Two years ago, when I was weighing the pros and cons of relocating to a new state for a job that I hoped would propel me further in my career, I looked at several factors. The idea of moving away from friends, family and a city I'd lived in for the last decade weighed heavily on my decision. But so did the reality that my job did not offer many avenues for advancement.
When I expressed to a male colleague my interest in pursuing leadership roles within graduate medical education, he remarked, "Why? The old boys' club won't ever let you run things the way you want to anyway."
To him, trying to demonstrate my capability to lead seemed a futile exercise. No one in power wanted to invite me to sit at the table where decisions were made. I did not fit the mold for what leaders in academic medicine looked like.
Plus, there was simply a dearth of female role models in administrative positions. Though the few women I had as role models were excellent, their battle scars were visible, and they were noticeably tired. Moreover, as someone who is not a physician, my options were even more limited within the institutional culture.
Ultimately, I decided that a change of scenery was the best way to achieve my career goals, and I applied for a position in the Duke University Health System. Following an initial phone interview with the director of graduate medical education at Duke, I immediately visited the School of Medicine webpage and clicked to find who held positions of senior leadership. Much to my surprise, I not only found that the medical school dean was a woman, but there were four other women listed in positions of senior leadership. Beyond that, there were 10 more women holding associate dean positions within the medical school hierarchy — one of whom became my boss when I accepted a position there.
In 2007, when she became the medical school's dean at Duke, Nancy Andrews, MD, PhD, wrote a piece published in the New England Journal of Medicine.1 Her appointment was noteworthy, as she was the first woman to hold the position. She took the opportunity to highlight the disparity in administrative positions held by women at medical schools and academic health centers. In her essay, Andrews predicted that women physicians would continue to be underrepresented in positions of leadership unless universities and hospital systems began to look beyond the traditional paths to leadership.
Unfortunately, 10 years later, Andrew's predictions have held true, and it seems as though very few hospital systems and universities have shifted outside of their traditional hiring searches in order to address gender disparities.
According to the Association of American Medical Colleges' Women in Medicine and Science Report, the number of women holding chair and dean positions has increased only slightly in the 10 years between 2004 and 2014.2 Even with the increase, only 16 percent of dean positions and 15 percent of department chair positions were held by women. The numbers are particularly bleak when you consider that women make up 46 percent of resident physicians in training.
In the current hierarchical structure, leadership positions change so infrequently that it is difficult to imagine a sea change. In addition to creating a barrier for women interested in leadership positions within academic medicine, the hierarchy proves counterintuitive to the very structure within which health care is delivered. As institutions embrace more interdisciplinary, team-based approaches to patient care, the notion of such a narrow leadership model seems antiquated.
THE MUSTACHE INDEX
In a novel, and somewhat light-hearted, attempt to further illuminate the gender disparity in medical leadership, a group of male and female researchers did a cross-sectional study of the leaders of U.S. academic medical departments. They knew men outnumbered women in leadership positions; what they discovered was that even a small subset of men — men with mustaches — outnumbered women in the top jobs at academic medical departments, according to photos posted on medical school web pages. Their conclusion: Even though there now are many more women in medicine than there used to be, and nearly half of all U.S. medical school students are women, women are rarer than mustachioed men when it comes to academic leadership. Though the delivery and practice of patient care have changed dramatically over the last few decades, the archetype for leadership in academic medicine has not evolved with the job.
The authors argue that more intentional efforts to recruit, retain and promote women into leadership positions must be pursued in order to improve the disparity. Their most practical suggestion calls on hiring committees to ensure that hiring criteria are well-defined and agreed-upon prior to evaluating any candidates. The process also should involve a thoughtful discussion about what skills are necessary to lead within a health care system, they said.
"Evidence-based policies that increase women in leadership positions are needed," concludes their report published in the BMJ (formerly the British Medical Journal.)3
In further emphasis of these points, a study published in Academic Medicine found the recruitment process for faculty leaders has changed very little in the last 25-30 years. Hiring committees have not adjusted their recruitment methods to ensure that their processes create leadership networks that resemble the workforces they lead.4
The survey of department of medicine chairs in academic medical schools across the United States revealed that the recruitment process is time-intensive and can take upwards of 24 months, while satisfaction with the outcome can vary widely. Shockingly, though very few searches resulted in even one woman finalist for the position, the majority of the respondents believed that they received a diverse pool of applicants. (The same also could be said for underrepresented minority candidates.) This finding raises several questions about how search committees define diversity and the likely biases that women and minorities face when applying for positions of leadership.
As long as the current gatekeepers to these positions do not recognize women as competitive candidates for leadership positions, the number of women in leadership will continue to lag behind their male counterparts. The attitude alone is enough to keep the door closed for many women seeking to lead within academic medical centers.
TRAINING LEADERS OF THE FUTURE
Perhaps the greatest gift a supervisor ever gave me was the opportunity to participate in an employer-sponsored leadership seminar. The seminar was good, and I learned plenty from the instruction and the cohort with whom I attended, but the most important lesson I learned was that someone thought I had leadership potential.
My boss created space within my role in the department to cultivate skills necessary to lead more effectively. She encouraged me to prioritize the sessions and to invest in myself during that time. Without her push, I might not have devoted energy toward my own development as a leader.
More departmental leaders should encourage junior faculty to consider their career aspirations and envision themselves in positions of leadership someday. It is not uncommon for a physician faculty member to be placed in the role of residency program director because they have an interest in and aptitude for teaching. Unfortunately, it is far less common for those individuals to have had any opportunities to develop additional skill sets required for the administrative and management aspects of the job. Leadership development should be seen as an additional track of faculty development.
Likewise, current leaders should be calling on department chairs and divisional leaders to think about their succession plans. They also should be empowered to think about what their next role could be and who within the ranks could someday step into their position.
There must be recognition that leadership should be refreshed periodically in order to grow vibrant institutions. True to this sentiment, after a decade in her role at Duke, Dr. Andrews stepped down in June 2017 from her post as dean. Mary Klotman, MD, succeeded Andrews as dean of the Duke School of Medicine — a promising move toward gender parity in leadership within academic medical centers. As a woman striving to find my way in my own career path, I certainly welcome the opportunity to have yet another female role model in such an influential position.
KATHERINE MCDANIEL is the GME educator in charge of faculty development at Duke University Hospital and Health System, Durham, North Carolina.
- Nancy Andrews, "Climbing through Medicine's Glass Ceiling," New England Journal of Medicine 357, no. 19 (2007): 1887-89. www.nejm.org/doi/full/10.1056/NEJMp078198#t=article (accessed July 11, 2017).
- Association of American Medical Colleges, The State of Women in Academic Medicine: A Pipeline and Pathway to Leadership, 2013-2014. https://members.aamc.org/eweb/upload/The%20State%20of%20Women%20in%20Academic%20Medicine%202013-2014%20FINAL.pdf (accessed July 6, 2017).
- Mackenzie R. Wehner et al., "Plenty of Moustaches But Not Enough Women: Cross Sectional Study of Medical Leaders," BMJ (Dec. 16, 2015). www.bmj.com/content/351/bmj.h6311 (accessed July 11, 2017).
- James D. Marsh and Ronald Chod, "Recruiting Faculty Leaders at U.S. Medical Schools: A Process Without Improvement?" Academic Medicine (May 2, 2017), published online ahead of print.
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