Women in Leadership

Abstract

The role of a surgeon is inherently that of a leader and as women become a larger minority in surgical specialties, the next step becomes greater representation of women in positions of surgical leadership. Leadership is a relationship of granting and claiming wherein society must accept that women are deserving of leadership and women must realize their rightfulness to lead. Implicit gender bias undermines this relationship by perpetuating traditional gender norms of women as followers and not as leaders. Though female representation in academia and leadership has increased over the past few decades, this process is unacceptably slow, in part due to manifestations of implicit bias including discrimination within academia, pay inequality, and lack of societal support for childbearing and childcare. The women who have achieved leadership roles are testament to woman's rightfulness to lead and their presence serves to encourage other young professional women that success is possible despite these challenges.

The representation of women in medicine and surgery has been an upward climb through history that began ∼150 years ago when the first American woman, Dr. Elizabeth Blackwell graduated from medical school. She was preceded by Dr. Miranda Stewart, who succeeded in her efforts by disguising herself as a male surgeon, under the name of Dr. James Barry, to gain acceptance in her specialty. Although Dr. Elizabeth Blackwell desired to practice surgery, the prospect of a female surgeon was not accepted by most patients and she was therefore encouraged toward medicine. The second woman to graduate from a U.S. medical school, Dr. Mary Edwards Walker, is considered the first American female surgeon. Her contributions to medical care during the Civil War gained her a Medal of Honor; however, she too struggled with financial hardship due to lack of patients who would accept a female surgeon. ¹ Over the following century, only a few exceptional women would similarly challenge their boundaries to achieve successful careers in surgery. These bright moments in history have served to light a path for more routine matriculation of female physicians into surgery, with an increase in percentage of women in U.S. medical school graduating in surgery increasing from <1% in 1970 to ∼35% in 2010, ² and this number has been steadily increasing.

Women in Leadership

The role of a surgeon inherently lends to positions of leadership and as women become a larger minority in surgical specialties, the next step becomes greater representation of women in positions of surgical leadership. This has been a slower process and one still in its infancy beginning with Dr. Olga Jonasson in 1987 who became the chair of the department of surgery at Ohio State University. ³ To follow over the next three decades, department chairs would be occupied by notable women including chairwoman Dr. Carol Scott-Conner in 1995 at the University of Iowa, Dr. Nancy Ascher at the University of California, San Francisco, and Dr. Julie Freischlag at the Johns Hopkins University. ³ To date, 20 chair positions are held by women in the country's 125 allopathic medical schools. ⁴ The successes achieved by past and current chairwomen have been hugely impactful just not only by their professional contributions but also serve as role models for what is possible and as advocates for young female medical students and trainees who seek not only careers in surgery but also careers in leadership. Though greater than ever before, the percentage of women in positions of surgical leadership is immeasurably small. On a more measurable scale, the percentage of female academicians also remains low with women constituting only 10% of professors, 20% of associate professors, and 27% of assistant professors in surgery by 2016. ⁵ This dramatic underrepresentation means that there are simply not enough female leaders to go around to affect their influence on the representation of women in surgical leadership for the future in a timely manner. It is estimated that it will take 49, 57, and 121 years, respectively, to reach gender parity among assistant professors, associate professors, and full professors of surgery. ⁶ So, what is contributing the inertia of women's representation in leadership?

There are several reasons why underrepresentation is so pronounced in surgical leadership including pay inequality, high rate of attrition of women in academia, and external pressures outside of career that challenge professional development. All of these factors are interrelated with implicit bias forming the underlying cause.

Implicit Bias

Overt sexism has been a clear barrier to career advancement of women in the medical field until recent history. With the passage of a series of legislation mandating gender equity in the workplace, explicit bias is no longer acceptable and women are legally armed to address this. However, implicit bias exists and continues to influence the success of women in the high acuity workplace. Implicit gender bias refers to the “subconscious attitudes or assumptions that may influence perception, judgment, and behavior toward a specific gender.” ⁷ Implicit gender bias is not only exerted upon a gender group by society but can also be internalized by the gender group under bias. A current theory of leadership outlined by DeRue and Ashford described leadership as a relationship of mutually reinforcing roles of leader and follower. ⁸ In the context of this article, leadership is both granted to women by society and women must claim it to reciprocally reinforce the relationship. It is implicit gender bias that contributes to a lack of external acceptance of women as leaders and a lack of belief by women in their rightfulness to lead.

Granting

Implicit gender bias in society portrays women as follower and not leader. This has been perpetuated in workplace culture for decades as traditionally women have held supportive nonauthoritative roles as secretaries, paralegals, and nurses. Supportive roles, though equally valuable to the success of any workplace, are devalued over the more visible, assertive roles traditionally held by men, that is, doctor, lawyer, and businessman. Even in the current medical workplace, women who share similar job positions to men tend to take on clinical and educator roles over academic roles, resulting in lower academic productivity and slower rates of promotion through academic rank. ⁹ Though not explicitly discriminatory, women fail to get recognition for less visible successes and in turn their ability to lead is not demonstrated or granted . ⁷

Mentorship and informal networking are also critical pathways to professional advancement. The differences in behavioral styles between sexes and the tendency to interact more easily with one's own gender contribute to stronger informal relationships between male leaders and male junior partners, placing men more strongly and seemingly more suited to opportunities for granting of leadership roles by their male-gendered supervisors. ⁷

Claiming

Implicit gender bias is not only externally exerted but also self-fulfilled. Since early childhood development, women have been cultivated to take on less assertive, unselfish, and nurturing traits considered a “protective” behavior style. ¹⁰ Though many leadership styles exist, the prototypical leader is one that has a confident manner and acts decisively and assertively. These traits are most closely linked to masculinity and an “acquisitional” behavior style. ¹⁰ Implicit bias presents an “identity threat” to women by devaluing their “protective” behavioral style. When a “protective” style is taken, women are more likeable; however, not respected and considered poorly suited to leadership due to this perception. Women are immediately at a disadvantage whereby they need to convince others of their leadership competence more so than do men. Additionally, conflict arises when women deliberately take on “acquisitional” behavior styles in an effort to claim positions of leadership. Taking on an unfamiliar behavior style generates a “threat” to self that is uncomfortable and anxiety provoking. In response, women are unlikely to conform to a style that offers greater professional success because to do so threatens their ability to remain genuine. ¹¹ In addition, “acquisitional” traits in women are negatively perceived as “bossy” rather than assertive or “demanding” rather than having high standards. Such conflict undermines the ability of women to claim the leadership roles to which they aspire and their ultimate goals become unrealized. This is well demonstrated in a survey study of American College of Surgeons general surgeons by Schroen et al, when asked to designate their ultimate goal for academic rank 25% of men designated chairmanship as an ultimate goal compared with only 5% of women respondents. ¹² Women are simply not empowered to claim themselves as the leaders they are capable of being.

Challenges in Academia

Academia is a particular environment in which female representation in leadership is low and the rate of advancement in rank is slow. A major reason for the lack of women in high-level academic positions is the high rate of attrition of women in academia during early career stages. According to a survey study of general surgeons, among those with the academic rank of assistant professors, 29% of women reported seriously considering leaving academia compared with 5% of men. ¹² The concept of a “broken pipeline” of women in academia has been popularized to convey the early departure of women from this arena before any career advancement is realized. In a survey study by Cropsey et al, ¹³ three major reasons for attrition reported by women faculty are lack of opportunities for professional development, low salary, and departmental chair or leadership issues. Additional factors cited more so by women respondents over men included gender discrimination and harassment as well as personal reasons.

Dissatisfaction and Discrimination

Women leave academia at lower academic ranks compared with male respondents, in part due to their dissatisfaction over the lack of opportunities for advancement. In a review by Sanfey et al, ¹⁴ one reason supposed as to why women are less exposed to such opportunities is that key conversations among senior and junior faculty that open such doors occur in personal settings (i.e., in the “locker room” or on the “golf course”) and in early morning departmental meetings when childcare responsibilities prevent women from being present. Moreover, the lack of women in the leadership and the lower levels of leadership held by women result in weaker informal networks that are less helpful for female advancement. ⁷ This type of covert discrimination is subtle and presents a unique and frustrating challenge for women confronted with this behavior. ¹⁵ In a survey study by Carr et al, gender discrimination was perceived by 47% of female faculty under the age of 50 years and by up to 70% of female faculty over the age of 50 years. Women were 2.5 times more likely to perceive gender discrimination compared with their male colleagues, demonstrating that gender discrimination is a prevalent and significant stressor in the workplace. ¹⁶ Schroen et al reported that women perceived harassment throughout their careers, during medical school (47%), residency (75%), and practice (64%) with the harasser being a senior surgeon (77%), surgeon–peer (55%), nonsurgeon physician (46%), or a patient or patient family member (25%). ¹² In response to such stressors, women demonstrate different patterns of assistance seeking and coping compared with men, which may lead them to be more susceptible to feelings of isolation and burnout. ¹⁷ The tendency for women to leave early in their career creates a cyclical pattern wherein fewer senior female mentors exist to cultivate junior female careers and dissuade their early departure.

Pay Inequality

The gender salary gap has long existed such that women in all workplace settings receive less pay for equal work. This gap has closed somewhat over the past few decades since the Equal Pay Act of 1963 ¹⁸ such that currently women receive around 80 cents on the dollar earned by men in comparable positions. Nevertheless, the United States remains well behind much of the developed world in gender equality, ranking 22nd best in terms of gender equality out of 135 countries by the World Economic Forum as of 2012. ¹⁹ The lack of equal reward for comparable productivity and seniority continues to be a subject motivating career dissatisfaction for women in the workforce. ¹⁴ In a study by Ash et al, this salary deficit becomes more pronounced as individuals progress in seniority with a difference of ∼485 dollars per year of seniority among internal medicine faculty. ²⁰ It is likely that this deficit becomes more pronounced among surgical subspecialties as earnings overall increase. Aside from purely financial measure, the impact of salary translates into value, with more value placed on the career of the higher earner in a marital relationship. Inevitably by comparison, one career becomes more susceptible to compromise to suit the needs of a relationship and this hierarchy is often determined by income. Salary also becomes an influencing factor in determining which spouse is more apt to leave a career to take on family care needs with the least amount of income lost. ¹⁴

External Pressures

Above all others, the responsibility of childbearing is distinct for women and is a major contributor to hindered professional development in surgery. Two choices are available to women surgeons who choose to pursue family and childbearing: forgo early opportunities for career advancement to complete childbearing at a young age or significantly delay childbearing until professional standing is established. In a survey study by Schroen et al, women more often reported intentionally delaying childbearing compared with men (63 vs. 41%, p  = 0.001) due to surgical training and professional demands. ¹² Those female surgeons who undertook childbearing chose to defer the decision to start a family until after completion of training, typically having children at an advanced maternal age with its attendant risks. The perception that childbearing disadvantages professional development is one demonstrated in multiple studies. ^{3 21 22}

The cost of childbearing is difficult to quantify, but there are multiple factors that contribute. Indirectly, there is an opportunity cost of time lost and career advancement delayed such that women without children, matched by experience and education to men, averaged 95% of men's wages compared with women with children who averaged only 75% of men's wages. ²³ Zhuge et al noted that most men acknowledge the sacrifices made by their wives to allow for their own career advancement and, reciprocally, women express that responsibilities to family preclude them from devoting the time needed to reach professional milestones. ²² More directly, childbearing is expensive and women surgeons are subject to greater cost of childcare due to lack of spousal support. Nearly 90% of married female academic surgeons report living in a dual-career household, whereas only 50% of male surgeons report dual-career households. Seventy-five per cent of academic surgeons pursue home-based childcare; however, among male surgeons, the spouse is the primary caregiver 63% of the time followed by an employed person 29% of the time. Among female surgeons, an employed person was the primary caregiver 88% of the time and the spouse was the primary caregiver only 5% of the time. ¹² This burden is further exacerbated by the lack of governmental parental support provided to working women. According to the Institute for Women's Policy Research at the University of California, Hastings College of Law, the United States ranked last out of 20 industrialized countries in a measure of flexible and family-friendly work arrangements. ²⁴ The United States is also the only industrialized nation that does not mandate a paid parental leave policy with fully paid maternity leave offered by only 16% of employers. ²⁵

Conclusion

Women in surgery who aspire for positions of leadership face a daunting challenge that is built upon decades of explicit gender discrimination and perpetuated today by implicit gender bias. Leadership is a relationship of granting and claiming wherein society must accept that women are deserving of leadership and women must realize their rightfulness to lead. However, this process is unacceptably slow, in part due to gender discrimination, pay inequality, and lack of societal support for childbearing and childcare. The women who have achieved leadership roles are testament to the fact that success is possible despite these challenges and their presence serves to encourage other young professional women to continue to strive for leadership.