Leaning further

Sharron Spicer, MD


Diversity is one factor that has a positive impact on organizational performance. Women remain underrepresented in leadership positions of medical organizations despite two decades of equal numbers of male and female medical school graduates. Using Sheryl Sandberg’s well-known book Lean In as a springboard for addressing the gender gap, I propose opportunities for medical organizations to improve their gender diversity, a strategy that has potential to improve the workplace for women and men, as well as for the organizations in which they work.



KEY WORDS: women in leadership, diversity, gender gap, biological factors, psychological factors, social factors, recommendations



“Today in the… developed world, women are better off than ever. We stand on the shoulders of the women who came before us, women who had to fight for the rights that we now take for granted. Since [the 1980s], women have slowly and steadily advanced, earning more and more of the college degrees, taking more of the entry-level jobs, and entering more fields previously dominated by men. Despite these gains, the percentage of women at the top of corporate America has barely budged over the past decade. This means that when it comes to making the decisions that most affect our world, women’s voices are not heard equally. If we can succeed in adding more female voices at the highest levels, we will expand opportunities and extend fairer treatment to all.” 1


Many are familiar with Sheryl Sandberg’s inspirational book Lean In (2013)1 in which the Facebook COO draws attention to the vast underrepresentation of women in leadership roles in government and industry. Sandberg demonstrates how biological, psychological, and sociological factors contribute to the gender gap, and, more important, how women and the organizations in which they work can change the milieu for the benefit of all. Sandberg draws particular focus to the ways that women sometimes unintentionally hold themselves back in their careers and encourages them to sit at the table and “lean in,” seek challenges, take risks, and pursue their goals. In this article, I reflect on Sandberg’s call to action and explore how it can be applied in health care to enhance the medical leadership roles of women.


The argument for diversity


It should hardly be necessary to justify the need for women to hold leadership positions, yet if any doubt remains, research shows that organizations with more diversity — whether in terms of gender, race, ethnicity, age, or global experience — demonstrate better financial performance, greater organizational collaboration, and more effective problem-solving. When organizations commit to diversified leadership, they also reap enhanced employee engagement and competitive advantage to attract and retain diverse talent.2-4 Having women in leadership roles, therefore, is not just a moral imperative, but also a strategy that brings about performance benefits to the organization.


The increase in the number of women in entry-level positions does not by itself close the gender gap in leadership.2 For two decades, women have outnumbered men in undergraduate medical school classes. That should mean that — all things being equal — women and men at mid-career levels should be represented in about equal numbers in leadership roles today. Yet, women are vastly underrepresented in medical leadership, holding only 13–15% of department chair positions in Canada and the United States.5

To be clear, I don’t equate number of women in leadership roles as the measure of equality, nor leadership itself to be a marker of success; yet, there continue to be barriers to women achieving leadership roles. Blatant or subtle discrimination still occurs and must be recognized and called out. Lesser known is a subtle and often invisible gender bias that arises from cultural assumptions and organizational structures, patterns, and practices.6 This so-called second-generation gender bias continues despite overt programs to attempt to fill the leadership gap.6 Only after prevailing corporate norms change will there be a significant impact on women’s representation.7 Let us look at how certain factors adversely impact women’s entry into and success in leadership roles and how they can be managed organizationally. Top


Factors impacting women’s leadership roles



As career-building often coincides with prime childbearing and caregiving years for women, the struggle to balance both — if that is what a woman chooses — can be a difficult one. More female than male physicians have young children in the home, and women physicians report spending considerably more time than male colleagues taking primary responsibility for their children.8 Women may need more flexibility to accommodate pregnancy, breastfeeding, and child care in the workplace. Often, women defer career advancement while their children are young. Not to be disheartened, though, women generally achieve leadership roles about seven years later than their male counterparts, according to psychiatrist Dr. Mamta Gautam.9 Much of our middle-aged working population contributes to care of parents or even disabled children or siblings. This role, too, falls more often to women.10



There are psychological differences, notes Sandberg,1 that influence women in advancing their career opportunities. Women are more critical in self-evaluation than men, both to themselves and in groups. Women have been shown to judge their own performance to be worse than it actually is, men view it as better. For example, in a group of surgical trainees, the women (who exhibited slightly greater technical skills) rated themselves lower than their male counterparts.


Women tend to attribute their successes to external factors, such as good luck or help from others, whereas men tend to credit talent and skills. When women fail at a project, they are more likely to attribute the poor performance to lack of ability, whereas men point to a task that might need improvement. When receiving negative feedback, women’s self-confidence decreases more than men’s. This internalization of “failure” leads to a sense of insecurity, which, in turn, can impact future performance. Enter imposter syndrome: the self-doubt that creates the distorted view that one is about to be discovered as a fraud. Women tend to experience the imposter syndrome more intensely and be limited by it more than men.


Even Sandberg describes her dance with imposter syndrome this way: “The real issue was not that I felt like a fraud, but that I could feel something deeply and profoundly and be completely wrong.” Ironically, however, receiving praise is not necessarily the antidote for imposter syndrome. Sandberg notes that girls and women may actually feel embarrassed or vulnerable when receiving public praise. She gives her own example of feeling extremely awkward being named to Forbes’ World’s 100 Most Powerful Women list in 2011.


Women are more cautious about changing roles and seeking new challenges, notes Sandberg. Men believe that they can do more than the status quo and reach for opportunities more quickly than women. Women may need more encouragement to consider new roles. “You have to take opportunities and make an opportunity fit for you, rather than the other way around,” Sandberg quotes Padmasree Warrior, chief technology officer of Cisco. Comfort with ambiguity of role is a feature that women leaders need to embrace.



In social relationships, women also differ from men. I have noticed that women tend to build horizontal relationships. Women’s relationships often cross sectors and are more peer-to-peer, including friendships and volunteer commitments outside the workplace. Men, more often, have a narrower group from which they draw their social connections, and very often these groups include colleagues. Men are more likely to cultivate vertical relationships through formal or informal mentoring roles and perform voluntary activities within the workplace. These patterns may impact promotion and selection for leadership. Certainly, we would benefit from the diversity of leaders who have experience in organizations outside our health system as well as within. Top


There are gender differences in communication styles. Even in childhood, boys are more likely than girls to raise their hands to give an answer in class, to keep their hand raised until they can speak, and to talk over girls. Women in the workplace tend to speak less than men, and men have consistently been shown to speak over women.1


Fewer women than men identify attaining leadership roles as a personal goal.1,5 Women are more likely to cite compassion, improving the lives of others, personal fulfillment, and a favourable work–life balance as their personal goals.1 Moreover, women tend to identify critical functions of leadership, such as nurturing, empowering and motivating others, as being “other-driven.”5


Motivation to attain a medical leadership position — or for that to be deemed “success” — may be a stronger attraction for more men than women. Women may see the self-promotion required to attain leadership roles as a deterrant.5 Roth et al.5 noted a surprising theme: women physicians, who are not in leadership positions, hold an uninviting view of leadership as being burdensome, lonely, and costly in terms of personal sacrifices. Those in medical leadership, however, viewed leadership as positive and motivating. As the paradigm of medical culture is shifting from an autocratic framework to a more collaborative one, the collaborative leadership style, which is more characteristic of women, as well as the younger generation, will become more and more valuable.5 Taken together, these observations suggest that women will be more drawn to leadership positions if the roles can be seen to contribute positively to the vision of the organization or value to society.5


Women may underestimate their capacities to fill posted roles. Sandberg1 notes that women are more likely to take themselves out of the running if they don’t fill all the criteria of a job description; men, on the other hand, are likely to apply if they meet even six or seven of ten criteria. Furthermore, notes Sandberg, if a woman applies and is not successful, she is more likely to see herself as a failure, but a man might simply see it as not being a good fit.


Many women describe coming into medical leadership activities accidentally, perhaps being asked to fill a role on a short-term basis and then finding themselves successful and enjoying the role.5 This shows value in a process to identify potential leaders and suggesting suitable roles in recruitment and succession planning.


Opportunities for organizational change


Closing the gender gap in medical leadership relies in creating more opportunities to attract, select, retain, and promote qualified women into these positions.5 Practical measures can be implemented in health care organizations to enhance opportunities for women. The benefits of these measures extend not only to women, but also to all who choose a leadership journey, as well as to the organizations themselves. Some of these positive measures are listed below.


Attract women to medical leadership

  • Make medical leadership attractive. Leaders who speak highly of their positive experiences in leadership roles, citing examples of professional development, personal fulfillment, and service opportunities, are likely to serve as inspiration to those who might consider such roles. On the contrary, referring to leadership as “crossing over to the dark side” or speaking disparagingly about their organization is not helpful.
  • Allow opportunities to continue other gratifying professional activities. For many physicians, clinical work is their sweet spot for inspiration and fulfillment. Ensuring opportunities for leaders to continue clinical work not only helps to maintain their credibility among peers, but it also provides oft-needed respite from the unrelenting demands of leadership. Top


Select qualified candidates who show potential

  • Approach and encourage potential leaders. Physicians, especially women, may not self-identify their own leadership skills and potential. They may wait for affirmation of their suitability for a particular role. They might be in the category of “accidental leaders” waiting to be discovered. Identifying a candidate suitable for a role could awaken a latent interest in leadership.
  • Ensure reasonable working hours. As women continue to take on the bulk of domestic and child care responsibilities, they may benefit from flexibility to work some of the time from home, have dial-in or virtual options to join meetings, and anticipate fewer early or late meetings. Providing flexibility might overcome real or perceived barriers to women (and men!) considering leadership roles.


Retain physicians in leadership roles

  • Mentor leaders at all stages. Mentorship of physicians is helpful to identify opportunities for growth. Women, in particular, benefit from the individual feedback provided by seasoned mentors of either gender. Perceived lack of support in a leadership role is a major deterrent for many women. A supportive mentor can provide a channel for learning and growth.
  • Provide leadership training. Leadership is not entirely innate; it employs skills that can be learned. Investing in leadership training pays dividends in creating more effective leaders. Interactive learning opportunities further develop the social networks so important to leaders. Top


Recognize contributions of leaders

  • Demonstrate and celebrate successes of medical leaders. Showcase the efforts and successes of formal and informal leaders who have contributed to improvements in the organization. Use awards, publications, display boards, and other means to spread the news of successes. Examine the gender balance of leader profiles in your organization. For example, if your department or faculty has photos of predominantly male forefathers, counter the imbalance with photos of current leaders — assuming, of course, that the gender split will be more even.
  • Recognize the importance of leadership through promotions. Reward leaders with tangible recognition such as titles, promotions and advancement in ways that research, innovation and medical education are recognized. While recognition for leadership is not usually the leaders’ motive, it sends an important message throughout the organization that leaders are appreciated and supported.


I close with an encouragement from Sheryl Sandberg1: “I hope you find true meaning, contentment, and passion in your life. I hope you navigate the difficult times and come out with greater strength and resolve. I hope you find whatever balance you seek with your eyes wide open. And I hope that you — yes you — have the ambition to lean in to your career and run the world. Because the world needs you to change it.”



1.Sandberg S. Lean in: women, work, and the will to lead. New York: Alfred A. Knopf; 2013.

2.Hunt V, Layton D, Prince S. Why diversity matters. New York: McKinsey & Co.; 2015. Available: https://tinyurl.com/y9rsnkfd (accessed 16 July 2018).

3.Noland M, Moran T. Study: firms with more women in the c-suite are more profitable. Harv Bus Rev 2016;8 Feb. Available: https://tinyurl.com/hne9emz (accessed 16 July 2018).

4.Why having more female leaders will benefit your business. Cape Town: GetSmarter; n.d. Available: https://tinyurl.com/yacd2equ (accessed 16 July 2018).

5.Roth VR, Theriault A, Clement C, Worthington J. Women physicians as healthcare leaders: a qualitative study. J Health Organ Manag 2016;30(4):648-66. DOI 10.1108/JHOM-09-2014-0164.

6.Ibarra H, Ely RJ, Kolb DM. Women rising: the unseen barriers. Harv Bus Rev 2013;Sept. available at: https://tinyurl.com/mucx4qs (accessed 16 July 2018).

7.Women at the top of corporations: making it happen. New York: McKinsey & Co.; 2010. Available: https://tinyurl.com/yc86etsa (accessed 16 July 2018).

8.National Physician Survey: 2010 survey results. Ottawa: College of Family Physicians of Canada, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada; 2010. Available: https://tinyurl.com/y9ls349y (accessed 16 July 2018).

9.Gautam M. Leadership for medical women. Ottawa: Physician Leadership Institute; May 2016)

10.Women and caregiving: facts and figures. San Francisco: Family Caregiver Alliance; 2003. Available: https://tinyurl.com/zq73oer (accessed 26 July 2018). Top



Sharron Spicer, MD, FRCPC, CCPE is a physician leader in Calgary, Alberta. Her clinical work as a pediatrician has included pediatric palliative care, complex feeding and nutrition and medical ethics. She is proud to serve on many local, provincial and national medical organizations.


Correspondence to:



This article has been peer reviewed.