Towards gender balance in the Australian intensive care medicine workforce

Achieving gender equity in intensive care medicine requires specific interventions to attract and retain female trainees and support their progress to leadership roles

For several decades, women have comprised about half of medical graduates in Australia.1 This is yet to translate into a gender‐balanced specialty workforce. In 2016, fewer than one in five practising surgeons, cardiologists and intensivists were women.2 In recognition of this, several Colleges have developed plans to improve gender balance within their specialty.

The Box shows the proportion of female trainees and Fellows in the College of Intensive Care Medicine (CICM) over the past ten years. While the proportion of female trainees has steadily increased to 41% in 2019, the increase in the proportion of female Fellows has been much slower, having essentially plateaued at 21%.

The gender imbalance in intensive care medicine is more pronounced in positions of leadership and academia, with women under‐represented on boards of critical care societies, as presidents of Colleges, on guideline panels and as speakers at critical care conferences.3,4,5,6

To achieve gender equity in intensive care medicine, specific interventions are needed to attract and retain female trainees, and support female intensivists to progress to clinical and academic leadership roles.

The CICM recently published a statement on gender balance, written in collaboration with the Women in Intensive Care Medicine Network of the Australian and New Zealand Intensive Care Society (WIN‐ANZICS).7 This statement considers four key domains:

• female representation in College leadership roles, with targets culminating in 50% representation;
• selection processes for trainee positions and employment opportunities;
• flexibility in the training program; and
• promotion of a culture of respect and inclusivity.

In this article, we review the rationale and evidence underpinning each domain of change. The problems considered here are not unique to intensive care medicine and this discussion is likely to resonate with those working to improve gender balance in other areas of medicine.

Key drivers of workforce gender imbalance

In order to understand the rationale for the strategies proposed in the CICM statement on gender balance,7 some insight into the causes of the persistent workforce gender imbalance in intensive care medicine is necessary.

In a recent qualitative study,8 critical care specialists and trainees from 13 Canadian university‐affiliated critical care training programs were interviewed regarding the drivers of workforce gender imbalance in intensive care medicine. Participants perceived three key drivers: long and inflexible working hours, a male‐dominated leadership group, and few female leaders and role models in the specialty. This highlighted the need for a critical mass of women in visible leadership roles to ensure that aspiring female trainees are not deterred from entering the specialty.

The study also noted a perception that women simply are not interested in pursuing a career in intensive care medicine, finding that almost a quarter of male intensive care doctors perceived women to be inherently unattracted to “high pressure” medical specialties.8 Crucially, none of the female participants shared this perception. The increasing number of female trainees (Box) also speaks against the theory that women are not interested in pursuing a career in intensive care medicine.

Interestingly, male and female participants in the study perceived different implications of the workforce gender imbalance. Female participants highlighted the lack of support networks and female mentors, and a pervasive insider culture (“old boys club”) that subtly alienates women and minorities. In contrast, some male participants perceived no important implications.8 These differences in outlook underscore the importance of engaging with women when devising strategies to address workforce gender imbalance.

Implicit gender bias — that unconsciously influences the expectations and evaluations of men and women — may be another driver of the observed imbalance.8,9,10,11 Salles and colleagues assessed the gender bias of surgeons and other health professionals using the Implicit Association Test, finding that both men and women implicitly associate men with career and surgery, and women with family and family medicine.11 These associations have the potential to negatively affect doctors working in, or aspiring to work in, specialties not associated with their own gender.

Evidence from the field of academic medicine suggests that female doctors do not progress through the career pipeline at the same rate as their male colleagues.12,13 For example, a 2014 cross‐sectional database review of academic physicians in the United States found that women in academic medicine were less likely to achieve associate or full professorships than their male counterparts, after adjusting for age, research productivity, specialty and years of experience.14

Women are also less likely to receive scientific research funding. A review of Swedish Research Council peer review scores found that female applicants for scientific grants in 1995 needed the equivalent of three additional papers in Nature to receive the same overall score as male applicants.15 A more recent study analysed application success of over 7000 principal investigators in Canadian Institutes of Health Research grant programs between 2011 and 2016, comparing these results with those of two different programs — one with and one without an explicit review focus on the calibre of the principal investigator. The authors found that women were less likely to receive research grants when selection focused on the calibre of the principal researcher rather than only the proposed research.16

Taken together, these findings indicate that women were not penalised because they had less experience or fewer professional achievements due to parental leave or part‐time work. Rather, they suggest that at key junctures of career progression, women were evaluated less favourably than equivalently qualified men because of conscious or unconscious gender bias.

Targets for female representation in the CICM

The CICM has joined with the Royal Australasian College of Surgeons (RACS), leading Australian businesses and the parliaments of over 40 countries in committing to ambitious targets for female representation.17,18,19,20 For example, the RACS aims for 40% female representation across specialty training and leadership positions by 2020.18 Targets are a transparent and measurable way to promote accountability and drive real change.10,19

Setting targets for female representation routinely generates controversy, with some commentators proposing that we should set gender aside and focus on merit‐based selection instead.10,21 However, merit‐based selection is predicated on a level playing field that simply does not exist, as the evidence above demonstrates. Specifically instructing managers that they represent a meritocratic organisation can actually amplify the impact of unconscious bias in professional selection processes.22 The challenge of objectively defining merit, let alone reliably selecting for it, has led many to conclude that merit‐based selection is a myth.10

Targets counteract the covert effect of gender bias by providing an overt or explicit goal for female representation. Moreover, there is evidence from the field of politics that women appointed under gender quotas perform at least as effectively as the men they have replaced.18

In setting targets for female representation in leadership roles, some medical societies, including the European Society of Intensive Care Medicine, advocate for workforce proportionate targets.21 In Australia, this would mean a target of about 20% female leaders to reflect the gender balance of the intensive care medicine specialist workforce. However, this approach both endorses the status quo and tends to perpetuate it. Female leaders act as role models and influence organisational practices and hiring decisions.8,10 Therefore, WIN‐ANZICS successfully advocated for targets of 50% female representation within both ANZICS and the CICM, to be achieved over several years.7

Selection processes and employment opportunities

Trainee and employment selection processes are critical points of career progression that can also be affected by gender bias. For example, Moss‐Racusin and colleagues found that an applicant given a male name was more likely to be appointed to a hypothetical laboratory manager position than an identical applicant with a female name.23

The impact of unconscious bias on these processes can be minimised by removing names from written applications and ensuring diverse interview panels.10,16 Situational judgement tests can increase the diversity of successful applicants in medical school applications and could therefore be used in trainee selection.24

Flexible training program

In Australia, women take the vast majority of parental leave and are more likely to decrease their working hours after having a child.25 Maintaining career progression during this period, which often coincides with advanced training and competition for a consultant job, is a major challenge for women in medicine. In response to this, the CICM has committed to creating and maintaining a flexible training program.

Specialty colleges can make parental leave and part‐time work less prohibitive and more appealing for all trainees, including new fathers.10 We suggest that the following approaches could be considered by the CICM and other specialty colleges:

• Develop a dedicated parental leave policy. Parental leave is an important special case because it disproportionately affects women and is incompatible with career‐development activities, unlike other interruptions to training such as research fellowships.
• Where a time limit is imposed for the total number of years allowed to complete training, exclude periods of parental leave from this time limit.
• Adopt a proactive approach to supporting doctors returning from leave, with return to work policies and refresher courses. For example, the CRASH (Critical care, resuscitation and airway skills in high fidelity simulation) course is a practical course for anaesthetists returning to work, and is also recommended by the CICM.26
• Require hospitals, particularly larger units, accredited for specialist training to provide high quality part‐time or flexible training roles.

Hospitals and intensive care units also have a substantial role to play in supporting parental leave and part‐time work.8 Some aspects of intensive care medicine practice that seem inherent to the specialty are simply practice patterns established by the pioneering intensivists — predominantly men without caring responsibilities — in response to the clinical demands and resources of the time. These practice patterns can evolve to suit the needs of a changing intensive care workforce. For example, many intensive care units traditionally rostered intensivists on clinical duty for seven days in a row. Long stretches of clinical duty can be particularly challenging for intensivists with young children. Decreasing the number of consecutive days on duty may be a more family friendly option, at the cost of more frequent clinical handover.

Promoting a culture of respect and inclusivity

The CICM is one of many Colleges to report that bullying, discrimination and sexual harassment occur commonly within the specialty and disproportionately affect women.27In order to eliminate extreme examples of unacceptable behaviour, we need to create respectful and inclusive workplaces. The RACS addresses this issue comprehensively in its “Building respect, improving patient safety” action plan, which includes the “Operating with respect” course.17 This course teaches participants to recognise and respond to inappropriate workplace behaviour and promote a positive workplace culture. Participants speak positively of the course and report that it is relevant to their work.17 The CICM has introduced a “Speaking up for workplace culture” module in its compulsory communication skills course, focusing on the skills required to call out casual bigotry, discrimination and bullying.7 Further evaluation is required to determine if these educational programs can ameliorate the exclusionary insider culture perceived by female critical care doctors.

Conclusion: reflecting on diversity and gender advocacy

A gender‐balanced intensive care medicine workforce is a worthy goal. Beyond the ethical imperative of gender equity, this will ensure that the specialty draws on the full talent pool of medical graduates and builds a workforce more representative of the diverse community of intensive care patients. While there is also a pressing need to improve other domains of workforce diversity, gender is easily targeted, partly because the data are already available — although data collection should be expanded to include gender non‐binary doctors.

Women incur an emotional and professional toll when they highlight the sexism they experience during their medical training and work. In contrast, a man's professional reputation is often enhanced when he displays pro‐diversity behaviours.10 This underscores the need for men, particularly those in influential leadership roles, to visibly engage in advocating for gender equity.

Specialty colleges and societies have a crucial leadership role in shifting the organisational culture in medicine.10 WIN‐ANZICS and the CICM are working together to improve gender balance in intensive care medicine.

Box – Proportion of female trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand, 2010–2019

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