Advancing women in medical leadership

Equity underpins workforce diversity, embraces and values differences, harnesses talents and skills, and represents and responds to community needs

Priscilla Kincaid‐Smith was a highly successful clinician academic: the first female professor of Medicine at the University of Melbourne and the first female president of both the Royal Australasian College of Physicians (RACP) and the World College of Physicians. In recognition, the RACP established the Priscilla Kincaid‐Smith Oration, which in 2018 was dedicated to women in medical leadership. This article reflects the oration, draws on evidence and shares personal career reflections, aiming to promote equity in medical leadership, irrespective of gender.

Gender equity refers to “fairness of treatment [for all], according to their respective needs,” which may include equal or different, yet equivalent, treatment across rights, benefits, obligations and opportunities.1 Equity underpins workforce diversity, embracing differences to create a productive environment where all are valued and talents and skills are optimally harnessed.1 A diverse workforce represents society, understands and responds to community needs,1 embodies the principles of equity and diversity and models the diffusion of prejudices and stereotypes, promoting a society free of discrimination. Arguably, medicine should embody and promote these aspirations.

In Australia and elsewhere, women have attained gender parity in medical school admissions for decades; however, under‐representation of women in senior leadership positions persists, and the age‐old argument that this is due to a time lag or pipeline effect clearly no longer applies.2 Internationally, medical leadership in public and private hospitals, colleges, societies and academia continues to be inequitable.3,4,5,6,7 In the United States, women represent only 3% of chairs and 10% of program directors in general surgery,6 and after adjustment for age, experience and measures of productivity, women were 37% less likely to be a cardiology professor.7 Women move into health care chief executive officer (CEO) positions in the United States at only half the rate of men and, more broadly, substantive income gaps remain.2,4,5 In Australia, around 30% of deans, chief medical officers or medical college board or committee members are women, while women make up 12.5% of CEOs in large hospitals.3 While progress towards equity is occurring, greater efforts are needed.5

We have now transitioned from a battle between genders and deliberate exclusion of women from leadership to a recognition of the need for all to actively champion change, irrespective of gender.1 However, unconscious gender bias still contributes to the so‐called glass ceiling or unspoken barriers to career progression, which prevail despite increased qualifications, employability and work performance among women.1,2,3 Contributing factors are now well recognised (Box 1).1,3,4,5,8 The Lancet has highlighted these challenges and commissioned a special issue on women in science, medicine and global health, noting, “Sadly, recent statistics affirm past trends of a leaky pipeline that show women's education and potential are being lost, at great cost to science and society: a waste of intellectual capital, lack of diversity in agenda setting, and the restriction of women's goals and rights”.5

Barriers to women in leadership

Research is now providing greater understanding on these barriers (Box 1).3,7 A sentinel contribution emerged from engagement and interviews with senior Australian leaders in health and academia, concluding that only a minority of leaders retain the belief that women are not interested in or suited to leadership. Rather, key barriers fall under three themes, capacity, perceived capability, and credibility, which once understood, can inform the codesign of effective strategies to progress towards equity in medical leadership.3 Personal reflections based around these themes are offered in Box 2.

Capacity

Capacity relates to limitations due to additional household and parenting duties disproportionately shouldered by women.2,8,9,10,11 Australian medical workforce data show women work equal hours initially, have a sharp decline corresponding to maternity leave and early preschool years, then a rise to similar hours to men.8,9,11 Parenting often coincides with critical career stages and can be highly disruptive for career advancement. Addressing these barriers requires action from the human capital, organisational, sociocultural and policy perspectives.2,12,13 Strategies that empower and support women to seek more flexibility and equitable balance for outside work and parenting are clearly important.2,3 These strategies need to also support flexibility for partners to participate in parenting responsibilities. The greatest determinant of retention and promotion of women in the Australian workforce is currently “normalising flexible work practices,” which in turn relates to the proportion of women in senior leadership roles.14,15 Flexibility requires partnership between employers and employees for mutual benefit, and greater research and translation into policy and practice is now needed to address these limitations to capacity and enable flexibility if we are to optimise retention and development of female talent.2

Capability

Capability relates to perceived capability or confidence women may hold in their ability to lead. Many factors influence this; however, women with similar qualifications are less likely to be in leadership roles, related to factors such as lower application rates despite equivalent or higher qualifications.3,7,15 Although evidence is less abundant in these areas, women are less likely to advocate for or promote themselves, with less nominations for awards or less actively seeking pay rises or career opportunities. Less affirmation can also occur when these practices are pursued.4,16 At present, women who do seek promotion often do so when they are mentored, supported or sponsored by others, which can inform organisational approaches to increasing women in leadership.2,13,16 As only 30% of variation in leadership appears heritable and the rest is attributable to environmental factors, including role models and early opportunities for leadership development,2,17 strategies to address perceived capability are important. These include leadership development focusing on awareness and support, more objective assessment of capability, enhanced mentoring, positive female role models and addressing the need for affirmation of women in leadership roles.2,4,16 Leadership training and mentoring opportunities increasingly target women, yet they can be prohibitively expensive. These can be delivered at lower, comparable cost to other programs, cofacilitated by leadership experts alongside credible medical and health professional role models, and need not apply corporate costing models. Greater opportunities are needed for affordable, accessible and evidence‐based leadership development opportunities at different career stages.

Alongside the need for mentoring and leadership training, it is important to recognise the potential bias and inequity once women apply for senior roles, self‐advocate or seek a pay rise, in part related to stereotypes of masculine and feminine leadership models.4,12,18 Once again, these important systemic barriers need to be objectively identified, monitored and addressed.

Credibility

Credibility relates to perceived traits that are consistent with leadership. Perspectives around credibility of women and feminine characteristics in leadership have deep sociocultural roots.12 There persists a bias in leadership and organisational culture linking traditionally masculine styles and values to leadership credibility.12,18 This can include assertive and potentially adversarial behaviour,1 which may reduce the motivation for women to seek or retain leadership positions. This association between traditional masculine leadership traits presents a credibility barrier, irrespective of gender, for people who aspire to transformational distributive leadership, with reliance on emotional intelligence compared with more performance‐based leadership styles and cultures associated with traditionally masculine traits.12 Overall, a preference for distributive leadership is more common among women, who are more likely to seek and consider input from teams and stakeholders.2,12,18 Monash Women in Leadership Program has run over 5 years, with participants consistently reporting preferences for distributive leadership styles, while noting it is relatively uncommon among their current leaders (unpublished data, 2014–2019).

Strategies to promote gender equity

It is beholden on our current leaders to move away from perceived gender‐characterised leadership styles, to identify non‐inclusive leadership styles, recognise that the “behaviour we walk past is the behaviour we accept”, and to call out and address this behaviour that challenges credibility and diversity of leadership. Other important strategies include greater representation of women in leadership and more credible male and female role models espousing distributive, inclusive leadership styles and values. The importance for women to internalise a leadership identity, through education, role modelling and mentoring has also gained recognition.4 Likewise, anchoring women's leadership in purpose and impact, rather than in personal ambition or power over others, can promote interest and enable leadership despite credibility issues, gender bias and lack of affirmation around women's legitimacy to lead. Hillary Clinton's reflections focus on these concepts and on the premise that women need not aspire to lead as men do to be credible, but rather to focus primarily on getting the job done and building a system that recognises impact.4

The themes outlined here, alongside leadership education, mentoring, established frameworks and gender planning, can enable progress towards gender equity and diversity in medical leadership.16 Other strategies include aspirational targets and mandatory quotas for women in leadership positions. These alone do not address capacity, capability, credibility and culture and can fail to retain women in leadership roles if broader problems are not addressed.4 Cross‐sector evidence shows that the gender gap can be reduced through strategies such as the Athena SWAN (Scientific Women's Academic Network) charter (www.ecu.ac.uk/equality-charters/athena-swan) and Science in Australian Gender Equity, which advance women's careers in science, technology, engineering, mathematics and medicine. These involve systems, organisation and individual level strategies, leveraging cross‐sector learnings, addressing recruitment, networking, mentoring, and projecting female role models.19

Work is underway in health care to codesign an aligned program across these three levels with an implementation roadmap and measurable and benchmarked outcomes.

In conclusion, deliberate efforts to exclude women from leadership roles are increasingly uncommon and progress is being made, yet gender inequity in medical leadership persists. Unconscious bias contributes to a persistent “glass ceiling” and causes of gender inequity remain and will require personal, organisational and broader sociocultural and policy efforts to change. More research will be crucial to codesign, implement and evaluate effective strategies to enable gender equity and diversity more broadly and, where effective, these should be scaled across our health system and beyond.