its recruitment strategy. In an effort to promote inclusivity at its annual General Council meeting, the CMA began offering a child care subsidy for delegates (both female and male) several years ago and, at the 2018 meeting, welcomed breastfeeding in the plenary sessions and offered a wellness/breastfeeding room.
It would be useful to collect data on the representation of female physicians in elected and staff leadership positions across the full range of medical organizations in Canada at all levels. Prospective data collection is necessary to monitor the gender gap, follow trends, and formulate strategies.
Clinical/administrative roles in hospitals
No database in Canada captures information on the numerous leadership roles that physicians play in hospitals. Physicians occupy positions, such as clinical division head, committee member/chair, chief of staff, president/vice-president of the medical staff, and CEO, but numbers are not known. Most regionalized jurisdictions no longer have hospitals, per se, and it is not easy to find information about medical staff structures across the acute care facilities within a region.
Ontario still has hospitals with individual boards; the CEO, chief of staff, and the president and/or vice-president of the medical staff association are typically included as ex officio non-voting members of the board. The Ontario Hospital Association represents virtually all hospitals in Ontario and lists its hospital members on its website.7 A review of the current gender composition of 133 hospital boards reveals that, of the 327 physicians serving in one of the abovementioned capacities, only 28% are female. Although this is double the representation of women on Canadian corporate boards, it still falls short of the reference point of 42%. Also, while 327 is a robust sample, it would be useful to round out the picture by being able to capture the full breadth of medical leadership roles in health facilities across Canada.
Faculties of medicine and dentistry
The underrepresentation of female physicians among the senior ranks of academic leadership is a longstanding issue. Gender-based data are not published systematically in Canada as they are in the United States by the Group on Women in Medicine and Science of the American Association of Medical Colleges (AAMC), which produces annual tabulations for a report: The State of Women in Academic Medicine. The most recent version, for 2015,8 shows that the percentage of MD faculty who are women declines steadily with increasing rank, from 51% at the instructor level to 20% at the full professor level.
Statistics Canada’s university and college academic staff system has a code to capture clinical full-time staff in faculties of medicine (including veterinary medicine) and dentistry. In 2016/17, women represented 50% of the faculty at the assistant, 41% at the associate, and 23% at the full professor levels.9 This is similar to the findings from the United States. Again, it would be useful to be able to monitor trend data. Top
The underrepresentation of women in medical and health care leadership is a global phenomenon. The World Economic Forum has reported that while women constitute 61% of employment in health care worldwide, over 2007–2017, they accounted for less than 40% of hiring in health care leadership positions.10
What are the barriers and enablers to seeking leadership positions?
Most of the literature on this topic has concentrated on female physicians in academic settings. Almost 30 years ago, Dr. Wendy Levinson and colleagues11 reported on a survey of academic female physicians in the United States regarding their experiences of combining career and family life. Clearly, time management associated with juggling family and career responsibilities was a challenge, if not a barrier, to career advancement. Almost seven in 10 respondents reported that having children had slowed their career progress either markedly (12%) or somewhat (56%). Levinson et al. recommended strategies including flexible tenure policies, systematic maternity leave policies, and role models and mentors.
In 2016, Drs. Paula Rochon, Frank Davidoff, and Levinson12 revisited this paper, asking “has anything changed in 25 years?” They noted the continued underrepresentation of female physicians in the senior ranks of academic medicine and recommended greater flexibility in structuring career paths and the use of metrics, such as those published by the AAMC.8
In 2018, Pattani et al.13 published a survey of full-time faculty members at a large university department of medicine in Canada. Most participants were aware of the existing gender gap in academic medicine and described social exclusion, reinforced stereotypes, and unprofessional behaviours as consequences of this gap in terms of organizational effectiveness and culture. Suggested improvements included:
Female physicians take on a greater share of the responsibilities of raising children and maintaining a household. Although not current, the findings of the CMA’s 2002 Physician Resource Questionnaire showed this very clearly.14 Among physicians with children under age 18 at home, female physicians reported almost three times the number of hours a week with primary responsibility for children compared with male physicians (42.2 versus 15.0 hours). Female physicians also reported spending more than 1.5 times as many weekly hours maintaining the household as male physicians (12.5 versus 8.0 hours). Anecdotal evidence suggests that a gap still remains. Top
In conversations with other female physicians, some comment on having to choose between the “mommy track and the tenure track.” A commentary on the Rochon et al.12 paper concluded with the following: “we do not wish our sons and daughters to grow up believing that women have to follow a different career path than men because they have greater responsibilities at home. We want them to grow up thinking that men and women equally share both domestic and work responsibilities.”15
Most recently Mangurian et al.16 highlighted additional barriers beyond inflexible leave polices, including unconscious bias against female physicians and sexual harassment, which is gaining overdue attention through the #MeToo movement. They identify a number of policies and actions in the categories of:
Costs and benefits
Based on a quick review of the literature, it would appear that more has been written about the costs of physician leadership than the benefits, in particular, the costs for female physicians. In a qualitative study of 35 female physicians at the Ottawa Hospital,17 participants clearly assessed leadership as costly in terms of both time away from their personal and family lives and time away from clinical practice. Other concerns included being perceived as depriving others of leadership opportunities, having to get their colleagues to cover their absences while executing their leadership responsibilities, fear of rejection among those who self-identify for a leadership position, a perceived lack of respect for leadership by physician peers and a perceived lack of support by nursing leaders. As the authors summarized their results, “on the whole, participants perceived that to be a leader in their current work context would be burdensome and unrewarding.”17
I believe there is benefit in leadership and value in service. It would be useful to know how other physicians and medical leaders define the benefits of leadership. Reinforcement of the positive aspects of leadership may serve as a powerful motivator, particularly if the message is delivered by other female physician leaders. In 2015, the Royal College of Physicians and Surgeons of Canada renamed the original CanMEDS manager role to leader.18 I look forward to seeing research around the measurement and acquisition of the competencies for the leader role and whether it subsequently affects the uptake of leadership opportunities by both female and male physicians alike. Top
It is heartening to see increased attention to improving equity, diversity, and inclusion in medical leadership across Canada. This commentary has approached the gender gap from a non-intersectional perspective, yet a key component in improving equity and diversity lies in taking an intersectional approach: we cannot overlook the lack of women in medical leadership without considering the current status of racialized, disabled, LGBTQI physicians, and other underrepresented groups as well. There is growing evidence to suggest that the interplay of these factors creates even greater barriers to career advancement and certainly warrants further discussion and exploration.19
In a Toronto Star commentary in September 2017 entitled “Canadian medicine has a diversity problem,” Dr. Adam Kassam20 illustrated his point about the health care system with the observation that, of the 39 federal health ministers since Health Canada was established in 1919, only nine have been women, one was First Nations, and one was from a visible minority.
Medical school is the logical place to begin growing this diversity, and it is encouraging to see recent developments in the universities and medical faculties across Canada. In June 2017, the University of Manitoba Rady faculty of health sciences launched the Indigenous Institute of Health and Healing (Ongomiizwin) under the leadership of Indigenous physician, Dr. Marcia Anderson.21 In 2016, the Admissions Review Committee of the faculty of medicine of Dalhousie University put forward recommendations to the dean intended to increase the number of African-Canadian and Indigenous medical students22; Dalhousie graduated six students of African descent in each of 2017 and 2018. The University of Toronto’s faculty of medicine has appointed Dr. Lisa Robinson as chief diversity officer.23 These measures will all contribute to a more diverse profession that is more fully representative of the patient population that we serve.
The negative consequences of the existing gender gap in medical leadership may have implications not only for physicians, but also for patients and the health care system. Implementation of gender equity strategies could benefit all physicians along with improving workplace culture and effectiveness. Furthermore, some studies have suggested that the gender gap may have implications for patient care and health outcomes.24,25 Finally, the experience of the corporate world suggests that diversity would be beneficial for the health care system. As the federal government’s Advisory Council for Promoting Women on Boards reported, “studies in Canada, the United States, Australia and Europe demonstrate that businesses with more women on their boards and in senior management outperform those with fewer women.”26
The CMA believes in a vibrant medical profession. With the increasing number of women entering medicine, we see the increasing need to encourage and support female physician leadership in Canada. It is needed, and now is the time. Top
1.Number of active physicians by age, sex and province/territory, Canada, 2018. Ottawa: Canadian Medical Association; 2018. https://tinyurl.com/y6vhy9cv (accessed 8 Aug. 2018).
2.Physician resource evaluation template. Unpublished. Ottawa: Canadian Medical Association; 2016.
3.Canadian medical education statistics. Table 29. Ottawa: Association of Faculties of Medicine of Canada; 2017. Available: https://tinyurl.com/yb3sotwc (accessed 8 Aug. 2018).
4.Regulators release new findings and trends on women on boards and in executive officer positions. Montréal: Canadian Securities Administrators; 2017. Available: https://tinyurl.com/yb7fmc9v (accessed 8 Aug. 2018).
5.May Cohen Award for Women Mentors. Ottawa: Canadian Medical Association; n.d. Available: https://tinyurl.com/ycogtk5y (accessed 8 Aug. 2018).
6.Leadership for medical women. Ottawa: Joule, Physician Leadership Institute; 2018. Available: https://tinyurl.com/y76wqtjk (accessed 8 Aug. 2018).
7.OHA members. Toronto: Ontario Hospital Association; n.d. Available: https://www.oha.com/membership/oha-members (accessed 8 Aug. 2018).
8.The state of women in academic medicine: the pipeline and pathways to leadership, 2015-2016. Table 4A. Washington: Association of American Medical Colleges; 2018. Available: https://www.aamc.org/members/gwims/statistics/ (accessed 8 Aug. 2018).
9.University and College Academic Staff System. Custom tabulation. Staff count by rank, gender and medical or dental appointment category, 2016/2017. Ottawa: Statistics Canada; 2017.
10.The global gender gap report 2017. Geneva: World Economic Forum; 2017. Available: https://tinyurl.com/ybufmzbs (accessed 9 Aug. 2018).
11.Levinson W, Tolle S, Lewis C. Women in academic medicine: combining career and family. N Engl J Med 1989;321:1511-7.
12.Rochon P, Davidoff F, Levinson W. Women in academic medicine: has anything changed in 25 years? Acad Med 2016;91(8):1053-6.
13.Pattani R, Marquez M, Dinyarian C, Sharma M, Bain J, Moore J, Straus S. The perceived organizational impact of the gender gap across a Canadian department of medicine and proposed strategies to combat it: a qualitative study. BMC Med 2018;16:48 https://doi.org/10.1186/s12916-018-1032-8.
14.Martin S. More hours, more tired, more to do: results from the CMA’s 2002 Physician Resource questionnaire. Data Supplements. CMAJ 2002;167(5):521-2. Available: https://tinyurl.com/yaukway4 (accessed 8 Aug. 2018).
15.Anderson R, Brady AK, Aitken ML. Gender equality in academic medicine requires changes for both men and women. Acad Med 2017;92(8):1067. doi: 10.1097/ACM.0000000000001791
16.Mangurian C, Linos E, Sarkar U, Rodriguez C, Reshma J. What’s holding women in medicine back from leadership. Harv Bus Rev 2018;19 June. Available: https://tinyurl.com/ycd6efrk
17.Roth V, Theriault, Clement C, Worthington J. Women physicians as healthcare leaders: a qualitative study. J Health Organ Manage 2016;30(4):648-665.
18.Frank J, Snell L, Sherbino J. CanMEDS 2015 physician competency framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015. Available: https://tinyurl.com/j53ulbz (accessed 8 Aug. 2018).
19.Ginther DK, Kahn S, Schaffer WT. Gender, race/ethnicity, and National Institutes of Health R01 research awards: is there evidence of a double bind for women of color? Acad Med 2016;91(8):1098-107. doi: 10.1097/ACM.0000000000001278
20. Kassam A. Canadian medicine has a diversity problem. The Star 2017;3 Sept. Available: https://tinyurl.com/yavgmhsj
21.Mayes A. Indigenous institute to be launched with celebration, dialogue. Winnipeg: Rady Faculty of Health Sciences, University of Manitoba; 2017. Available: https://tinyurl.com/ydfzsd8c (accessed 8 Aug. 2018).
22.Recommendations to the dean, Faculty of Medicine. Halifax: Dalhousie University Admissions Review Committee; 2016. Available: https://tinyurl.com/yd9xzhzx (accessed 8 Aug. 2018).
23.Chief diversity officer. Toronto: University of Toronto, Faculty of Medicine; 2018. Available: https://tinyurl.com/y83nb9ab (accessed 8 Aug. 2018).
24.Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for medicare patients treated by male vs female physicians. JAMA Intern Med 2017;177(2):206-13. doi:10.1001/jamainternmed.2016.7875
25.Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U.S.A. 2018. https://doi.org/10.1073/pnas.1800097115
26.Good for business: a plan to promote the participation of more women on Canadian boards. Ottawa: Advisory Council for Promoting Women on Boards; 2014. Available: https://tinyurl.com/yc9dnwlt (accessed 8 Aug. 2018).
I thank Owen Adams, chief policy advisor at the Canadian Medical Association, for providing the data for this article and useful comments on the manuscript.
F. Gigi Osler, BScMed, MD, FRCSC, is head of the Section of Otolaryngology-Head and Neck Surgery at St. Boniface Hospital, assistant professor in the Department of Otolaryngology-Head and Neck Surgery at the University of Manitoba, and, currently, president of the Canadian Medical Association. Top
This article has been peer reviewed.