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. 2023 May 17:1–7. Online ahead of print. doi: 10.1007/s12630-023-02458-7

Misconceptions about women in leadership in academic medicine

Idées reçues concernant les femmes en position de leadership en médecine universitaire

Maya J Hastie 1,, Allison Lee 1, Shahla Siddiqui 2, Daryl Oakes 3, Cynthia A Wong 4
PMCID: PMC10188227  PMID: 37193865

Abstract

Despite progress made over the past decade, women are under-represented in positions of leadership in academic medicine. Women physicians face numerous challenges throughout their careers. Despite achieving leadership positions, women in leadership continue to experience the impact of those challenges. In this review, we describe four misconceptions about women in leadership, along with their impact and recommendations. First, we describe differences between mentorship and sponsorship, as well as their impact on attaining leadership positions. Second, the gender pay gap persists throughout women’s careers, regardless of leadership positions. Third, we explore the role of self-efficacy in leadership in the context of stereotype threats. Fourth, gendered expectations of leadership characteristics place an undue burden on women, detracting from their leadership effectiveness. Organizations can address the challenges women face by creating robust mentorship and sponsorship networks, establishing transparent and equitable pay policies, promoting and normalizing a broader range of leadership styles, and improving work flexibility and support structure. Ultimately, such changes serve all members of the organization through increased retention and engagement.

Keywords: gender bias, pay gap, stereotype threats, women in leadership, women in medicine


Despite progress over the past decade, women’s careers in medicine still lag behind those of men.1 In the USA, women represent close to half of medical school graduates, 40% of full-time faculty members, and only 18% of department chairs or deans.1 Hypotheses have been offered to explain the status of women in medicine.1 Factors influencing a career path can be grouped in four categories: structural, situational, environmental, and motivational.2 Structural factors, related to the institutional resources, include absence of mentoring and role models and a persistent gender pay gap. Situational factors include dependent care obligations, which are often experienced as uneven and detrimental to a woman’s career and were acutely highlighted during the COVID-19 pandemic. Environmental factors describe the work culture and its impact, including persistent gender biases.3 Motivational factors refer to interest in, and drive for, leadership.

These factors contribute to what has been described in the business sector as horizontal and vertical gender segregation.4 In academic medicine, horizontal segregation refers to the under-representation of women in some medical specialties, while vertical segregation refers to their under-representation in positions of leadership and in remuneration.

For women in academic medicine, positions of leadership are achieved despite the presence of such challenges, not because of their absence. Likewise, it is often assumed that positions of leadership protect women from such experiences. In this review, we describe four common misconceptions that surround women in leadership in academic medicine (Figure and Table). We discuss their impact on women and their careers and we suggest a path forward for individuals and institutions.

Figure.

Figure

Promoting women in leadership by identifying and addressing misconceptions

Table.

Women in leadership: misconception, facts, and recommendations

Misconception Fact Recommendation for individuals Recommendation for organizations
Women need more mentoring Women need more sponsorship Seek opportunities for sponsorship

Provide women with:

∙ Visibility

∙ Access to sponsors

∙ Incremental leadership positions

Pay gap disappears with leadership Women in leadership are paid less than men in leadership Engage in active negotiations for equitable remuneration

∙ Design transparent pay structures

∙ Report accurate and comprehensive pay data

∙ Define metrics and recognize citizenry work contributions

∙ Include women in executive decision-making process

Women lack leadership self-efficacy Women have self-efficacy and resilience to achieve goals in the face of adversity Recognize their own ability at achieving goals despite challenges

∙ Identify and manage the prevailing stereotypes that impact women and their career paths

∙ Provide opportunities to build confidence

Women’s leadership style is less effective Gendered stereotypes undermine leadership effectiveness Identify communities for support and collaboration

∙ Recognize effectiveness of collaborative leadership styles

∙ Promote the most qualified individual for the position

∙ Develop metrics for assessment of leadership outcomes

Misconception 1: Women need (more) mentoring

While mentoring is desirable at all stages of a career, what women need is sponsorship

The under-representation of women in leadership in academic medicine is often attributed to lack of mentoring. Mentoring is described as “a dynamic, reciprocal relationship in a work environment between an advanced career incumbent (mentor) and a beginner (protégé).”5 Mentoring, whether formal or informal, is desirable at all career stages, but is especially valuable during early career development. Traditionally structured as a dyad, the mentee typically receives advice, feedback, and coaching over time as part of a longitudinal personal relationship.6 Furthermore, a network of mentors may provide additional career benefits.7 Effective mentoring is associated with improved faculty retention, satisfaction, academic productivity, and promotion.8

Well studied in the business world, and now increasingly being recognized in medicine, is that a lack of sponsorship is a major reason underlying the gender achievement gap at upper levels of leadership.8,9 Sponsorship has been described as a “helping relationship in which senior, powerful people use their personal clout to talk up, advocate for and place a more junior person in a key role.”9

Sponsorship and mentorship differ in several aspects. First, sponsorship is usually episodic and focused on high-visibility opportunities.8 In contrast with mentoring, a personal long-standing relationship is unnecessary, but the sponsor must be familiar with the protégé’s skill set. Second, while mentoring may be perceived as one-directional, with the mentor transferring benefits to the mentee, sponsorship is more transactional, with both parties having clear goals and expectations. For example, the sponsor may benefit from having an ally in certain positions. Finally, there is an inherent risk to the sponsor of putting their reputation on the line; accordingly, the expectation from the protégé is to rise to the task. Thus, “a mentor is someone who has knowledge and will share it with you, a sponsor is a person who has power and will use it for you.”9

While women and people from minoritized backgrounds in medicine are most in need of sponsoring opportunities, they are less likely than men to receive sponsorship from either men or women sponsors.10 A recent qualitative report described the experiences of men and women chairs in emergency medicine. Men described the support of sponsors to help advance in leadership, while women described “advancing through their own hard work and effort.”11 In addition, women tend to be less comfortable with self-promotion and continually navigate concerns about potential backlash because of gendered role expectations.12 Sponsors can advocate for protégés in ways that protégés may have difficulty doing for themselves.

Recommendations

It is incumbent on women to seek out sponsors—not necessarily individuals who are similar and can offer advice, but ones with influence on decision-making processes or structures. Nevertheless, lack of visibility and being at an advanced career stage may decrease access to sponsorship.13 Those in positions of influence should be willing to support and amplify the work of women and members of under-represented groups.14 In addition, leaders of departments and organizations should recognize the challenges that women face throughout their careers and continue to face after attaining leadership roles. Leaders should deliberately provide women with opportunities for incremental leadership positions, and, importantly, with the resources to succeed, to provide them with the skills, experience, and credibility to advance into future high level leadership opportunities.

Misconception 2: The pay gap disappears with leadership positions

Women leaders are paid less than men in leadership positions

Women in leadership in medicine have shown exceptional performance and have managed to successfully navigate their professional environments.15 Despite their achievements and this recognition, women in leadership continue to face gender discrimination in the form of a pay gap.

Women throughout their medical careers make less than their men counterparts, even after accounting for part-time work and time off for childbearing and parental duties. This disparity is present across medical specialties, and is more pronounced in male-dominated or procedure-based specialties.1620 Assuming a 40-year medical career, this discrepancy in pay will result in women physicians making USD 2 million less than men.19 Nevertheless, the pay gap is not eliminated by achieving a top leadership position. A survey of emergency medicine departments in the USA revealed that women in leadership positions “work more clinical hours and are paid less” than their men counterparts.17 This conclusion is consistent with data provided by the Association of American Colleges annual Faculty Salary Report. In 2019, compensation for women chairs and division chiefs in academic medical programs was 21% less than their men counterparts.21

Recommendations

Historically, gendered pay disparities have been addressed by “enhancing” women’s negotiation skills and asking women to lean-in. Nevertheless, the pay gap is a structural, institutional problem, not an individual one. Eliminating the gap starts with institutions providing transparent and accurate reporting of the aggregate pay data, which includes relevant demographic information such as race, country of origin, and specialty.20 Pay data include salary, but also the less visible sources of compensation such as hiring bonuses, remunerated leadership roles, research funding, and “in kind” support.14 Second, institutions should establish a transparent pay structure to eliminate the influence of bias in hiring and promotion practices. Third, compensation plans should be based on clearly defined metrics. As importantly, compensation plans should include all contributions to the workplace, including “nonprocedural” work that does not generate revenue but serves institutional missions20 such as mentoring and advising activities. In addition, participation in volunteer roles often labelled as good citizenry or “office housework” falls disproportionately on women.22 Finally, women should be included in all stages of hiring and executive decision-making processes.

Misconception 3: Women lack leadership self-efficacy

Women have self-efficacy, or the capacity to engage in behaviours necessary to achieve goals in the face of adversity, also known as resilience

Early literature exploring women’s career paths focused on internal psychological barriers that prevent career progression and advancement and described the self-limiting beliefs and behaviours that women may experience. Women usually provide lower assessments of their own past leadership performance and potential future ability to lead than men do.23 Self-efficacy, as described by Bandura in the 1970s, refers to an individual’s belief in their own capacity to achieve their own goal.24

Recent work has challenged these assumptions about women’s leadership self-efficacy, suggesting that external factors influence women’s self-perceived ability to succeed. Anna Fels reported, based on interview data with women in medicine, that women’s ambitions may be thwarted by the lack of recognition and the presence of gendered stereotypes, which lead many women to “routinely underestimate their abilities.”25

The presence of gendered leadership stereotypes contributes to the vertical gender segregation observed in academic medicine. Stereotype threats are a situational threat affecting the performance of the members of the “group about whom the negative stereotypes exist.”26 Stereotype threats may challenge a career path and may ultimately be internalized by those experiencing them.26 In a multicentre randomized study, women surgical residents who were exposed to a stereotype-threat trigger subsequently had lower scores on their surgical assessments.27 Similarly, women exposed to stereotype threats “showed a decrease in both quality and quantity of their managerial decisions.”4 These stereotype threats also affect negotiation skills and self-promotion, leading women to rate their abilities “less favourably than equally performing men.”28

Recommendations

Navigating stereotype threats in academic medicine requires leadership and organizational awareness and support. In a series of semistructured interviews, Black women in academics described their approaches to navigating stereotype threats; these approaches were categorized by investigators as implicit and explicit peer education and leadership engagement.29

Implicit peer education refers to the practice whereby targets of stereotyped threats modulate their behaviours to disprove the prevailing stereotypes. This includes code switching, to “alter a presentation and expression of self based on [the] audience.”29 Explicit peer education is a strategy of using direct communications to bring the stereotypes and their impact to the surface. Both widely employed approaches are taxing on the under-represented individual and constitute a burden. Instead, leadership should be engaged in promoting an equitable working environment to recognize and address the prevailing stereotypes.26,29 Organizations should actively address clichés that preclude women from moving up the leadership ladder, starting early in women’s careers.

Self-efficacy can thus be reframed as the capacity to engage in behaviours necessary to achieve one’s set goals in the face of adversity, also known as resilience.30 Resilience refers to the process by which individuals show “positive adaptation and competence despite experiencing adversity.”30 Accordingly, women’s success in academic medicine in the face of adversity is an expression of their resilience. Confidence should be built from an early stage among women in academics by encouraging ideas and providing platforms for development of ideas, thus building resilience.

Misconception 4: There are fewer women because their leadership style is less effective

Women face gendered stereotypes that undermine their leadership effectiveness

Throughout their careers, women in medicine face gender stereotypes and structural barriers; some aspects of these biases are more pronounced when women are in positions of advanced leadership.31,32 As described in the role congruity theory, dissonance exists between the characteristics ascribed to women and the expected traits of a leader, between the “predominantly communal qualities that perceivers associate with women and the predominantly agentic qualities they believe are required to succeed as a leader.”33 Traditionally, characteristics of an effective leader are described as having high self-confidence, assertiveness, and decisiveness.33 By contrast, women are expected to be communal and diplomatic. In fact, women who display agentic behaviours often face criticism and are perceived as arrogant, aggressive, difficult, or impulsive.3335 In addition, women leaders face a likeability-competence double bind—if they are not likeable, they will not be accepted as leaders, but if they are likeable, they are deemed less competent.35 Balancing these gendered social expectations represents an additional burden on women leaders, potentially detracting from their professional objectives and leadership effectiveness.35 In addition, these expectations impose on women the need to carefully curate their external professional persona, whether in tone, posture, or discourse. These expectations about leadership styles may explain, in part, the over-representation of men in leadership positions, even in specialties in which the majority of physicians are women.1

Recommendations

The persistence of hierarchical systems within medicine may perpetuate the prevalent misconceptions about effective leadership styles. Nevertheless, it is well understood that collaboration and teamwork are more important than hierarchy in optimizing group performance.36 Leaders who have a strong moral compass and are authentic role models are better stewards of the organizational purpose.37 It is incumbent on institutions of academic medicine to promote the most qualified individual for the proposed position, rather than rely on outmoded and often irrelevant metrics for leadership positions. Further, explicit expectations and metrics for success in leadership roles are needed to promote balanced evaluations and recognition of the value brought by a broader range of leadership styles.

Conclusion

Women leaders are under-represented in academic medicine, to the detriment of individual women, departments, medical schools, patients, and society. Women can “lean-in” as they seek sponsors to promote their accomplishments, establish formal and informal networks of professional support, build a professional identity anchored in their individual strengths, and design personal strategies to manage their family demands. Nevertheless, navigating a biased and inequitable professional environment places a significant cognitive, psychological, and emotional strain on women and those from under-represented groups in medicine.3840 Women in medicine are known to be at higher risk for burnout than their men colleagues are.41 This may explain, in part, the attrition of women from academic medicine.1 The recent COVID-19 pandemic further amplified the negative impact on women’s careers, especially women with dependent-care obligations.42

It is time to unmask and discredit myths about women in leadership in academic medicine. Institutions must “lean-in” to promote work environments where resources and opportunities are shared equitably, where individual strengths are recognized and amplified, and where differences in leadership style are celebrated.

Acknowledgments

Author contributions

Maya Jalbout Hastie, Allison Lee, Shahla Siddiqui, Daryl Oakes, and Cynthia A. Wong contributed to all aspects of this manuscript, including study conception and design; acquisition, analysis, and interpretation of data; and drafting the article.

Disclosures

There are no commercial or noncommercial affiliations that are or may be perceived to be a conflict of interest with the work for each author and there are no other associations, such as consultancies.

Funding statement

The authors have no financial disclosures including no funding sources (e.g., departmental, hospital, institutional, commercial) were received supporting the submitted work.

Editorial responsibility

This submission was handled by Dr. Sangeeta Mehta, Guest Editor, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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