- Email: [email protected]
Challenges Confronting Female Surgical Leaders: Overcoming the Barriers
Journal of Surgical Research 132, 179 –187 (2006) doi:10.1016/j.jss.2006.02.009
Challenges Confronting Female Surgical Leaders: Overcoming the Barriers Rena B. Kass, M.D.,* Wiley W. Souba, M.D., Sc.D., M.B.A.,*,1 and Luanne E. Thorndyke, M.D.† *Department of Surgery; †Department of Medicine, Penn State College of Medicine and Penn State Hershey Medical Center, Hershey, Pennsylvania Submitted for publication January 12, 2006
Background. The number of women reaching top ranks in academic surgery is remarkably low. The purpose of this study was to identify: 1) barriers to becoming a female surgical leader; 2) key attributes that enable advancement and success; and 3) current leadership challenges faced as senior leaders. Methods. Semi-structured interviews of ten female surgical leaders queried the following dimensions: attributes for success, lessons learned, mistakes, key career steps, the role of mentoring, gender advantages/ disadvantages, and challenges. Results. Perseverance (60%) and drive (50%) were identified as critical success factors, as were good communication skills, a passion for scholarship, a stable home life and a positive outlook. Eighty percent identified discrimination or gender prejudice as a major obstacle in their careers. While 90% percent had mentors, 50% acknowledged that they had not been effectively mentored. Career advice included: develop broad career goals (50%); select a conducive environment (30%); find a mentor (60%); take personal responsibility (40%); organize time and achieve balance (40%); network (30%); create a niche (30%); pursue research (30%); publish (50%); speak in public (30%); and enjoy the process (30%). Being in a minority, being highly visible and being collaborative were identified as advantages. Obtaining buy-in and achieving consensus was the greatest leadership challenge reported. Conclusions. Female academic surgeons face challenges to career advancement. While these barriers are real, they can be overcome by resolve, commitment, and developing strong communication skills. These elements should be taken into consideration in 1
To whom correspondence and reprint requests should be addressed at Department of Surgery, The Milton S. Hershey Medical Center, Pennsylvania State University, 500 University Drive, PO Box 850, Hershey, PA 17033. E-mail: [email protected].
designing career development programs for junior female surgical faculty. © 2006 Elsevier Inc. All rights reserved. Key Words: female surgeon; academic leaders; leadership; women in medicine; faculty development.
INTRODUCTION
The past three decades have seen a steady increase in the numbers of women applying to and being accepted into medical school, such that in 2005 women comprised 49% of all medical students [1]. The number of women pursuing careers in academic medicine has also increased, albeit more slowly. Despite more women in the “pipeline,” women remain seriously underrepresented among tenured faculty and in positions of leadership in academic medicine [2]. In 2005, women represented only 32% of medical school faculty, 15% of full professors, and 11% of department chairs [1]. These gender discrepancies were more pronounced in academic surgery where women represented 16% of the faculty and 6% of full professors [1], and only 2% of department chairs (personal communication w/ Hershel Alexander, Director of Faculty Data Systems and Studies, American Association of Medical Colleges; January 9, 2006). The absolute number of women reaching the top ranks in academic surgery is remarkably low. A number of studies have attempted to understand the barriers confronting women in medicine [3– 6] and to identify potential remedies [2, 3, 7]. This study was undertaken to identify key attributes and practices that enable academic advancement and success; barriers and obstacles for women seeking leadership positions in academic surgery; and current leadership challenges facing female surgical leaders in their senior leadership roles.
179
0022-4804/06 $32.00 © 2006 Elsevier Inc. All rights reserved.
180
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
METHODS
We performed a semi-structured telephone interview of female leaders in academic surgery. Potential participants identified for the study were senior female faculty who had achieved the position of chair, center director, surgeon-in-chief, or program director. Structured, but open-ended questions were developed to evaluate the following dimensions of leadership: personal attributes of success, lessons learned, obstacles encountered and how these were overcome, mistakes to avoid, career advice, the role of mentoring, gender advantages/disadvantages, and challenges faced as senior leaders. The IRB-approved questionnaire was designed to be approximately 30 min in length. Between April and August 2005, two investigators (LT and RK) conducted interviews of 10 female senior academic leaders. Potential participants were sent a letter of invitation to participate in the study. To allow for adequate time for reflection and preparation, those who agreed were sent the questionnaire (Appendix 1) in advance of the interview. The interviews were audio taped, fully transcribed, and subjected to analysis. Interviewers also recorded field notes during the interviews. All participants agreed to the audio taping, with the assurance of confidentiality. One audiotape was technically inadequate; field notes provided the only source of data for this interview. Analysis of the data included the following steps: 1) multiple readings of the transcripts to identify major themes, 2) summarizing and coding of data elements by responses and respondents, 3) grouping responses to refine themes, and 4) creating files of quotes and examples to illustrate themes. Coding taxonomies by two reviewers (LT and RK) were compared and consensus emerged through discussion between both readers of the transcripts. RESULTS
Letters of invitation were sent to 11 women; 10 agreed to participate. Five were current or previous chairs, one was surgeon-in-chief, three were directors or division chiefs, and one was a hospital medical director. Passages from the transcripts that exemplify themes or illustrate specific data elements are quoted as results in this report. Any identifying information is withheld. Where appropriate, the frequencies with which particular views were expressed are noted. Personal Attributes
The leaders were asked to identify personal attributes that may have contributed to their academic success. Several prominent themes emerged. The majority of women (60%) attributed perseverance and resiliency to their success, as exemplified by this response:
“Perseverance and not taking ‘no’ for an answer. When I was in high school the guidance counselor told me that women did not become doctors . . . then when I did not get into medical school, the pre-med advisor . . . said ‘why don’t you just settle down and be an engineer?’ I said no, I want to be a doctor . . . I reapplied and got in. When I got out of my training and didn’t have any publications, my chairman said, ‘it’s going to be an uphill battle to be an academic surgeon’. I said well that’s what I want to be. So I would say . . . the thing that distinguishes the ones that make it through to the end is perseverance, desire and drive.”
Inner drive and a strong work ethic was the second most common attribute, cited by 50% of the participants, including surgeons whose roles had become more administrative. “You have to be willing to work hard. Some people think being an administrator is easy and that you just sit at your desk all day and you don’t have to worry about people dying in the intensive care [unit] . . . In some respects, it’s just as hard as taking call, although the outcomes aren’t [as] significant.”
A passion for surgical practice and research was noted by 40% “Passion helps to breed success no matter what job you’re in, but probably more so in surgery. If you’re passionate about what you do and you love what you do, it makes it quite easy.” “To be successful in academic surgery means you want to answer questions and then tell the rest of the world about it.”
Approximately one third of participants relayed the importance of having a stable home life and/or life balance. “I was married in medical school and my husband has been extremely supportive . . . I think that’s very important . . . in the sense that you create a stable home environment for yourself by finding the right person to marry and then sticking with them and they stick with you . . . It is as much you as them, it’s a two way street and you have to realize how important (it is) . . . keeping your personal life in order (and) that kind of thing.”
Communication skills were identified by 30% as an important attribute. Proficiency in presentation skills was also cited. “Leadership is really all about building relationships and communication and interacting, relating with . . . all different kinds of people with all different kinds of thought and different kinds of agendas.”
Organizational skills, flexibility, and a sense of humor were important attributes noted by 20% of the participants. Other traits listed by one or more respondents included the following: compassion, honesty, a collaborative approach, disdain for authority, maintaining physical fitness, courage, risk taking, taking responsibility for one’s actions, relational skills, a standard of excellence, gentleness, and, finally, this: “One of the key reasons for my success is a high tolerance for chaos. Some people have a high tolerance, some people don’t. Some people can kind of block out everything except one thing. Other people can kind of live with a million things, demands on them at the same moment, and not get edgy.”
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS
Key Lessons
Lessons for success in the world of academic surgery were queried. The first theme that emerged was a positive attitude. Responses stressed the need for honesty, reliability, self-motivation, self-examination, and self-confidence. Leaders noted how important it is “to enjoy yourself on the way.” “Have confidence in yourself, in your abilities and (don’t) be intimidated. Surgeons can be a very brutal group of people to work with. They have very strongly-held opinions and they get very emotional if their thoughts are not the thoughts that you have. Sometimes they don’t want to see another side to the story so it’s very important not be intimidated by all these conflicting ideas but to calmly state your position, have confidence and forge ahead.” “Have a positive outlook. We’re taught as surgeons, (and) this is beat into you even (at) M&M, (to) blame people. Everything we do is negative; that’s how we’re taught to teach. I think the old adage of trying to “catch people doing things right” (should be) the main thing. It’s just such a negative world, and so you need to create a culture of objectivity and professionalism and respect.” “Your success is measured by your own barometer. You’re certainly not going to be successful in everyone’s eyes in all areas . . . everybody comes to this with a different perspective as to what’s valuable and what’s important . . . you have to follow your bliss . . . do all those things that make you, at the end of the day, feel like you’ve done the right thing.”
A second theme centered on acquiring and honing specific skill sets in public speaking, writing, time management, and leadership. “Publish. Publish. Publish. That is the ticket . . . the thing we have to hammer home to young women. A lot of it may be bogus and there is an awful lot of rubbish in the literature. But those are the tickets. Those are what people look for. I said to many a young person who I have mentored, ‘people can’t read, but they can count’—and they do.” “Have an educated voice. When you speak up . . . whether it be at a conference, a small meeting, whether you’re counseling a resident, you need to be educated about what you’re talking about and know the data . . . so have an educated voice no matter what you’re doing.”
181
“You’ve got to be able to work with others . . . You have to treat people that you work with as your team.” “Figure out how to relate and communicate with other people who are not used to women doctors or women leaders . . . you have to figure out what style works for you and what style works in your local environment.” “You can never communicate enough. Even though you think that you’ve made things perfectly clear and you’ve talked about them in a faculty meeting, there are still going to be people that didn’t hear, didn’t think it applied to them, didn’t remember what you said, or interpreted it some other way than what you thought.” “You need everyone, everywhere. I know the dean well. I know the head of human resources. I need everybody because . . . the people who are going to help your job be very successful are not in your office or in your department. They are outside. You have to meet everyone everywhere and realize that the power that you have is because they all know you.”
A final theme addressed issues for women. Points included learning the system and the rules of the game, [8] knowing one’s limitations, having a good infrastructure, integration within the profession, and eschewing insults of gender bias while selectively challenging inequities. “Never trust they’re looking out for you, because they’re looking out for themselves. They’re not going to tell me you need to join the AAS; they never told me to join anything . . . they don’t look out for you and I think they especially don’t look out for women. You have to go out there on your own, and don’t be afraid to do that.” “We’re playing by a different game. Men are playing ball, and there’s a coach and you have to play within that world; we play dolls and everything is equal. You have to play by the rules, and play ball and always talk to the coach and make the coach look good, and if you have a good idea, give it to the coach so the coach can look good.” “Try to be part of the solution to issues and not create problems . . . especially as a woman in surgery, if you’re seen as somebody who complains all of the time and isn’t part of fixing the problem, you become labeled very early on. In men, that [labeling] doesn’t actually happen as frequently.”
“[My] advice to a young person and not necessarily to a woman, but anybody, is not to put off things. You have to prioritize and some things just do not get done . . . Try to do things in a timely fashion because otherwise you do get totally overwhelmed.”
“The tendency for minorities is to stay on the outside and yell about what is going on in the inside. And that has stranded a lot of careers and a lot of progress. So my advice is: learn the system, get into it. You don’t have to become like a man, you don’t have to swear like a trooper, but get into the system, learn the system, and then change it from inside.”
“You shouldn’t expect to know how to do an administrator job anymore than you knew how to operate when you started medical school . . . Management is a defined skill set and you can learn it. It is analogous to . . . writing: if you’re having trouble writing papers, you can learn how to write. It’s not something that you’re either born knowing how to do or not to do. So for me, that was a key insight.”
“Integrate into the surgical profession. Liking your fellow surgical colleagues . . . that’s absolutely essential. You have to really like it . . . and feel very much a part of that group and that culture. Developing that whole network of academic friends that become very important people to you . . . that’s one place where a lot of woman surgeons don’t click. They don’t, for whatever reason . . . feel as integrated into the profession as they can be.”
“Those of us, who have gone to medical school, have not necessarily been trained to be leaders per se, so there is an additional skill set that we need to develop.”
A third theme focused on interpersonal and communication skills, the ability to work with a team, and networking.
Major Obstacles
The majority of women identified significant obstacles. Barriers included the lack of effective mentors, traditional sexism of a male-dominated culture, a hostile work environment, and personal illness. A significant majority
182
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
(80%) reported overt discrimination, gender prejudice and sexual harassment, with 40% citing limited job opportunities related to these factors. “It’s very difficult, particularly when I was younger, to be taken seriously by fellows. You know, even as a resident, as a junior faculty member, I really had to prove myself . . . almost every single day . . . in ways that I don’t think men have to.” “The obvious one is gender prejudice. I am [petite] . . . and I was pretty good looking when I was a young woman and those actually counted against me, eliciting comments like ‘oh you are too cute to be a surgeon’, ‘you got your husband, why don’t you quit now’, ‘you just are taking a place that should be occupied by a man’, and ‘you are too little’, ‘you are not strong enough’ etc. There was inappropriate touching and inappropriate comments in the operating room which I still have a hard time talking about.” “I would go on interviews and people would ask, ‘What makes you think you can tell a group of . . . mostly male surgeons, what to do and that they are going to listen to you?’ They would phrase it various ways but . . . . they were really asking, ‘Look, you’re a woman, you’re soft-spoken, you don’t look like what we expect, what makes you think . . . you can come here and run the place?’ ”
In overcoming the obstacles of gender prejudice, 30% of women responded that their strategy was to be “better”—more prepared, more credentialed, more skilled—in effect, to be not just equal, but better than their male counterparts. Several discussed another consideration: their physical features and appearance. “I tried to avoid acting or looking like a sexual object. The conflict, of course, is that you know it’s great to feel feminine and sexual . . . those aren’t bad things. It’s just you can’t do it in the workplace. The message should be you have to look professional and then beyond that, you . . . want some freedom [and] some latitude.” “I would demean myself if I changed my outlook and the way I dress . . . I really overcame [prejudice] by doing better than anybody else . . . later on people used to tell me that they forgot how small I was and thought I was actually a large person, so I guess I had ‘arrived’ at that point.”
Several advised that women should not take gender prejudice personally. “Avoid looking for insult . . . . innuendo and hidden meaning. But, challenge(e) it [discrimination] when it occurs. What has been so difficult for young women . . . when they don’t get the job, they don’t get an advancement, the tendency is to look and say that it is discrimination and not, ‘did I really deserve this?’ I think that is an insight which has to be rather painfully learned.” “Don’t take is personally . . . it would have been any woman. . . Instead of getting blown apart, get real focused on [who you are] and where you want to go.”
rectly, and to be prepared to leave if open dialogue doesn’t result in change. “Speak up, be honest, be forthright, address the issues head on, set up a meeting, go and talk about those issues, but in the end, I actually resigned one position because I could not get the salary equity changed. The older I got, I felt more comfortable in my own skin to make those decisions. At a more junior level, I would have kept doing the work and would have said, well I just failed and didn’t get an appropriate salary and plugged along. There are male leaders that are older that will try [to] get away with giving a lower level of salary especially to junior women. I think that the national data bears out that not only is there salary inequity, but again there’s most commonly, increased workload, so probably even more salary inequity.”
Hostile cultures were also described as obstacles, but no participant individually identified this factor as a personal obstacle. Rather, these leaders discussed the impact of organizational culture on them and suggested that women should consider this factor in the process of job selection. “There are certain cultures that can be hostile to powerful woman, and the closer you get to the money, obviously, the more obvious the obstacles become.” “I have been successful in what I considered to be a hostile environment by making myself visible and valuable in ways that were important to the environment. But that’s not a good way to live . . . it’s much better to be in an environment where you think you’re contributing and they’re happy to have you contribute.”
Advantages of Gender
Despite gender-specific barriers, 80% identified genderspecific advantages. Better teamwork, gentler tissue handling, better communication skills, and the ability to multi-task were noted. Three participants felt that the influence of women within the surgical profession might help to change the surgical stereotype. Not all leaders held this view. “The field of surgery will benefit from having more gender balance. Woman surgeons are perceived as less intimidating, easier to talk to and easier to work with in many respects. You know it’s unfair, because there are a lot of really wonderful male surgeons that have wonderful personal characteristics but you never hear about them. Having more women in the field I think really will help to break that stereotype.” “We bring a different perspective to the field in terms of patient care. Women spend more time with patients and with their families, are much more compassionate at the bedside, and you see that difference with the vast majority of women, whether they be in surgery or . . . some other medical specialty.” “People talk about woman being more nurturing and all that stuff but I’m not really even 100% sure that that’s true . . . or that it’s necessarily desirable.”
“You can’t worry about the inequities. I think you need to address them, but you cannot take them home and worry about them and live with them . . . because the biggest inequities are going to be the higher you get.”
Thirty percent noted that being female provided a higher visibility. One cautioned that a high profile may be a double-edged sword:
One identified salary inequity as a major obstacle. To overcome this, she suggested addressing the issue di-
“You’re visible, especially when you get to a certain level. . . but it also sets a pretty high set of hoops that you have to get
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS
TABLE 1
through repeatedly and your failures are more obvious. So your wins are bigger wins, your failures are more obvious and potentially more dreadful.”
Mentoring
The great majority (90%) stated they have had a mentor or mentors during their career. Half of the women, however, admitted that they had not been effectively mentored. Most cited multiple mentors; 60% used mainly male mentors because of the lack of females in the profession. “I tell people to keep their eyes open for multiple mentors . . . [one can] teach me how to best care for a patient, another person may teach me lessons of life, another person can help me with my research approach. It’s kind of like men; I just don’t think that one can do everything for you!” “I’ve acquired a rolling set of mentors throughout my career and I think we all have something to learn from the people ahead of us . . . I don’t think there’s a time . . . when you can stop being mentored.”
Eight leaders (80%) stated that they either had had female mentors or felt that it was important for woman to have a female mentor. Female mentors were sought particularly for guidance on family or lifestyle issues or as role models. “I went and sought out the chief of surgery, [and said], I really would like to go into surgery and I’m thinking about what programs I should go to. This male chief surgeon said to me . . . you’re a good Italian woman and you need to have a family and surgery should not be your career goal . . . That’s where I think I began to then seek out women.” “It was very difficult for me to have children and try to balance all of that . . . it would have been nice to connect with someone else who had experienced some of the same things But those people [weren’t] around.”
These leaders stressed the importance of being proactive in the process of identifying, seeking, and engaging a mentor. One cautioned that the purpose of mentoring is not to provide a template to be copied: “I have sought mentors. I go ask people their advice. I don’t wait until they come look for me. I think that is the other thing women have to do. Men do it all of the time.” “You can’t take on the personality of somebody else. That’s not the point of the mentor. The point is . . . to look at someone, see what part of their approach to life, to work, will work for you.” “A nice person is not nearly as important as an empowered mentor.”
Career Steps
A number of “steps to success,” were identified for female surgeons who want to advance in academic surgery (Table 1). The most commonly cited strategies include the following: identify an effective mentor, set career goals, publish, and take personal responsibility
183
Steps to Academic Career Success 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Actively pursue/engage a mentor Set career goals Refine writing skills and publish Take responsibility for your future/career Develop organization/time management skills Be visible through networking and service Develop a focus of expertise Make time for research Follow your passion/dream Public speaking and presentations Carefully choose your environment
60% 50% 50% 40% 40% 30% 30% 30% 30% 30% 30%
Recommendations for Junior Female Surgical Faculty (in order of decreasing numbers of citation).
for managing one’s academic career. One participant delineated the following steps: “First and foremost she needs to decide what she wants to be when she grows up [surgeon-scientist, clinician-educator] and then find an environment that wants to actually embrace her, develop and make (her) into a real live academic surgeon . . . have a well-empowered mentor . . . who has control . . . to make you successful or not. Then you’ve got to really take total responsibility for your future . . . . Make sure you start punching those academic buttons or else you’ll never get promoted . . . develop that whole network of colleagues that allows you to become integrated in your profession.”
Several noted the need to join specific organizations to gain national visibility. “The key for surgery has to do with connections . . . and know[ing] what are the key organizations in your specialty. You have to get visibility that extends beyond your own institution. It is not just a matter of teaching and operating and taking care of patients, you have to write. But then to get the national level visibility, you have to go to the meetings, discuss papers, present papers and be on committees. Because that’s how people see you and eventually judge you. And if you’re not out there going to the meetings, joining the organizations, you’re not going to have that network.”
Finally, participants commented on the impact of a balanced life. “ . . . in the traditional model, the male surgeon did his cases, stayed after work late to write papers . . . and the wife was home taking care of the kids and running the household. . . Women don’t have that opportunity . . . so it’s okay to say for this ten year period of time, my focus is going to be a little bit more on my family . . . I’m still going to be productive . . . but I’m not going to marry myself to my job . . . For a long time I was made to feel that I was a lesser individual because I wasn’t on the fast track to be a professor. It’s important for women to feel that there are many ways to contribute and to advance . . . It’s going to take longer . . . but the gains that you will make in your personal life will offset that time.”
Mistakes to Avoid
Two participants identified the failure to carefully select a work environment as a mistake they made. Two
184
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
additional participants noted the choice of location/ environment is a critical “step” for junior faculty to make. “ . . . need to make sure you are around people that are wanting you to advance and are willing to lose you. And that the reason they are training you is that they know you will leave them.” “Know your local environment. Young women say ‘at my place there is no counsel, no mentoring,’ you know a whole series of complaints. The truth is that you took the job. Why did you take the job? You have to think about how the environment is going to work for you . . . . whether the environment will let you advance on a national or international arena.” “If you have a set of goals, you have to make sure that your vision for your future, meshes with the vision of the environment.”
Failure to recognize gender differences in conflict resolution underscores the following “mistake”: “I think that they (male surgeons) are used to there being winners and losers. I think it’s part of the culture. When I took over, if somebody came to me with a problem and I could solve it— great. If I couldn’t completely solve it, I (would try) to resolve something so that both parties got something. I was actually very proud that I could come up with a creative way around a conflict. I think there were some situations where I came to a compromise that should (have been) satisfactory to both parties. And the thing that was always striking was that whatever person got more did not think they had gotten as much as they should have. When you’re managing men they’re much happier if there’s a winner and a loser. I think the winner is much happier, obviously, than the loser. You would think would be happier if they were getting something, but if they see a winner and a loser, they think maybe next time they might be the winner.”
Despite the acknowledged importance of mentors, participants cautioned that advice from senior mentors may be outmoded and that some mentors can be selfserving. Other mistakes included the following: having a superiority complex, not protecting time for self/ family, not acknowledging mistakes, and being impatient. An important imperative for women: “I learned not to cry. Women must not cry.” Leadership Challenges
The greatest leadership challenge, noted by 60% of participants, was obtaining buy-in, building consensus and leading people through change. Maintaining clinical skills, creating positive cultures, keeping communication open, avoiding burnout, recognizing and implementing ideas, dealing with difficult personalities, being a role model, management of funds, and making tough decisions were challenges identified by one or more leaders. “I just wanted them to do their job, do a good job, and I couldn’t ever imagine that they wouldn’t be trying to work hard and do the right thing. There are just people out there that aren’t, you have to deal with them for the good of the department and that’s really tough.”
Collaboration and the creation of teams, a top challenge for one participant, was also considered a critical
element of successful leadership and the “key to innovation.” Another noted: setting high goals—and achieving them. “My challenge is to really walk the walk. I’m here to build a culture that’s hopefully positive, a program that will let me train the surgical leaders of the future and (provide) quality care that will be the envy of the world and measure that care. Develop the quality metrics to allow us to actually build that platform. That means recruiting people to high-risk jobs. So . . . that’s my challenge . . . to pull it off.”
DISCUSSION
While the number of women entering medical school has risen progressively in the past 35 years, the surgical specialties continue to attract relatively few women [9]. Further, the number of women surgeons who seek a career in academic medicine and advance to become a leader in the field is remarkably low. In 2005, only 7 of 301 surgical chairs (2%) were female. This ranks among the very lowest percentage of all departments in academic health centers (personal communication, Alexander, AAMC). Research in this area has often focused on identifying barriers to women, [5, 7, 10] factors constraining women in academic medicine, [11, 12] or identifying obstacles to advancement [6, 7, 10, 12]. This paper presents the perspectives of those who have overcome the barriers to become leaders. The study was designed to probe the experience and perspectives of senior female surgical leaders. The nature of the topic area, and the value of capturing subtleties in the views of these leaders, necessitated a qualitative approach to the study. The study design was based in open-ended questions that did not force the respondents to comment on pre-specified points of view. This method was designed to maximize the yield of a broad base of original, discrete data elements. Survey techniques such as check-off lists and Likert scales were specifically excluded from the design of the interview questionnaire to promote the generation of ideas directly from the respondents. Thus, the congruence of some of the discrete data elements from multiple sources is important, and may suggest the prevalence of a specific perspective, belief, or concern regarding the particular dimension queried. This study focused on women who have achieved positions of leadership in academic surgery in an attempt to identify key attributes and practices that enable advancement and success, as well as strategies to confront and surpass the obstacles that continue to challenge women in medicine. These women are an elite group and have a unique perspective. Their comments are insightful and inspiring. Female leaders in academic surgery are in an excellent position to identify needs and skills that may be incorporated into programs to assist junior women (and men) in academic surgery and medicine. They are useful for junior
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS
faculty, both men and women, who face obstacles yet aspire to be leaders in their profession. The women faced significant obstacles. Barriers included the lack of effective mentors, traditional sexism of a male-dominated culture, limited job opportunities, and a hostile work environment. Despite the barriers, these women were able to overcome both personal and professional obstacles to advance to leadership. Although not directly queried, none of the leaders voice a regret about career choice, mirroring the findings of others [13, 14]. Personal attributes of perseverance, drive, and a strong work ethic were identified by a majority of leaders as critical success factors. Initiative, curiosity, and courage were also cited. Importantly, a sense of humor seemed to be a mechanism to effectively navigate difficult personal interactions as well as hostile environments. The reporting of overt discrimination or gender prejudice by a significant majority of those in our study has also been reported by others [15–18]. Several women stated that their strategy to overcome prejudices and gender bias was to be better than all of the others. One stated, “I overcame the prejudice by being so good that people wanted me and they did not care that I wore a skirt.” Another quipped, “One of the ways we coped was just to be over prepared. Be better than anybody.” And from another, “ . . . you have to be really good . . . then you can be really different [female] if you are really good.” Many of the women seemed to make a conscious effort to depersonalize themselves from the impact of specific incidents of discrimination. Techniques to survive hostile environments and gender prejudice included not “playing the victim,” avoid looking for insult, and have a “thick skin.” The most poignant advice came the following story. “I actually had a dean tell me, in the last two years, that he could not give me a chair job because I was a woman. Many people did not believe that he actually had verbalized this. [What is important, is that] you cannot hate that man . . . you cannot worry about the inequities . . . You need to address them, but you cannot take them home and live with them.” A number of attributes identified by these surgical leaders are less related to personal characteristics and more tied to skills or behaviors that can be learned, developed, or enhanced. Communication skills, and effective public speaking techniques, time management, conflict management, interpersonal skills, writing skills and organizational dynamics were identified as important. The leaders recognized that leadership and management were skill sets that needed to be learned. Much has been written about mentoring and the need for effective, positive mentoring experiences for both women and men [6, 19, 20 –25]. While the great majority (90%) of these female leaders did identify a
185
mentor at some point in their careers, half of the women admitted that they have not been effectively mentored. Identifying and linking with an “empowered mentor” was considered a critical step for successful advancement in academia. While most acknowledged that women do need female mentors, the reality of the gender distribution in surgery precluded this as a possibility for most, and continues to be a challenge for young female surgeons today. The impact of family and lifestyle choices was not a specific focus of this study. It is interesting to note, however, that even with the freedom of open-ended questions, none of the women identified family or social responsibilities, children, or traditional gender roles as obstacles or barriers to becoming a top female surgical leader. On the contrary, several women identified the importance of crafting a stable home life as a strategy for success. Most perceived advantages to being a woman in the field of surgery. Advantages were identified for the individual herself, the field of surgery, and for patients. They included those related to individual physical features (greater visibility being a minority), temperament (collaboration, teamwork, listening skills, relational skills), and professionalism (compassionate and caring, less hostile, potential to change the traditional surgical stereotype). As one leader stated, “the field will benefit from having more gender balance. It could change the stereotype of the surgeon as arrogant, workaholic, and intimidating. Sexism is changing, but slowly.” Another finished: “right now is a great time for women in our field.” In the area of career advice, these female leaders identified a number of “steps to success” that junior female surgeons who want to advance in a career in academic surgery should take. These are summarized in Table 1. The most commonly cited strategies included the following: identify an empowered mentor, set broad career goals, publish, and take personal responsibility for managing one’s academic career. Such advice is applicable across the much broader scale of academic medicine in general. At the Penn State College of Medicine, for example, a Junior Faculty Development Program has been implemented through the Office of Professional Development that combines a comprehensive curriculum in topics of academic career development with a structured mentoring program linked to the completion of an individual project [26]. The global objectives of this program include the items listed by these leaders. Integration into the surgical profession was another critical step listed. “Liking your colleagues and feeling a part of the surgical culture” was viewed as essential for integrating into the profession and achieving success. One leader noted that many women fail to integrate within their professions, a statement supported
186
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
by a recent study, [12] where 25% of female academic surgeons felt isolated from their surgical colleagues for reasons of ethnic, cultural or gender differences, as compared to only 1% of their male counterparts. Another suggested inviting colleagues out to dinner. The “social capital” gained from informal gatherings has been well documented to promote not only success of the individuals, but greater productivity of the organization as a whole [27]. Each of the participants was asked to identify their greatest challenge as a leader in academic surgery. Obtaining buy-in and achieving consensus was the greatest leadership challenge, cited by 60% of those interviewed. Many referenced the significant changes occurring in the healthcare environment and within academic health centers themselves, and the need to provide strong leadership during these challenging times. Despite the challenges, however, a notable feature of these female leaders in academic surgery was the palpable optimism, confidence, and enthusiastic energy characteristic of highly effective leaders, whether they are female or male. In summary, female academic surgeons face significant challenges to their career advancement. These barriers are real and, unfortunately, have persisted over time even as women continue to make inroads in accessing a career in medicine. Obstacles include maledominated cultures, gender discrimination, limited job opportunities, and hostile work environments. These female leaders demonstrate that obstacles can be overcome by resolve, commitment, and learned skills in a variety of areas. Recommendations for overcoming barriers and advancing in academic surgery involve particular individual attributes and personal accountability for professional development and management of one’s academic career. Several areas are identified that might be an appropriate focus for faculty development initiatives targeted to junior female surgical faculty and others.
APPENDIX 1. FEMALE LEADERSHIP QUESTIONNAIRE INTERVIEW QUESTIONS
1. What personal attributes (at least 4) have helped you achieve success in academic surgery? 2. What are some of the key lessons you have learned for succeeding in the world of academic surgery? 3. What major obstacles did you face, and how did you overcome them? What are three key mistakes to avoid? 4. How would you advise a junior female surgeon who wanted to advance her career in academic surgery? What steps should she take? 5. Please comment about mentoring... Did you have a mentor during your career? If so, at what stage was
it most helpful? Are your mentors men, women, or both? Do you think women need female mentors? 6. What advantages do you see of being a woman in surgery? For the individual herself, the field, and the patient(s). 7. Now that you are in a position of leadership, what is your greatest challenge? 8. Do you have any other thoughts or comments? ACKNOWLEDGMENTS The authors would like to acknowledge Hershel Alexander and Mary Blew for their assistance in preparing this manuscript.
REFERENCES 1. 2.
3. 4.
5. 6.
7.
8. 9. 10.
11. 12. 13.
14.
15. 16.
17.
18. 19.
Women in U.S. academic medicine: Statistics and medical school benchmarking. AAMC Annual Report 2004 –2005. Bickel J, Wara D, Atkinson B, et al. Increasing women’s leadership in academic medicine: Report of the AAMC project implementation committee. Acad Med 2002;77:1044. Nora LM. Commentary: Academic medicine gets a poor report card—What are we going to do? Acad Med 2002;77:1062. Tesch BJ, Wood HM, Helwig AL, Nattinger AB. Promotion of women physicians in academic medicine: Glass ceiling or sticky floor? JAMA 1995;273:1022. Sonnad SS, Colletti LM. Issues in the recruitment and success of women in academic surgery. Surgery 2002;132:415. Yedidia MJ, Bickel J. Why aren’t there more women leaders in academic medicine? The views of clinical department chairs. Acad Med 2001;76:453. Wright AL, Schwindt MA, Bassford TL, et al. Gender differences in academic advancement: Patterns, causes, and potential solutions in on US college of medicine. Acad Med 2003;78:500. Heim P. Hardball for women: Winning at the game of business. New York: Penguin Group 1992:290. Baxter N, Cohen R, McLeod R. The impact of gender on the choice of surgery as a career. Am J Surg 1996;172:373. Colletti LM, Mulholland MW, Sonnad SS. Perceived obstacles to career success for women in academic surgery. Arch Surg 2000;135:972. Bickel J. Women in academic medicine. JAMWA 2000;55:10. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310. Mizgala CL, Mackinnon SE, Walters BC, Ferris LE, McNeill IY, Knighton Y. Women surgeons: Results of the Canadian population study. Ann Surg 1993;218:37. Frank E, Brownstein M, Ephgrave K, Neumayer L. Characteristics of women surgeons in the United States. Am J Surg 1998;176:244. Capek L, Edwards DE, Mackinnon SE. Plastic surgeons: A gender comparison. Plastic Reconstr Surg 1997;99:289. Dresler CM, Padgett DL, Mackinnon SE, Patterson A. Experiences of women in cardiothoracic surgery: A gender comparison. Arch Surg 1996;131:1128. Carr PL, Ash AS, Friedman RH, Szalacha L. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Ann Int Med 2000;132:889. Kornstein SG, Norris SL, Woodhouse SW. Women in medicine: Shaping the future. VMQ 1998;125:44. Bickel J. Looking for mentor replacement therapy? A coach may be the answer. JAMWA 2003;58:210.
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS 20.
Cain JM, Schulkin J, Parisi V, Power ML, Holzman GB, Williams S. Effects of perceptions and mentorship on pursuing a career in academic medicine in obstetrics and gynecology. Acad Med 2001;76:628. 21. Johnson JC, Williams B, Jayadevappa R. Mentoring program for minority faculty at the University of Pennsylvania School of Medicine. Acad Med 1999;74:376. 22. Jackson VA, Palepu A, Szalacha L, et al. Having the right chemistry: A qualitative study of mentoring in academic medicine. Acad Med 2003;78:328. 23. Tracy EE, Jagsi R, Starr R. Outcomes of a pilot faculty mentoring program. Am J ObGyn 2004;191:1846.
187
24.
Staveley-O’Carroll K, Pan M, Meier A, Han D, et al. Developing the young academic surgeon. J Surg Res 2004;118:109.
25.
Lewis RJ. Some thoughts regarding gender issues in the mentoring of future academicians. Acad Emerg Med 2003; 10:59.
26.
Thorndyke LE, Gusic ME, George JH, et al. Empowerment of junior faculty through development and mentoring. Acad Med (accepted for publication March 2006).
27.
Day D. Leadership development: A review in context. Leadership Qtrly 2001;11:581.
Challenges Confronting Female Surgical Leaders: Overcoming the Barriers Rena B. Kass, M.D.,* Wiley W. Souba, M.D., Sc.D., M.B.A.,*,1 and Luanne E. Thorndyke, M.D.† *Department of Surgery; †Department of Medicine, Penn State College of Medicine and Penn State Hershey Medical Center, Hershey, Pennsylvania Submitted for publication January 12, 2006
Background. The number of women reaching top ranks in academic surgery is remarkably low. The purpose of this study was to identify: 1) barriers to becoming a female surgical leader; 2) key attributes that enable advancement and success; and 3) current leadership challenges faced as senior leaders. Methods. Semi-structured interviews of ten female surgical leaders queried the following dimensions: attributes for success, lessons learned, mistakes, key career steps, the role of mentoring, gender advantages/ disadvantages, and challenges. Results. Perseverance (60%) and drive (50%) were identified as critical success factors, as were good communication skills, a passion for scholarship, a stable home life and a positive outlook. Eighty percent identified discrimination or gender prejudice as a major obstacle in their careers. While 90% percent had mentors, 50% acknowledged that they had not been effectively mentored. Career advice included: develop broad career goals (50%); select a conducive environment (30%); find a mentor (60%); take personal responsibility (40%); organize time and achieve balance (40%); network (30%); create a niche (30%); pursue research (30%); publish (50%); speak in public (30%); and enjoy the process (30%). Being in a minority, being highly visible and being collaborative were identified as advantages. Obtaining buy-in and achieving consensus was the greatest leadership challenge reported. Conclusions. Female academic surgeons face challenges to career advancement. While these barriers are real, they can be overcome by resolve, commitment, and developing strong communication skills. These elements should be taken into consideration in 1
To whom correspondence and reprint requests should be addressed at Department of Surgery, The Milton S. Hershey Medical Center, Pennsylvania State University, 500 University Drive, PO Box 850, Hershey, PA 17033. E-mail: [email protected].
designing career development programs for junior female surgical faculty. © 2006 Elsevier Inc. All rights reserved. Key Words: female surgeon; academic leaders; leadership; women in medicine; faculty development.
INTRODUCTION
The past three decades have seen a steady increase in the numbers of women applying to and being accepted into medical school, such that in 2005 women comprised 49% of all medical students [1]. The number of women pursuing careers in academic medicine has also increased, albeit more slowly. Despite more women in the “pipeline,” women remain seriously underrepresented among tenured faculty and in positions of leadership in academic medicine [2]. In 2005, women represented only 32% of medical school faculty, 15% of full professors, and 11% of department chairs [1]. These gender discrepancies were more pronounced in academic surgery where women represented 16% of the faculty and 6% of full professors [1], and only 2% of department chairs (personal communication w/ Hershel Alexander, Director of Faculty Data Systems and Studies, American Association of Medical Colleges; January 9, 2006). The absolute number of women reaching the top ranks in academic surgery is remarkably low. A number of studies have attempted to understand the barriers confronting women in medicine [3– 6] and to identify potential remedies [2, 3, 7]. This study was undertaken to identify key attributes and practices that enable academic advancement and success; barriers and obstacles for women seeking leadership positions in academic surgery; and current leadership challenges facing female surgical leaders in their senior leadership roles.
179
0022-4804/06 $32.00 © 2006 Elsevier Inc. All rights reserved.
180
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
METHODS
We performed a semi-structured telephone interview of female leaders in academic surgery. Potential participants identified for the study were senior female faculty who had achieved the position of chair, center director, surgeon-in-chief, or program director. Structured, but open-ended questions were developed to evaluate the following dimensions of leadership: personal attributes of success, lessons learned, obstacles encountered and how these were overcome, mistakes to avoid, career advice, the role of mentoring, gender advantages/disadvantages, and challenges faced as senior leaders. The IRB-approved questionnaire was designed to be approximately 30 min in length. Between April and August 2005, two investigators (LT and RK) conducted interviews of 10 female senior academic leaders. Potential participants were sent a letter of invitation to participate in the study. To allow for adequate time for reflection and preparation, those who agreed were sent the questionnaire (Appendix 1) in advance of the interview. The interviews were audio taped, fully transcribed, and subjected to analysis. Interviewers also recorded field notes during the interviews. All participants agreed to the audio taping, with the assurance of confidentiality. One audiotape was technically inadequate; field notes provided the only source of data for this interview. Analysis of the data included the following steps: 1) multiple readings of the transcripts to identify major themes, 2) summarizing and coding of data elements by responses and respondents, 3) grouping responses to refine themes, and 4) creating files of quotes and examples to illustrate themes. Coding taxonomies by two reviewers (LT and RK) were compared and consensus emerged through discussion between both readers of the transcripts. RESULTS
Letters of invitation were sent to 11 women; 10 agreed to participate. Five were current or previous chairs, one was surgeon-in-chief, three were directors or division chiefs, and one was a hospital medical director. Passages from the transcripts that exemplify themes or illustrate specific data elements are quoted as results in this report. Any identifying information is withheld. Where appropriate, the frequencies with which particular views were expressed are noted. Personal Attributes
The leaders were asked to identify personal attributes that may have contributed to their academic success. Several prominent themes emerged. The majority of women (60%) attributed perseverance and resiliency to their success, as exemplified by this response:
“Perseverance and not taking ‘no’ for an answer. When I was in high school the guidance counselor told me that women did not become doctors . . . then when I did not get into medical school, the pre-med advisor . . . said ‘why don’t you just settle down and be an engineer?’ I said no, I want to be a doctor . . . I reapplied and got in. When I got out of my training and didn’t have any publications, my chairman said, ‘it’s going to be an uphill battle to be an academic surgeon’. I said well that’s what I want to be. So I would say . . . the thing that distinguishes the ones that make it through to the end is perseverance, desire and drive.”
Inner drive and a strong work ethic was the second most common attribute, cited by 50% of the participants, including surgeons whose roles had become more administrative. “You have to be willing to work hard. Some people think being an administrator is easy and that you just sit at your desk all day and you don’t have to worry about people dying in the intensive care [unit] . . . In some respects, it’s just as hard as taking call, although the outcomes aren’t [as] significant.”
A passion for surgical practice and research was noted by 40% “Passion helps to breed success no matter what job you’re in, but probably more so in surgery. If you’re passionate about what you do and you love what you do, it makes it quite easy.” “To be successful in academic surgery means you want to answer questions and then tell the rest of the world about it.”
Approximately one third of participants relayed the importance of having a stable home life and/or life balance. “I was married in medical school and my husband has been extremely supportive . . . I think that’s very important . . . in the sense that you create a stable home environment for yourself by finding the right person to marry and then sticking with them and they stick with you . . . It is as much you as them, it’s a two way street and you have to realize how important (it is) . . . keeping your personal life in order (and) that kind of thing.”
Communication skills were identified by 30% as an important attribute. Proficiency in presentation skills was also cited. “Leadership is really all about building relationships and communication and interacting, relating with . . . all different kinds of people with all different kinds of thought and different kinds of agendas.”
Organizational skills, flexibility, and a sense of humor were important attributes noted by 20% of the participants. Other traits listed by one or more respondents included the following: compassion, honesty, a collaborative approach, disdain for authority, maintaining physical fitness, courage, risk taking, taking responsibility for one’s actions, relational skills, a standard of excellence, gentleness, and, finally, this: “One of the key reasons for my success is a high tolerance for chaos. Some people have a high tolerance, some people don’t. Some people can kind of block out everything except one thing. Other people can kind of live with a million things, demands on them at the same moment, and not get edgy.”
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS
Key Lessons
Lessons for success in the world of academic surgery were queried. The first theme that emerged was a positive attitude. Responses stressed the need for honesty, reliability, self-motivation, self-examination, and self-confidence. Leaders noted how important it is “to enjoy yourself on the way.” “Have confidence in yourself, in your abilities and (don’t) be intimidated. Surgeons can be a very brutal group of people to work with. They have very strongly-held opinions and they get very emotional if their thoughts are not the thoughts that you have. Sometimes they don’t want to see another side to the story so it’s very important not be intimidated by all these conflicting ideas but to calmly state your position, have confidence and forge ahead.” “Have a positive outlook. We’re taught as surgeons, (and) this is beat into you even (at) M&M, (to) blame people. Everything we do is negative; that’s how we’re taught to teach. I think the old adage of trying to “catch people doing things right” (should be) the main thing. It’s just such a negative world, and so you need to create a culture of objectivity and professionalism and respect.” “Your success is measured by your own barometer. You’re certainly not going to be successful in everyone’s eyes in all areas . . . everybody comes to this with a different perspective as to what’s valuable and what’s important . . . you have to follow your bliss . . . do all those things that make you, at the end of the day, feel like you’ve done the right thing.”
A second theme centered on acquiring and honing specific skill sets in public speaking, writing, time management, and leadership. “Publish. Publish. Publish. That is the ticket . . . the thing we have to hammer home to young women. A lot of it may be bogus and there is an awful lot of rubbish in the literature. But those are the tickets. Those are what people look for. I said to many a young person who I have mentored, ‘people can’t read, but they can count’—and they do.” “Have an educated voice. When you speak up . . . whether it be at a conference, a small meeting, whether you’re counseling a resident, you need to be educated about what you’re talking about and know the data . . . so have an educated voice no matter what you’re doing.”
181
“You’ve got to be able to work with others . . . You have to treat people that you work with as your team.” “Figure out how to relate and communicate with other people who are not used to women doctors or women leaders . . . you have to figure out what style works for you and what style works in your local environment.” “You can never communicate enough. Even though you think that you’ve made things perfectly clear and you’ve talked about them in a faculty meeting, there are still going to be people that didn’t hear, didn’t think it applied to them, didn’t remember what you said, or interpreted it some other way than what you thought.” “You need everyone, everywhere. I know the dean well. I know the head of human resources. I need everybody because . . . the people who are going to help your job be very successful are not in your office or in your department. They are outside. You have to meet everyone everywhere and realize that the power that you have is because they all know you.”
A final theme addressed issues for women. Points included learning the system and the rules of the game, [8] knowing one’s limitations, having a good infrastructure, integration within the profession, and eschewing insults of gender bias while selectively challenging inequities. “Never trust they’re looking out for you, because they’re looking out for themselves. They’re not going to tell me you need to join the AAS; they never told me to join anything . . . they don’t look out for you and I think they especially don’t look out for women. You have to go out there on your own, and don’t be afraid to do that.” “We’re playing by a different game. Men are playing ball, and there’s a coach and you have to play within that world; we play dolls and everything is equal. You have to play by the rules, and play ball and always talk to the coach and make the coach look good, and if you have a good idea, give it to the coach so the coach can look good.” “Try to be part of the solution to issues and not create problems . . . especially as a woman in surgery, if you’re seen as somebody who complains all of the time and isn’t part of fixing the problem, you become labeled very early on. In men, that [labeling] doesn’t actually happen as frequently.”
“[My] advice to a young person and not necessarily to a woman, but anybody, is not to put off things. You have to prioritize and some things just do not get done . . . Try to do things in a timely fashion because otherwise you do get totally overwhelmed.”
“The tendency for minorities is to stay on the outside and yell about what is going on in the inside. And that has stranded a lot of careers and a lot of progress. So my advice is: learn the system, get into it. You don’t have to become like a man, you don’t have to swear like a trooper, but get into the system, learn the system, and then change it from inside.”
“You shouldn’t expect to know how to do an administrator job anymore than you knew how to operate when you started medical school . . . Management is a defined skill set and you can learn it. It is analogous to . . . writing: if you’re having trouble writing papers, you can learn how to write. It’s not something that you’re either born knowing how to do or not to do. So for me, that was a key insight.”
“Integrate into the surgical profession. Liking your fellow surgical colleagues . . . that’s absolutely essential. You have to really like it . . . and feel very much a part of that group and that culture. Developing that whole network of academic friends that become very important people to you . . . that’s one place where a lot of woman surgeons don’t click. They don’t, for whatever reason . . . feel as integrated into the profession as they can be.”
“Those of us, who have gone to medical school, have not necessarily been trained to be leaders per se, so there is an additional skill set that we need to develop.”
A third theme focused on interpersonal and communication skills, the ability to work with a team, and networking.
Major Obstacles
The majority of women identified significant obstacles. Barriers included the lack of effective mentors, traditional sexism of a male-dominated culture, a hostile work environment, and personal illness. A significant majority
182
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
(80%) reported overt discrimination, gender prejudice and sexual harassment, with 40% citing limited job opportunities related to these factors. “It’s very difficult, particularly when I was younger, to be taken seriously by fellows. You know, even as a resident, as a junior faculty member, I really had to prove myself . . . almost every single day . . . in ways that I don’t think men have to.” “The obvious one is gender prejudice. I am [petite] . . . and I was pretty good looking when I was a young woman and those actually counted against me, eliciting comments like ‘oh you are too cute to be a surgeon’, ‘you got your husband, why don’t you quit now’, ‘you just are taking a place that should be occupied by a man’, and ‘you are too little’, ‘you are not strong enough’ etc. There was inappropriate touching and inappropriate comments in the operating room which I still have a hard time talking about.” “I would go on interviews and people would ask, ‘What makes you think you can tell a group of . . . mostly male surgeons, what to do and that they are going to listen to you?’ They would phrase it various ways but . . . . they were really asking, ‘Look, you’re a woman, you’re soft-spoken, you don’t look like what we expect, what makes you think . . . you can come here and run the place?’ ”
In overcoming the obstacles of gender prejudice, 30% of women responded that their strategy was to be “better”—more prepared, more credentialed, more skilled—in effect, to be not just equal, but better than their male counterparts. Several discussed another consideration: their physical features and appearance. “I tried to avoid acting or looking like a sexual object. The conflict, of course, is that you know it’s great to feel feminine and sexual . . . those aren’t bad things. It’s just you can’t do it in the workplace. The message should be you have to look professional and then beyond that, you . . . want some freedom [and] some latitude.” “I would demean myself if I changed my outlook and the way I dress . . . I really overcame [prejudice] by doing better than anybody else . . . later on people used to tell me that they forgot how small I was and thought I was actually a large person, so I guess I had ‘arrived’ at that point.”
Several advised that women should not take gender prejudice personally. “Avoid looking for insult . . . . innuendo and hidden meaning. But, challenge(e) it [discrimination] when it occurs. What has been so difficult for young women . . . when they don’t get the job, they don’t get an advancement, the tendency is to look and say that it is discrimination and not, ‘did I really deserve this?’ I think that is an insight which has to be rather painfully learned.” “Don’t take is personally . . . it would have been any woman. . . Instead of getting blown apart, get real focused on [who you are] and where you want to go.”
rectly, and to be prepared to leave if open dialogue doesn’t result in change. “Speak up, be honest, be forthright, address the issues head on, set up a meeting, go and talk about those issues, but in the end, I actually resigned one position because I could not get the salary equity changed. The older I got, I felt more comfortable in my own skin to make those decisions. At a more junior level, I would have kept doing the work and would have said, well I just failed and didn’t get an appropriate salary and plugged along. There are male leaders that are older that will try [to] get away with giving a lower level of salary especially to junior women. I think that the national data bears out that not only is there salary inequity, but again there’s most commonly, increased workload, so probably even more salary inequity.”
Hostile cultures were also described as obstacles, but no participant individually identified this factor as a personal obstacle. Rather, these leaders discussed the impact of organizational culture on them and suggested that women should consider this factor in the process of job selection. “There are certain cultures that can be hostile to powerful woman, and the closer you get to the money, obviously, the more obvious the obstacles become.” “I have been successful in what I considered to be a hostile environment by making myself visible and valuable in ways that were important to the environment. But that’s not a good way to live . . . it’s much better to be in an environment where you think you’re contributing and they’re happy to have you contribute.”
Advantages of Gender
Despite gender-specific barriers, 80% identified genderspecific advantages. Better teamwork, gentler tissue handling, better communication skills, and the ability to multi-task were noted. Three participants felt that the influence of women within the surgical profession might help to change the surgical stereotype. Not all leaders held this view. “The field of surgery will benefit from having more gender balance. Woman surgeons are perceived as less intimidating, easier to talk to and easier to work with in many respects. You know it’s unfair, because there are a lot of really wonderful male surgeons that have wonderful personal characteristics but you never hear about them. Having more women in the field I think really will help to break that stereotype.” “We bring a different perspective to the field in terms of patient care. Women spend more time with patients and with their families, are much more compassionate at the bedside, and you see that difference with the vast majority of women, whether they be in surgery or . . . some other medical specialty.” “People talk about woman being more nurturing and all that stuff but I’m not really even 100% sure that that’s true . . . or that it’s necessarily desirable.”
“You can’t worry about the inequities. I think you need to address them, but you cannot take them home and worry about them and live with them . . . because the biggest inequities are going to be the higher you get.”
Thirty percent noted that being female provided a higher visibility. One cautioned that a high profile may be a double-edged sword:
One identified salary inequity as a major obstacle. To overcome this, she suggested addressing the issue di-
“You’re visible, especially when you get to a certain level. . . but it also sets a pretty high set of hoops that you have to get
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS
TABLE 1
through repeatedly and your failures are more obvious. So your wins are bigger wins, your failures are more obvious and potentially more dreadful.”
Mentoring
The great majority (90%) stated they have had a mentor or mentors during their career. Half of the women, however, admitted that they had not been effectively mentored. Most cited multiple mentors; 60% used mainly male mentors because of the lack of females in the profession. “I tell people to keep their eyes open for multiple mentors . . . [one can] teach me how to best care for a patient, another person may teach me lessons of life, another person can help me with my research approach. It’s kind of like men; I just don’t think that one can do everything for you!” “I’ve acquired a rolling set of mentors throughout my career and I think we all have something to learn from the people ahead of us . . . I don’t think there’s a time . . . when you can stop being mentored.”
Eight leaders (80%) stated that they either had had female mentors or felt that it was important for woman to have a female mentor. Female mentors were sought particularly for guidance on family or lifestyle issues or as role models. “I went and sought out the chief of surgery, [and said], I really would like to go into surgery and I’m thinking about what programs I should go to. This male chief surgeon said to me . . . you’re a good Italian woman and you need to have a family and surgery should not be your career goal . . . That’s where I think I began to then seek out women.” “It was very difficult for me to have children and try to balance all of that . . . it would have been nice to connect with someone else who had experienced some of the same things But those people [weren’t] around.”
These leaders stressed the importance of being proactive in the process of identifying, seeking, and engaging a mentor. One cautioned that the purpose of mentoring is not to provide a template to be copied: “I have sought mentors. I go ask people their advice. I don’t wait until they come look for me. I think that is the other thing women have to do. Men do it all of the time.” “You can’t take on the personality of somebody else. That’s not the point of the mentor. The point is . . . to look at someone, see what part of their approach to life, to work, will work for you.” “A nice person is not nearly as important as an empowered mentor.”
Career Steps
A number of “steps to success,” were identified for female surgeons who want to advance in academic surgery (Table 1). The most commonly cited strategies include the following: identify an effective mentor, set career goals, publish, and take personal responsibility
183
Steps to Academic Career Success 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Actively pursue/engage a mentor Set career goals Refine writing skills and publish Take responsibility for your future/career Develop organization/time management skills Be visible through networking and service Develop a focus of expertise Make time for research Follow your passion/dream Public speaking and presentations Carefully choose your environment
60% 50% 50% 40% 40% 30% 30% 30% 30% 30% 30%
Recommendations for Junior Female Surgical Faculty (in order of decreasing numbers of citation).
for managing one’s academic career. One participant delineated the following steps: “First and foremost she needs to decide what she wants to be when she grows up [surgeon-scientist, clinician-educator] and then find an environment that wants to actually embrace her, develop and make (her) into a real live academic surgeon . . . have a well-empowered mentor . . . who has control . . . to make you successful or not. Then you’ve got to really take total responsibility for your future . . . . Make sure you start punching those academic buttons or else you’ll never get promoted . . . develop that whole network of colleagues that allows you to become integrated in your profession.”
Several noted the need to join specific organizations to gain national visibility. “The key for surgery has to do with connections . . . and know[ing] what are the key organizations in your specialty. You have to get visibility that extends beyond your own institution. It is not just a matter of teaching and operating and taking care of patients, you have to write. But then to get the national level visibility, you have to go to the meetings, discuss papers, present papers and be on committees. Because that’s how people see you and eventually judge you. And if you’re not out there going to the meetings, joining the organizations, you’re not going to have that network.”
Finally, participants commented on the impact of a balanced life. “ . . . in the traditional model, the male surgeon did his cases, stayed after work late to write papers . . . and the wife was home taking care of the kids and running the household. . . Women don’t have that opportunity . . . so it’s okay to say for this ten year period of time, my focus is going to be a little bit more on my family . . . I’m still going to be productive . . . but I’m not going to marry myself to my job . . . For a long time I was made to feel that I was a lesser individual because I wasn’t on the fast track to be a professor. It’s important for women to feel that there are many ways to contribute and to advance . . . It’s going to take longer . . . but the gains that you will make in your personal life will offset that time.”
Mistakes to Avoid
Two participants identified the failure to carefully select a work environment as a mistake they made. Two
184
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
additional participants noted the choice of location/ environment is a critical “step” for junior faculty to make. “ . . . need to make sure you are around people that are wanting you to advance and are willing to lose you. And that the reason they are training you is that they know you will leave them.” “Know your local environment. Young women say ‘at my place there is no counsel, no mentoring,’ you know a whole series of complaints. The truth is that you took the job. Why did you take the job? You have to think about how the environment is going to work for you . . . . whether the environment will let you advance on a national or international arena.” “If you have a set of goals, you have to make sure that your vision for your future, meshes with the vision of the environment.”
Failure to recognize gender differences in conflict resolution underscores the following “mistake”: “I think that they (male surgeons) are used to there being winners and losers. I think it’s part of the culture. When I took over, if somebody came to me with a problem and I could solve it— great. If I couldn’t completely solve it, I (would try) to resolve something so that both parties got something. I was actually very proud that I could come up with a creative way around a conflict. I think there were some situations where I came to a compromise that should (have been) satisfactory to both parties. And the thing that was always striking was that whatever person got more did not think they had gotten as much as they should have. When you’re managing men they’re much happier if there’s a winner and a loser. I think the winner is much happier, obviously, than the loser. You would think would be happier if they were getting something, but if they see a winner and a loser, they think maybe next time they might be the winner.”
Despite the acknowledged importance of mentors, participants cautioned that advice from senior mentors may be outmoded and that some mentors can be selfserving. Other mistakes included the following: having a superiority complex, not protecting time for self/ family, not acknowledging mistakes, and being impatient. An important imperative for women: “I learned not to cry. Women must not cry.” Leadership Challenges
The greatest leadership challenge, noted by 60% of participants, was obtaining buy-in, building consensus and leading people through change. Maintaining clinical skills, creating positive cultures, keeping communication open, avoiding burnout, recognizing and implementing ideas, dealing with difficult personalities, being a role model, management of funds, and making tough decisions were challenges identified by one or more leaders. “I just wanted them to do their job, do a good job, and I couldn’t ever imagine that they wouldn’t be trying to work hard and do the right thing. There are just people out there that aren’t, you have to deal with them for the good of the department and that’s really tough.”
Collaboration and the creation of teams, a top challenge for one participant, was also considered a critical
element of successful leadership and the “key to innovation.” Another noted: setting high goals—and achieving them. “My challenge is to really walk the walk. I’m here to build a culture that’s hopefully positive, a program that will let me train the surgical leaders of the future and (provide) quality care that will be the envy of the world and measure that care. Develop the quality metrics to allow us to actually build that platform. That means recruiting people to high-risk jobs. So . . . that’s my challenge . . . to pull it off.”
DISCUSSION
While the number of women entering medical school has risen progressively in the past 35 years, the surgical specialties continue to attract relatively few women [9]. Further, the number of women surgeons who seek a career in academic medicine and advance to become a leader in the field is remarkably low. In 2005, only 7 of 301 surgical chairs (2%) were female. This ranks among the very lowest percentage of all departments in academic health centers (personal communication, Alexander, AAMC). Research in this area has often focused on identifying barriers to women, [5, 7, 10] factors constraining women in academic medicine, [11, 12] or identifying obstacles to advancement [6, 7, 10, 12]. This paper presents the perspectives of those who have overcome the barriers to become leaders. The study was designed to probe the experience and perspectives of senior female surgical leaders. The nature of the topic area, and the value of capturing subtleties in the views of these leaders, necessitated a qualitative approach to the study. The study design was based in open-ended questions that did not force the respondents to comment on pre-specified points of view. This method was designed to maximize the yield of a broad base of original, discrete data elements. Survey techniques such as check-off lists and Likert scales were specifically excluded from the design of the interview questionnaire to promote the generation of ideas directly from the respondents. Thus, the congruence of some of the discrete data elements from multiple sources is important, and may suggest the prevalence of a specific perspective, belief, or concern regarding the particular dimension queried. This study focused on women who have achieved positions of leadership in academic surgery in an attempt to identify key attributes and practices that enable advancement and success, as well as strategies to confront and surpass the obstacles that continue to challenge women in medicine. These women are an elite group and have a unique perspective. Their comments are insightful and inspiring. Female leaders in academic surgery are in an excellent position to identify needs and skills that may be incorporated into programs to assist junior women (and men) in academic surgery and medicine. They are useful for junior
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS
faculty, both men and women, who face obstacles yet aspire to be leaders in their profession. The women faced significant obstacles. Barriers included the lack of effective mentors, traditional sexism of a male-dominated culture, limited job opportunities, and a hostile work environment. Despite the barriers, these women were able to overcome both personal and professional obstacles to advance to leadership. Although not directly queried, none of the leaders voice a regret about career choice, mirroring the findings of others [13, 14]. Personal attributes of perseverance, drive, and a strong work ethic were identified by a majority of leaders as critical success factors. Initiative, curiosity, and courage were also cited. Importantly, a sense of humor seemed to be a mechanism to effectively navigate difficult personal interactions as well as hostile environments. The reporting of overt discrimination or gender prejudice by a significant majority of those in our study has also been reported by others [15–18]. Several women stated that their strategy to overcome prejudices and gender bias was to be better than all of the others. One stated, “I overcame the prejudice by being so good that people wanted me and they did not care that I wore a skirt.” Another quipped, “One of the ways we coped was just to be over prepared. Be better than anybody.” And from another, “ . . . you have to be really good . . . then you can be really different [female] if you are really good.” Many of the women seemed to make a conscious effort to depersonalize themselves from the impact of specific incidents of discrimination. Techniques to survive hostile environments and gender prejudice included not “playing the victim,” avoid looking for insult, and have a “thick skin.” The most poignant advice came the following story. “I actually had a dean tell me, in the last two years, that he could not give me a chair job because I was a woman. Many people did not believe that he actually had verbalized this. [What is important, is that] you cannot hate that man . . . you cannot worry about the inequities . . . You need to address them, but you cannot take them home and live with them.” A number of attributes identified by these surgical leaders are less related to personal characteristics and more tied to skills or behaviors that can be learned, developed, or enhanced. Communication skills, and effective public speaking techniques, time management, conflict management, interpersonal skills, writing skills and organizational dynamics were identified as important. The leaders recognized that leadership and management were skill sets that needed to be learned. Much has been written about mentoring and the need for effective, positive mentoring experiences for both women and men [6, 19, 20 –25]. While the great majority (90%) of these female leaders did identify a
185
mentor at some point in their careers, half of the women admitted that they have not been effectively mentored. Identifying and linking with an “empowered mentor” was considered a critical step for successful advancement in academia. While most acknowledged that women do need female mentors, the reality of the gender distribution in surgery precluded this as a possibility for most, and continues to be a challenge for young female surgeons today. The impact of family and lifestyle choices was not a specific focus of this study. It is interesting to note, however, that even with the freedom of open-ended questions, none of the women identified family or social responsibilities, children, or traditional gender roles as obstacles or barriers to becoming a top female surgical leader. On the contrary, several women identified the importance of crafting a stable home life as a strategy for success. Most perceived advantages to being a woman in the field of surgery. Advantages were identified for the individual herself, the field of surgery, and for patients. They included those related to individual physical features (greater visibility being a minority), temperament (collaboration, teamwork, listening skills, relational skills), and professionalism (compassionate and caring, less hostile, potential to change the traditional surgical stereotype). As one leader stated, “the field will benefit from having more gender balance. It could change the stereotype of the surgeon as arrogant, workaholic, and intimidating. Sexism is changing, but slowly.” Another finished: “right now is a great time for women in our field.” In the area of career advice, these female leaders identified a number of “steps to success” that junior female surgeons who want to advance in a career in academic surgery should take. These are summarized in Table 1. The most commonly cited strategies included the following: identify an empowered mentor, set broad career goals, publish, and take personal responsibility for managing one’s academic career. Such advice is applicable across the much broader scale of academic medicine in general. At the Penn State College of Medicine, for example, a Junior Faculty Development Program has been implemented through the Office of Professional Development that combines a comprehensive curriculum in topics of academic career development with a structured mentoring program linked to the completion of an individual project [26]. The global objectives of this program include the items listed by these leaders. Integration into the surgical profession was another critical step listed. “Liking your colleagues and feeling a part of the surgical culture” was viewed as essential for integrating into the profession and achieving success. One leader noted that many women fail to integrate within their professions, a statement supported
186
JOURNAL OF SURGICAL RESEARCH: VOL. 132, NO. 2, MAY 15, 2006
by a recent study, [12] where 25% of female academic surgeons felt isolated from their surgical colleagues for reasons of ethnic, cultural or gender differences, as compared to only 1% of their male counterparts. Another suggested inviting colleagues out to dinner. The “social capital” gained from informal gatherings has been well documented to promote not only success of the individuals, but greater productivity of the organization as a whole [27]. Each of the participants was asked to identify their greatest challenge as a leader in academic surgery. Obtaining buy-in and achieving consensus was the greatest leadership challenge, cited by 60% of those interviewed. Many referenced the significant changes occurring in the healthcare environment and within academic health centers themselves, and the need to provide strong leadership during these challenging times. Despite the challenges, however, a notable feature of these female leaders in academic surgery was the palpable optimism, confidence, and enthusiastic energy characteristic of highly effective leaders, whether they are female or male. In summary, female academic surgeons face significant challenges to their career advancement. These barriers are real and, unfortunately, have persisted over time even as women continue to make inroads in accessing a career in medicine. Obstacles include maledominated cultures, gender discrimination, limited job opportunities, and hostile work environments. These female leaders demonstrate that obstacles can be overcome by resolve, commitment, and learned skills in a variety of areas. Recommendations for overcoming barriers and advancing in academic surgery involve particular individual attributes and personal accountability for professional development and management of one’s academic career. Several areas are identified that might be an appropriate focus for faculty development initiatives targeted to junior female surgical faculty and others.
APPENDIX 1. FEMALE LEADERSHIP QUESTIONNAIRE INTERVIEW QUESTIONS
1. What personal attributes (at least 4) have helped you achieve success in academic surgery? 2. What are some of the key lessons you have learned for succeeding in the world of academic surgery? 3. What major obstacles did you face, and how did you overcome them? What are three key mistakes to avoid? 4. How would you advise a junior female surgeon who wanted to advance her career in academic surgery? What steps should she take? 5. Please comment about mentoring... Did you have a mentor during your career? If so, at what stage was
it most helpful? Are your mentors men, women, or both? Do you think women need female mentors? 6. What advantages do you see of being a woman in surgery? For the individual herself, the field, and the patient(s). 7. Now that you are in a position of leadership, what is your greatest challenge? 8. Do you have any other thoughts or comments? ACKNOWLEDGMENTS The authors would like to acknowledge Hershel Alexander and Mary Blew for their assistance in preparing this manuscript.
REFERENCES 1. 2.
3. 4.
5. 6.
7.
8. 9. 10.
11. 12. 13.
14.
15. 16.
17.
18. 19.
Women in U.S. academic medicine: Statistics and medical school benchmarking. AAMC Annual Report 2004 –2005. Bickel J, Wara D, Atkinson B, et al. Increasing women’s leadership in academic medicine: Report of the AAMC project implementation committee. Acad Med 2002;77:1044. Nora LM. Commentary: Academic medicine gets a poor report card—What are we going to do? Acad Med 2002;77:1062. Tesch BJ, Wood HM, Helwig AL, Nattinger AB. Promotion of women physicians in academic medicine: Glass ceiling or sticky floor? JAMA 1995;273:1022. Sonnad SS, Colletti LM. Issues in the recruitment and success of women in academic surgery. Surgery 2002;132:415. Yedidia MJ, Bickel J. Why aren’t there more women leaders in academic medicine? The views of clinical department chairs. Acad Med 2001;76:453. Wright AL, Schwindt MA, Bassford TL, et al. Gender differences in academic advancement: Patterns, causes, and potential solutions in on US college of medicine. Acad Med 2003;78:500. Heim P. Hardball for women: Winning at the game of business. New York: Penguin Group 1992:290. Baxter N, Cohen R, McLeod R. The impact of gender on the choice of surgery as a career. Am J Surg 1996;172:373. Colletti LM, Mulholland MW, Sonnad SS. Perceived obstacles to career success for women in academic surgery. Arch Surg 2000;135:972. Bickel J. Women in academic medicine. JAMWA 2000;55:10. Schroen AT, Brownstein MR, Sheldon GF. Women in academic general surgery. Acad Med 2004;79:310. Mizgala CL, Mackinnon SE, Walters BC, Ferris LE, McNeill IY, Knighton Y. Women surgeons: Results of the Canadian population study. Ann Surg 1993;218:37. Frank E, Brownstein M, Ephgrave K, Neumayer L. Characteristics of women surgeons in the United States. Am J Surg 1998;176:244. Capek L, Edwards DE, Mackinnon SE. Plastic surgeons: A gender comparison. Plastic Reconstr Surg 1997;99:289. Dresler CM, Padgett DL, Mackinnon SE, Patterson A. Experiences of women in cardiothoracic surgery: A gender comparison. Arch Surg 1996;131:1128. Carr PL, Ash AS, Friedman RH, Szalacha L. Faculty perceptions of gender discrimination and sexual harassment in academic medicine. Ann Int Med 2000;132:889. Kornstein SG, Norris SL, Woodhouse SW. Women in medicine: Shaping the future. VMQ 1998;125:44. Bickel J. Looking for mentor replacement therapy? A coach may be the answer. JAMWA 2003;58:210.
KASS, SOUBA, AND THORNDYKE: CHALLENGES CONFRONTING FEMALE SURGICAL LEADERS 20.
Cain JM, Schulkin J, Parisi V, Power ML, Holzman GB, Williams S. Effects of perceptions and mentorship on pursuing a career in academic medicine in obstetrics and gynecology. Acad Med 2001;76:628. 21. Johnson JC, Williams B, Jayadevappa R. Mentoring program for minority faculty at the University of Pennsylvania School of Medicine. Acad Med 1999;74:376. 22. Jackson VA, Palepu A, Szalacha L, et al. Having the right chemistry: A qualitative study of mentoring in academic medicine. Acad Med 2003;78:328. 23. Tracy EE, Jagsi R, Starr R. Outcomes of a pilot faculty mentoring program. Am J ObGyn 2004;191:1846.
187
24.
Staveley-O’Carroll K, Pan M, Meier A, Han D, et al. Developing the young academic surgeon. J Surg Res 2004;118:109.
25.
Lewis RJ. Some thoughts regarding gender issues in the mentoring of future academicians. Acad Emerg Med 2003; 10:59.
26.
Thorndyke LE, Gusic ME, George JH, et al. Empowerment of junior faculty through development and mentoring. Acad Med (accepted for publication March 2006).
27.
Day D. Leadership development: A review in context. Leadership Qtrly 2001;11:581.