‘A leaking pipeline.’ Addressing gender inequities in medical leadership

“Are you married?”

That was the first thing Michelle Cohen heard on her first day of training with a surgeon.

“As soon as I walked into the OR to introduce myself … it was an older doc and he turned and looked at me and his very first question was ‘Are you married?’ He continued to pester me on that,” says Cohen, a family physician from Brighton, Ont., and faculty member in the Department of Family Medicine at Queen’s University.

Gender discrimination is a frequently cited culprit for inequity in the workplace. Based on 2019 U.S. data, approximately one in four female staff in the departments of anesthesiology, emergency medicine, orthopedic surgery and general surgery reported experiencing disrespect based on their gender. Two of these departments (orthopedics and general surgery) were also among the departments with the smallest proportion (less than one third) of female full-time faculty.

Historically, medicine has been a male-dominated field. Increasingly, over the past decade, shifting perspectives on gender in the workplace have emerged. Perhaps on the wing of worldwide movements such as #TimesUp and #metoo, the spotlight on gender inequity is becoming ever more visible. November marked the historic win of Kamala Harris, who is the first Black, South-Asian female to become a vice-president elect in the United States. But while the political glass ceiling has begun to shift, has medicine kept pace in addressing gender inequities?

Interest in pursuing academic medical leadership is often cultivated during medical training. Despite a continuing trend of more women than men enrolling in Canadian medical schools – 56 per cent of first-year medical students in 2017-18 were female – fewer women advance in their careers to hold academic leadership positions.

During her training, Lesley Barron, a general surgeon who practiced at Georgetown Hospital in Halton, Ont., says: “There were only two female surgeons, a vascular and a general surgeon, and another one joined in the time that I was doing my surgical training in Canada, and none of them were married or had children. They certainly weren’t supportive of female trainees in terms of acknowledging that there was a gender bias, or that it was harder for women trainees to get through training.”

Much of the existing data on gender inequities in medical leadership stems from the United States. In 2018, the Association of American Medical Colleges (AAMC) conducted a survey among 154 U.S. medical schools and found that despite a progressive rise in the number of female department chairs over 10 years, women only made up 18 per cent of all department chairs. Within cohorts of both new assistant and associate professors starting in 2008-2009, a greater percentage of men than women advanced after seven years. While there is less data available in Canada, it is known that out of the 17 Canadian medical schools, five had female deans in 2020, up from two in 2017.

The obstacles are multifaceted and complex. They include gendered expectations and implicit biases on women’s perceived merit and capabilities.

Cohen, who has published work on the Canadian gender pay gap in medicine, wrote about her encounter in a blog post. “I remember he (the surgeon) gave us this long lecture about the problem with lady doctors: ‘The problem with lady doctors is your standards are too high. You think because you’re so educated and accomplished that no man is good enough for you and you end up unmarried and having to go through fertility treatments because you wait too long to have babies,’” she says. “There is absolutely no way he would have spoken to a male trainee that way.”

A survey about gender equity in medicine that involved 431 respondents ranging from Canadian medical students to physicians indicated that 69 per cent of female respondents agreed with the statement that gender plays an important role in determining future career opportunities. Only 33 per cent of male respondents agreed.

Furthermore, trainees of diverse specialties have been shown to regard female physician instructors as less able as educators. Ultimately, implicit biases against women can contribute to low confidence and self-doubt and can adversely impact upward mobility. In fact, the gender equity survey showed that 54 per cent of female respondents felt they received less recognition than their male colleagues for the same work compared to just 13 per cent of male respondents feeling the same way about their female colleagues.

A leaking pipeline is an analogy used to describe the loss of women leaders somewhere along the journey toward their leadership goals.

“There are these pipeline pathways to become a physician-in-chief at a hospital, to become a CEO, to become a dean,” says Lisa Richardson, a general internist at University Health Network who holds several leadership appointments including vice-chair of culture & inclusion the University of Toronto’s Department of Medicine, strategic advisor in Indigenous health for U of T’s Faculty of Medicine and strategic lead in Indigenous health for Women’s College Hospital. “In fact, you have to have done all of these other jobs beforehand. So, there’s all of this planning that has to go into it … and nobody knows about that. How do we make explicit those pathways? Because it’s not appropriate that they’re just within certain circles or known by those that are chosen. It needs to be transparent.”

Richardson says she did not have the same access to leadership as her male colleagues during her training. “And I’m not sure why … I thought about why I was never encouraged, for example, to apply for a teaching medical residents initiative. I looked back at my (evaluations) and they were really good and I was always wondering, why? I thought, maybe it was because people thought I wasn’t interested because I had my kids.”

Family medicine is recognized as being among the most flexible specialties when it comes to work-life balance. Interestingly, Canadian Institute for Health Information data from 1978 to 2019 show that women have consistently represented a larger portion of family physicians compared to specialists. In 2019, 47.5 per cent of family medicine physicians were female while 38 per cent of specialists were female.

The historically female burden of household responsibility perhaps explains why there are fewer women in surgical specialties, and accordingly, fewer women in positions of academic leadership within those specialties. The AAMC reported that departments with the most full-time female faculty in 2018 were similar to specialties with the most female residents, including obstetrics and gynecology (64 per cent female residents), pediatrics (58 per cent female residents) and family practice (51 per cent female residents). Meanwhile, among the specialties with the fewest women in positions of academic leadership were surgery and orthopedic surgery.

“We aren’t yet at the point where men can breastfeed. There are certain realities that are gender-based,” says Batya Grundland, who is a family physician and obstetrical care provider at Women’s College Hospital as well as the associate program director in curriculum and remediation in the Department of Family Medicine at U of T.

“When I was on maternity leave with my third child, I had about three job offers for different leadership opportunities … and I had to say no,” she recalls. “I had to call my chief and ask them, ‘Are they ever going to offer me anything again?’”

One area of improvement involves addressing the deficiency of Canadian data. Barron, who formerly sat on the board of the Ontario Medical Association and the Physician Payment Review Board in Ontario, says, “Data is power. When you don’t value something and don’t want to correct these problems, you don’t research it.

“Lack of data is a way of the patriarchy suppressing this issue when you don’t actually release: ‘Well, how many women are there in leadership?’”  

Barron says institutions need to ensure that there is adequate female representation at leadership tables. “It’s a circle of women not being at the table to demand the data is collected,” she says. “We haven’t seen men who are willing to step back at these leadership positions to make space at tables.”

She says a potential solution is term limits. “You shouldn’t be able to hold the same leadership position for eight, 10, even 20 years.”

Sharon Straus, a geriatrician and clinical epidemiologist who also serves as physician-in-chief at St. Michael’s Hospital and director of the site’s Knowledge Translation Program, says the paucity of Canadian data is systemic. “Partly it’s because of the way we work in Canada – that as academics, for example, we are not employed by the universities. I’m based at St. Mike’s and we’re considered self-employed. We don’t actually have data even across all of our academic hospitals.”

While research in the area is limited, in a qualitative study in 2018 on the organizational impact of gender bias involving faculty members at the Department of Medicine at U of T, Straus and her colleagues found that participants described reinforced stereotypes, unprofessional behaviours and social exclusion as consequences of an identified gender gap on organizational effectiveness and workplace culture.

One improvement discussed in the study involves revising processes of recruitment, hiring and promotion.

A lot of what we found in our work was that jobs just get created for people,” Straus says. “Women are less likely to be a part of informal networking so then they might not have jobs created for them.

“So, it’s about having explicit job postings, making sure there’s a broad search, making sure search committees represent the diversity of the population, making sure we address unconscious bias as well as conscious bias, making sure that we have a standardized process in the questions that we use so that we don’t ask different candidates different questions (…) providing opportunities for informal networking, in particular, with senior people who may be good role models.”

Working from the ground up to ensure that female trainees are well-supported by their mentors may also help mitigate these gaps. Elaborating on her role as a mentor, Grundland says, “The leadership trajectory for women, whether justifiably or not, tends to be different from men. I’ve had women mentors who have reminded me of this—that often, when we are in the peak of our childbearing years, for many of us our productivity goes down, the amount of leadership we take on goes down. When that’s done and our kids get older, we tend to really move forward and excel (…) I’ve had that reassurance and I try to remind women of that.”

Richardson says more diversity is needed in academic appointments.

“Diversity of all kinds is important around leadership tables,” she says. “We know that if one looks to the bottom line, for example, in the business sector, boards that are more diverse have a better bottom line in terms of productivity.

“In the academic sector, diverse departments have increased productivity based on all of the metrics, like grants and publications. To create inclusive policies and environments for people to feel a sense of belonging, having representation is really important at the senior level – not only to influence decisions that are made but also so that others can see themselves represented in those senior roles.”

Richardson adds a final thought: “We need to be more intentional with mentorship, with transparency and with pipeline development and understand the specific barriers that women face, and in particular, women from underrepresented groups face …  and really focus on building that work.”