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Perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11 781 anaesthesiologists
British Journal of Anaesthesia, xxx (xxx): xxx (xxxx) doi: 10.1016/j.bja.2019.12.022 Advance Access Publication Date: xxx Clinical Investigation
CLINICAL INVESTIGATION
Perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11 781 anaesthesiologists ~ es6, Marko Zdravkovic1,2, Denisa Osinova3, Sorin J. Brull4, Richard C. Prielipp5, Claudia M. Simo Joana Berger-Estilita7,*, and Collaborators 1
Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor,
Slovenia, 2Faculty of Medicine, University of Maribor, Maribor, Slovenia, 3Department of Anaesthesiology and Intensive Care, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, University Hospital Martin, Martin, Slovak Republic, 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA, 5University of Minnesota Medical School, Minneapolis, MN, USA, 6Department of Anaesthesiology, ^ ncer Do Estado de Sa ~ o Paulo, Faculdade de Medicina da Universidade de Sa ~ o Paulo, Hospital Sı´rio Libane ^s, Instituto Do Ca ~ o Paulo, Brazil and 7Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Sa Switzerland *Corresponding author. E-mail: [email protected]
Abstract Background: Women make up an increasing proportion of the physician workforce in anaesthesia, but they are consistently under-represented in leadership and governance. Methods: We performed an internet-based survey to investigate career opportunities in leadership and research amongst anaesthesiologists. We also explored gender bias attributable to workplace attitudes and economic factors. The survey instrument was piloted, translated into seven languages, and uploaded to the SurveyMonkey® platform. We aimed to collect between 7800 and 13 700 responses from at least 100 countries. Participant consent and ethical approval were obtained. A quantitative analysis was done with c2 and Cramer’s V as a measure of strength of associations. We used an inductive approach and a thematic content analysis for qualitative data on current barriers to leadership and research. Results: The 11 746 respondents, 51.3% women and 48.7% men, represented 148 countries; 35 respondents identified their gender as non-binary. Women were less driven to achieve leadership positions (P<0.001; Cramer’s V: 0.11). Being a woman was reported as a disadvantage for leadership and research (P<0.001 for both; Cramer’s V: 0.47 and 0.34, respectively). Women were also more likely to be mistreated in the workplace (odds ratio: 10.6; 95% confidence interval: 9.4e11.9; P<0.001), most commonly by surgeons. Several personal, departmental, institutional, and societal barriers in leadership and research were identified, and strategies to overcome them were suggested. Lower-income countries were associated with a significantly smaller gender gap (P<0.001). Conclusions: Whilst certain trends suggest improvements in the workplace, barriers to promotion of women in key leadership and research positions continue within anaesthesiology internationally. Keywords: anaesthesiology; gender equity; gender gap; global survey; leadership; physician perception; research; work attitudes
Accepted: 20 December 2019 © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved. For Permissions, please email: [email protected]
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Editor’s key points Factors contributing to gender disparity in leadership and research in anaesthesiology have not been well defined. An internet-based survey was designed to investigate career opportunities in leadership and research amongst anaesthesiologists, and gender bias attributable to workplace attitudes and economic factors. Based on 11 746 respondents representing 148 countries, women were less driven to achieve leadership positions and were also more likely to be mistreated in the workplace. In addition, being a woman was reported as a disadvantage for leadership and research. A number of personal, departmental, institutional, and societal barriers in leadership and research were identified.
The last few decades have witnessed an increasing number of women active in medical professions across the world. Data from both Europe and North America1e4 indicate that there are more women than men physicians, with the proportion of women approaching 75% in some European countries.1 This trend will likely continue as the number of women medical students continues to grow.5 Although women make up a substantial proportion of the physician workforce, they are consistently under-represented in important governance positions. They are less likely to achieve academic promotion,6 submit and be successful in grant applications and research funding,7 and achieve key leadership positions.8e10 This concept has been described as the ‘leaky pipeline’.11 Anaesthesiology mirrors these broader trends,12e18 although most of the gender equity data in anaesthesiology are solely numeric,12,13,15e18 of small scale, and primarily explore North American practise. Whilst numeric data clearly document the problem, they do not provide insights into why these differences occur.13 Factors contributing to this gender disparity in anaesthesiology are commonly extrapolated from other medical fields19,20 or even other sectors, such as business administration.21,22 Current explanations are multifactorial with bias undoubtedly a major contributor19; however, many other factors likely contribute. Fisler and colleagues23 developed a multidimensional perspective on achieving gender parity, which has departmental and peer forces at its core. Therefore, focussing departmental efforts on improving gender equity will influence practising anaesthesiologists on a daily basis and will, over time, reach other healthcare sectors.23 However, there are scarce data about departmental opportunities and attitudes in anaesthesiology. To promote leadership, research, and clinical opportunities based on abilities rather than gender, a global assessment is necessary. With this international cross-sectional survey, we aimed to further define the current global perception of gender equity amongst anaesthesiologists, specifically in the areas of departmental leadership, research, and co-worker attitudes in the clinical workplace. We also explored the career aspirations and time spent on career advancing activities. Finally, we aimed to describe perceived barriers to leadership and research, and propose interventions to help improve gender equity. We hypothesised that (i) anaesthesiologists perceive identical career opportunities in leadership and research, independent of gender; (ii) career aspirations and time devoted
to career advancement are independent of gender; and (iii) anaesthesiologists experience gender-unbiased attitudes in the workplace and that there is no perceived gender bias because of economic factors as determined by national income groups defined by the World Bank in 2019.24 Gender equity and equality are two strategies to produce fairness. Gender equality represents the fair treatment of women and men, whereas gender equity denotes social justice providing resources to both men and women to support success in their careers.
Methods Ethics approval This international, internet-based, cross-sectional survey was approved by the Ethics Committee at the University Medical Centre Maribor, Maribor, Slovenia (Ref.: UKC-MB-KME-75/19). At the end of the survey, respondents were obliged to provide explicit consent for participation and data analysis.
Instrument development We developed the questionnaire based on three aspects of anaesthesiologists’ careers: leadership opportunities, research opportunities, and clinical work attitudes. All questions were aimed for the primary unit (i.e. department) where the respondents worked. A 46-item questionnaire was constructed in English (Supplementary questionnaire). Five items were compulsory, including confirmation of the work in the operating theatre as an anaesthesiologist, a question asking whether the respondent was the current head of a department (if affirmative, the set of questions on departmental leadership aspirations was skipped), gender, question about previous research experience (leading to two different sets of questions based on the response), and participant’s consent. Respondents were also asked to include their city and country of practise, although these were non-compulsory fields. Six of the 46 survey items were open-ended questions that explored respondents’ interest in various leadership roles, perceived barriers to leadership and research, suggestions for improving gender equality, and other comments. The terms ‘women’ and ‘men’ usually refer to gender (a cultural construct), whereas the terms ‘female’ and ‘male’ usually refer to sex (a biological construct).25 Because the survey was designed as a worldwide cultural survey, we have used the terms ‘women’ and ‘men’ throughout the paper, with the exception of the actual survey, in which we followed the feedback from the piloting process and used ‘female’ and ‘male’. We also used the word ‘gender’ throughout the paper as a reference to the roles, behaviours, and characteristics that a time-societal duality attributes distinctively to men and women.26 The draft questionnaire was piloted by 18 clinicians (trainees and consultants) from 10 countries and six professionals with background in medical education research and qualitative research methodology (see Acknowledgements). The English version was translated into French, German, Italian, Portuguese, Russian, and Spanish by native speakers, and translated back to English by a different native speaker. The back-translated English versions were compared with the original English version for accuracy. Inconsistencies were adjudicated by a third reviewer. The questionnaire was hosted
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Fig. 1. (a) Survey completion rate calculation and respondent exclusion flow chart. (b) World map of survey completion rate targets. Green indicates countries for which the minimum target number was reached, red indicates that the target was not reached, and grey indicates that no data were collected. Created at www.mapchart.net.
online at SurveyMonkey (San Mateo, CA, USA) with the restriction of one response per device enabled.
Survey distribution and sample size calculation As the primary mode of survey distribution was through social media using the ‘snowballing’ sampling technique,27,28 selection bias was reduced by aiming to collect between 7600 and 13 700 responses from at least 100 countries.28 This number was estimated from the World Federation of Societies of Anaesthesiologists (WFSA) data as representing 10% of each of the national society’s members, or as five responses per million population, with a ‘cut-off’ number of 500 (Supplementary Table S1). The survey link was primarily distributed through LinkedIn, Facebook, Twitter, and e-mail invitations, with supporting (inter)national societies e-mailing the link via their own mailing lists (see Acknowledgements for the list of supporting societies). Up to two reminders were sent.
theory30). Answer reduction was performed by JB-E and crosschecked by CMS. Both authors performed interim analyses, in clusters of 1500 answers, to check for saturation. Open-ended questions were analysed for common themes and categories through open coding. Open codes were reanalysed for duplications and overlapping themes. Final verification of categories was attained through peer debrief (MZ).
Results The survey was available for completion for a total of 6 weeks, from September 14, 2019 to October 26, 2019. Of 15 714 respondents who started the survey, 3968 (25%) were not included in the main analysis (Fig 1). The survey completion rate was 80.8%. We performed a separate descriptive analysis of the non-binary gender group of respondents (n¼35) because further statistical tests were not warranted because of a low overall number of respondents in this gender group.
Respondent characteristics Data analysis Surveys in which respondents did not indicate gender were excluded from the analysis. Responses from men and women were compared, as were responses from countries with high-, upper middle-, and lower middle-/low-income economies.24 Quantitative data were analysed using Pearson’s c2 statistics for contingency table analyses (two sided). We used Cramer’s V as the measure of strength of association (weak: >0.05; moderate: >0.10; strong: >0.15; and very strong: >0.25).29 Further effect size estimations were performed on two-bytwo contingency tables, and reported as odds ratio (OR) with 95% confidence intervals (CIs). Parametric data were reported as mean (standard deviation [SD]) and analysed with Student’s t-test. Significance was set at P<0.05. The statistical analysis was performed using SPSS Statistics 20 (IBM Inc., Chicago, IL, USA). The qualitative analysis of open-ended questions was performed by two authors (JB-E and CMS) using an inductive approach and a thematic content analysis (grounded
Of the 11 746 respondents from 148 self-identified countries (Fig 1), 1488 (12.7%) did not declare their country of practise. One hundred and eleven countries (75%) reached the calculated minimum target of respondents (Supplementary Table S2). There were 6030 (51.3%) women and 5716 (48.7%) men respondents, with the mean ages (SD) 41 (10) and 43 (11) yr, respectively (P<0.001). The respondent level of practise included 888 (7.6%) women and 1304 (11.1%) men trainees in the first and second halves of their training; 4166 (35.6%) women and 5351 (45.7%) men specialists had less than or more than 10 yr of experience. The proportion of men respondents was higher only within the ‘specialist for more than 10 yr’ group, whilst women predominated in the other three groups (P<0.001). The departmental gender structure analysis showed a mean women:men ratio of 0.48 (0.21) (Supplementary Fig. S1). When asked about family commitments, 3095 (51.4%) women and 3385 (59.5%) men reported having childcare responsibilities (OR: 1.39 95% CI: 1.29e1.49), favouring men; (P<0.001). In a subset analysis for level of practise, this
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difference emerged with trainees in the second half of training (36.8% men compared with 29.1% of women had childcare responsibilities; P<0.001), and continued in specialists for less than 10 yr (66.7% vs 56.2%, respectively; P<0.001) and in specialists with more than 10 yr of experience (64.9% and 61.5%, respectively; P¼0.01). We compared demographically the 2883 excluded respondents with the 11 781 included on two questions. (The response rate was insufficient for the other demographic questions.) The excluded respondents were younger (mean [SD] 39.8 [11.2] yr vs 42.0 [10.6] yr; t-test P<0.001) and a higher proportion of trainees than specialists (573 [28.7%] vs 2192 [18.7%], respectively; c2 P<0.001; Cramer’s V: 0.10).
Leadership and research When asked, ‘My gender is a disadvantage when competing for a leadership position in my department’, 1796 (34.6%) women agreed or strongly agreed compared with 198 (4.7%) men (P<0.001; Cramer’s V: 0.47 [very strong gender association]). In pursuit of research, the percentages were lower but still different from for men. When those who have done some research were asked, ‘My gender is a disadvantage when doing research at my department’, 402 (12.9%) women agreed or strongly agreed, compared with 104 (3.0%) of men
(P<0.001; Cramer’s V: 0.34 [very strong gender association]). For those who had never conducted any research, 263 (10.2%) of women agreed or strongly agreed compared with 59 (3.0%) men (P<0.001; Cramer’s V: 0.32 [very strong gender association]). Women aspired less frequently than men to taking a leadership position in their departments, but they manifested an equal desire for research and a higher desire for clinical work achievement (Table 1). Both men and women favoured sub-chair leadership roles in preference to becoming the head (chair) of their department (P<0.001 for both; Cramer’s V: 0.41 for women and 0.44 for men [very strong associations]). The desired sub-chair leadership roles were qualitatively assigned into five categories: research, education, patient safety, quality improvement, and clinical work. Men reported that they spend more time on career development activities (Table 1). Women were more likely to be the current heads of departments than the immediate-past head (OR: 3.00 [95% CI: 2.74e3.29]; P<0.001). Amongst 2304 (19.6%) respondents who were current or past heads of departments, 822 (35.7%) were women and 1482 (64.3%) were men. The barriers to taking the leadership position and in performing research were further explored qualitatively through open-ended questions; 3647 (31.0%) responded to the openended question on barriers to leadership and 3740 (31.8%) for
Table 1 Career aspirations in leadership, research, and clinical work for women vs men and work hours. Values are n (%) or mean (standard deviation). *c2 test reported comparing frequency distributions within 52 contingency tables. **Independent sample t-test. yA 5-point Likert scale was used, in which 1¼not important; 5¼very important for career plans. zIncludes clinical work, research/ academic work, and any leadership positions. Career aspect
Measurement scale
Women
Men
P-value (Cramer’s V)
Leadership Taking a leadership position in my department
5-point Likert scaley
2.90 (1.31)
3.17 (1.36)
Strongly agree Agree Unsure Disagree Strongly disagree Strongly agree Agree Unsure Disagree Strongly disagree
367 (7.1%) 715 (13.8%) 1525 (29.4%) 1445 (27.8%) 1143 (22.0%) 941 (18.1%) 1742 (33.5%) 1469 (28.3%) 651 (12.5%) 391 (7.5%)
426 (10.1%) 803 (19.0%) 1224 (28.5%) 994 (23.5%) 798 (18.9%) 814 (19.3%) 1579 (37.4%) 1054 (25.0%) 443 (10.5%) 331 (7.8%)
<0.001* (0.11; moderate association) <0.001** <0.001* (0.10; moderate association)
5-point Likert scaley
2.85 (1.30)
2.88 (1.31)
Strongly agree Agree Unsure Disagree Strongly disagree
376 800 723 425 288
338 573 536 316 217
5-point Likert scaley
4.32 (1.09)
4.26 (1.10)
<0.001* (0.05; no or very weak association) ¼0.001**
<20 h 20e40 h 41e60 h 61e80 h >80 h
277 (4.6%) 908 (15.1%) 3128 (52.0%) 1335 (22.2%) 370 (6.1%)
223 (3.9%) 597 (10.5%) 2892 (50.7%) 1465 (25.7%) 525 (9.2%)
<0.001* (0.09; weak association)
I would like to become the head of my department in the future (current/past heads of departments excluded)
I would like to take some other leadership role in my department in the future (excluded current/past heads of departments)
Research Doing research
I would like to do research in the future (amongst those who have not done any research so far)
Clinical work Doing clinical work
Time spent on career Average weekly hoursz
(14.4%) (30.6%) (27.7%) (16.3%) (11.0%)
(17.1%) (28.9%) (27.1%) (16.0%) (11.0%)
<0.001* (0.06; weak association)
¼0.033* (0.03; no or very weak association) ¼0.203** ¼0.166* (NA)
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research. For both questions, saturation was reached after the interim analysis of the first 1500 responses, and one author (MZ) cross-checked the remaining responses for coverage. The codes were sorted into four major themes (personal, departmental, institutional and governmental, and societal changes) and organised into a framework (Table 2); many overlapping codes between leadership and research were identified. All 3322 (28.3%) responses to the question, ‘Please suggest what could be done to improve gender equality in leadership, research, and/or clinical work at your department’ were analysed and categorised into four major themes: personal, departmental, institutional, and societal changes (Table 3). Overall, 411 (11.3%) reported no existing barriers for leadership and 489 (13.1%) for research, and 598 (18.0%) did not suggest strategies for gender parity because they did not perceive inequalities in their work environment.
Socio-economic factors Women anaesthesiologists perceived that co-worker attitudes towards them were worse than those perceived by men anaesthesiologists (surgeons [P<0.001; Cramer’s V: 0.20]; patients [P<0.001; Cramer’s V: 0.18]; nurses [P<0.001; Cramer’s V: 0.13]; anaesthesiology colleagues [P<0.001; Cramer’s V: 0.26]) (Fig 2). When asked, ‘Have you ever been mistreated at your workplace because of your gender?’ 2564 women (43.6%) and 374 men (6.8%) agreed (OR: 10.6 [95% CI: 9.4e11.9]; P<0.001). The sources of mistreatment were reported as surgeons (n¼1935), anaesthesiology colleagues (n¼1425), patients (n¼1165), nurses (n¼971), and others (n¼345). The most common in the latter category were the heads of departments or direct superiors (n¼165), administrative staff (n¼53), doctors from other specialities (n¼40), and patient relatives (n¼25). The mistreatment was reported 701 times (24.2%), and amongst the reported incidents, support was provided in 394 cases (56.1%). Amongst the non-reported mistreatments, support was provided in 872 cases (40.5%). In lower-income countries, women anaesthesiologists perceived their gender to be less of a disadvantage in taking the departmental leadership position or doing research (Fig 3). Similarly, they perceived better treatment from surgeons, patients, nurses, and anaesthesiology colleagues.
Non-binary gender respondents Of a total of 35 respondents identified as being a non-binary gender (mean [SD] age: 47.8 [12.5] yr), 23 were specialists with more than 10 yr of professional experience and 15 had childcare responsibilities in the home. Most respondents disagreed that their gender was disadvantageous for leadership roles (n¼24) or a research position (n¼27). Nine reported having been mistreated in the workplace because of their non-binary gender, mainly by surgeons or their supervisors.
Discussion Our data suggest that approximately equal proportions of men and women were interested in, and responded to, our survey. The data also show that women anaesthesiologists are equally driven to progress in research, slightly more at clinical work, but they are less focused on achieving leadership positions compared with their men colleagues. Although both men and women respondents perceived that their gender was a
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disadvantage when competing for a departmental leadership position or doing research, more women felt hindered. In addition, more women felt mistreated at their workplace by surgeons, patients, nurses, and anaesthesiology colleagues. Men appear to spend more time focused on career development activities. Overall, a positive trend towards gender parity was noted. Women were less interested in pursuing a leadership position. This finding is not new, and the reasons behind it have been usually attributed to the ‘motherhood penalty’31 (i.e. career breaks attributable to pregnancy, part-time work attributable to child-rearing, and emotional load attributable to household responsibilities). When explored qualitatively, other factors surface, including the absence of menattributed personal traits, the stereotypic assumptions of men leaders, or the ‘impostor syndrome’.32 This unconscious bias, despite western egalitarian beliefs, influences leadership in a top-down fashion and was equally shown by both genders.11,33 Being a woman is still viewed as a disadvantage; reducing hours or taking time off from one’s profession to start a family may hinder advancement towards an academic or leadership position.18 Interestingly, more men than women reported they had childcare responsibilities at home. This is consistent with a recent report that women surgery residents were less likely to have children.34 A possible explanation is that women choose not to have children to have more chances of a successful career. Our qualitative analysis shows that the paucity of mentorship programmes for women, gender discrimination in the workplace, lack of role models, and the heavy burden on family duties constitute the main obstacles to equality. Our survey also shows that the unconscious bias in anaesthesiology goes beyond the gender issue. Being foreign; from a different race, religion, or caste; or even from a different region in the same country were mentioned as barriers for academic and administrative progression. The limited existing data on this issue suggest that discrimination is significantly worse in ‘non-mainstream’ groups, particularly when individual characteristics are intersectional (i.e. being a disabled person of colour).11 As individuals, these minorities have limited power to confront these diversity issues; those in a position of power, capable of decision-making, need to be actively enlightened and involved on issues about discrimination.11,23 The equal interest in research between genders may be a reflection of younger women wanting to ascend in academia, combined with a recent burst of national and international institutional gender-equity measures.13,35e37 Another important piece of the puzzle may be the worldwide workforce generation shift. Millennials, born between the early 1980s and mid-1990s, are the majority of medical students, residents, and a small percentage of junior faculty.38 This generation is ‘deeply empowered, collaborative, and innovative’,39 and may change the paradigm of leadership and academic progression by actively choosing a ‘healthier’ workelife balance, therefore investing fewer hours in their career, and by facilitating an ‘accessible digital network’ and overriding many of the formalities associated with research. Finally, they are proactive, techno-savvy, kinaesthetic learners, and are drawn to organisations that offer an engaging, supportive, and nonhierarchical atmosphere.40 This generation may well be changing the focus of research as a necessary criterion for promotion to a genuine curiosity and improvement in healthcare.
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Table 2 Major themes derived from the qualitative analysis of open-ended questions on perceived barriers for leadership positions and research. The bold fonts span the domains for which the comments are relevant. *Research barriers only. HOD, head of department.
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Departmental
Institutional and governmental
Societal
Men preference unconscious bias against women (higher expectations of women leaders) Lack of role models Resistance to change generation gap: it has always been that way Clientelism / nepotism / cronyism / “Mafia”/ corruption / bureaucracy Androcentrism, gerontocracy, oligarchy & misogyny (“sect”, “old-boys club”) Centralization of decisions / abuse of power Job insecurity / fixed-term contracts Absence of available leading positions Crowded senior academics / low turn-over / poor investment in younger generation / no research culture* Conflicting interests from other (healthcare) professions Favouritism / lack of transparency in role attribution / being member of a political party Current trend to feminize leadership roles / strong gender equality measures (in some countries) Barriers from hospital management Intrinsic features Social instability Learning climate Decisions dominated by non-physicians Age, experience, impostor syndrome, personality Lack of (skilled) mentorship Coercive administration traits (undecisive, shy, confrontational, War Lack of academic development strategies perfectionist), burned-out, non-native speaker Lack of funding/support Career progression manipulation (lack of support Lack of skills: management, communication, Poor infrastructure* Devaluation slow progression) research* Poor journal access* of currency* Lack of networking opportunities Personal inertia, procrastination, unwillingness to Barriers from government Intrinsic Barriers do research* Inefficient ethical committees Paternalistic, non-democratic HOD leadership, HOD “Non-mainstream”: religious & caste Overly restrictive research regulations* not research-oriented* discrimination/racism/regionalism/gender or No national research structure* Leadership role comes on top of clinical duties/ need sexual preference biases, disabled/health issues, Research results do not please politicians* for extra commitment (overtime) foreign training, locum position, single parent, self HOD does not favour/hire women (including due to employed religious issues) Extrinsic competitors Lack of financial reward /undervalue of leadership Time management, peer competition, military and research obligations, unsupportive spouse, overambition, Need for additional political/administrative work publication pressure Coping with variations of servilism Gender-linked factors Leadership reserved for academics Lack of authority, absenteeism, career breaks (due to No time for own professional development pregnancy, family, childcare), “non-male” Lack of team effort for collecting data/following behaviour, “female” emotional overload protocols/obtaining patient consent* Poor statistical support, inadequate documentation,* no research protected time* Staff shortage, department not dedicated to research, lack of case-mix Extrinsic Barriers Highly competitive role (peer envy, mobbing) Private practice/clinical work associated with (financial) bonuses Inadequate distribution or absence of grant money* Feasibility due to pregnancy Structural and professional barriers between intensive care medicine & anaesthesiology Inaccessibility of collaboration with men-driven specialties
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Personal
Table 3 Major themes derived from the qualitative analysis of open-ended question on suggested strategies to overcome gender inequity in leadership and research. The bold fonts span the domains for which the comments are relevant. *Gender equality represents the fair treatment of women and men, whereas gender equity denotes social justice, giving both men and women the resources they need to be successful. CPD, continuous professional development. Personal
Departmental
Institutional
Societal
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Zero tolerance for discrimination e elimination of old mental models e education e raise awareness of gender discrimination e more transparency Have gender equity as a mission statement Be a role-model Change maternity leave policies (“equal paid leave for both parents”) be confident, speak-up, report Establishment of women quotas concerns, be rational, impartial, Establishment of gender equity groups and associations honest and respectful of others have work ethics, be professional Change the monetarist health system be up-to-date and invest in CPD Empower women e “allow women to participate in the same activities as men” Make Changes Start enlightenment programs/discussions on gender bias training and identification change your personal beliefs Stronger implementation of existing gender-neutral/equity rules use coaching Equality* measures Equality* measures improve gender bias in Changes in culture be a team-player equal work and research adopt meritocracy Surgery better education for change your place of work time ¼ equal funding have a gradual exposure to hospital benchmarking children in gender equity Do not take advantage of gender equal pay for equal work leadership funding for adequate staffing better education for women equal work ethics alone to attain a leadership role adapt roster to family involvement of national equal household chore equal rights or advance professionally commitments societies/medical associations distribution equal punitive measures (flexibility) create a psychologically safe Have role-models recruiting qualified women better access to childcare in the working environment democratic elections equal possibility to work workplace Changes in Medicine part-time, equal roster allow part-time re-entry after Design overhaul in Medicine equal maternity/paternity leave childbirth More women in conference networking enhancement allow and recognise home-based panels transparency in opportunities work (research) More women professors for leadership special working conditions Increase visibility of women during Expect a generational change pregnancy support facilities at work (laundry, take-away food, etc) merit-based rotating departmental leadership Mobbing reporting systems/ heavy punishments for inflictors Briefings & auditing of gender disparities Interprofessional learning/teambuilding Better communication and support between women Mentorship programmes for women/ men sponsors Gender-neutral job applications/ job interviews, transparent recruitment Be adequately funded/ have better academic support (more collaboration with universities) Adequate staffing
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Fig. 2. Men (black) and women (grey) anaesthesiologists’ perceptions of co-worker attitudes (treatment Better, Equal, or Worse) towards women anaesthesiologists compared with men. P-values of c2 statistics are reported for 23 contingency tables.
The high proportion of women who reported having been mistreated at work is alarming. Such a finding is consistent with a trend reported in critical care medicine, in which discrimination reports, including sexual harassment, were twice as frequent amongst women.41 Such forms of conduct have a negative effect on the self (including burnout and suicidal thoughts)42 and the team, and hamper career progression.43 All healthcare institutions must have a zero tolerance approach to discrimination (gender or otherwise) by issuing guidelines and enforcing accountability, with clear consequences for inappropriate behaviour. Such guidelines must apply equally to women, men, and non-binary genders. We also noted a smaller gender gap in low- and lower middle-income countries, mostly situated in Africa and in the Middle East. Albeit not directly related to the medical profession, data from the African Development Bank indicate a concern that traditions, such as early marriage and childbearing, may hold back women from entrepreneurship.26 Since 2003, African governments have made commitments towards women’s empowerment, instituted gender policies, and launched several large-scale initiatives towards equity.26 This almost 20 yr investment may be paying off. The
situation in the Middle East is more difficult to assess; although highly heterogeneous in income, Arab countries have the lowest woman-participation rate in active life, despite various efforts towards education equality. This seems to have less to do with religion than with social conduct, reinforced by the legal system.26 Overall, these countries appear to have progressed the furthest in terms of gender equality, which may be the reason for the smaller perceived gender gap. There are several limitations to our study: (i) the sample was neither random nor homogeneous across the globe; (ii) we could not control for the possibility that each participant replied more than once (although we allowed only one response per device, and used a relatively short collection time period); (iii) respondents who were previously impacted by gender bias were probably more motivated to reply; (iv) some collaborators were accused of ‘spreading a feminist survey’, which may have influenced the response rate in some countries; (v) the exact response rate cannot be determined, but instead we calculated the completion rate (>80%) and we achieved the precalculated minimum target number of respondents; (vi) the survey was fully anonymous, and
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Fig. 3. Women perception of gender bias from respondents from high-income (filled circles), upper middle-income (diamond), and lower middle-income/low-income (triangle) countries. a) The upper three panels are perceptions of gender being a disadvantage for taking a leadership position at the department or for doing research (amongst those who have done some research and those who have not). b) The lower four panels are perceptions of attitudes towards women anaesthesiologists in the clinical workplace. P-values are reported for c2 statistics on 33 contingency tables.
therefore, we were not able to precisely characterise the nonresponders; (vii) more insights about childcare responsibilities could have been provided with additional questions about the identity of the primary caregiver; (viii) the membership of an affiliated national organisation in the WFSA is voluntary, so it is possible that the total number of anaesthetists per participating country was underestimated; and (ix) we did not reach the minimum target number of responses in several Asian countries and in the USA, probably because of survey fatigue and site blocking. Finally, some aspects of gender issues were not included in the survey, because these would have increased the length of the instrument and probably lead to a lower response rate. Nonetheless, this survey summarises the responses of nearly 12 000 international anaesthesiologists, and provides an unprecedented, large-scale assessment of the prevailing attitudes of overt and implicit gender bias within anaesthesiology around the world. In addition, it increases visibility of disparities and contributes to raising awareness of several types of discrimination in anaesthesiology. Two major strengths of the study include (i) the wide global, multilingual coverage made possible by social media, which increased the efficiency of recruitment efforts, which is a new and welcomed current trend in research33; and (ii) the possibility of
opting out of the analysis at the end of the survey, rather than inferring consent from survey completion.28 In summary, we characterised current gender inequity perceptions amongst anaesthesiologists globally. Whilst some trends suggest improvements in the workplace, we have reconfirmed the perception of an extensive network of barriers to promotion of women and men in key leadership and research positions within our speciality. More importantly, the analysis of suggestions for gender parity improvement has yielded a range of strategies, which can be considered and hopefully implemented by practising anaesthesiologists in their departments. Accepting the goal of zero (gender) discrimination and universal tolerance, our findings should contribute to better targeted departmental interventions to overcome barriers for all genders and improve attitudes in the workplace. One of the essential prerequisites is merit-based rotation of availability of leadership and research positions, which was found to be the key factor for healthy business development and innovation.
Authors’ contributions Study conception/design: MZ, DO, JB-E, SJB, RCP. Survey design: all authors.
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Data acquisition: all authors. Data analysis: MZ, JB-E, CMS. Writing paper: MZ, DO, JB-E, SJB. Revising paper: all authors. All authors approved the final version of the paper.
Declarations of interest SJB has intellectual property assigned to Mayo Clinic (Rochester, MN, USA), has received research funding from Merck & Co. (funds to Mayo Clinic), and is a consultant for Merck & Co. (Kenilworth, NJ, USA); is a principal and shareholder in Senzime AB (publ) (Uppsala, Sweden); and is a member of the Scientific Advisory Boards for ClearLine MD (Woburn, MA, USA), The Doctors Company (Napa, CA, USA), and NMD Pharma (Aarhus, Denmark). RCP serves on the speaker’s bureau for Merck Co, Inc., and is a consultant for Fresenius Kabi. Other authors have no conflicts of interest to declare.
Acknowledgements For piloting the questionnaire, the authors thank the following (i) anaesthesiologists: Andreja Moller Petrun, Mirt Kamenik, Jozica Wagner Kovacec, Domen Kogler, Marko Lokar, Katarina Katja Primozic, Bogdan Zdravkovic, Barbara Pecovnik, Pieter Mertens, Maria Lurdes Castro, Tina Heidi Pedersen, Beatriz Noronha, Ross Hofmeyr, Thomas Chloros, Filip Depta, Jana Sendreyova, Natalia Bogdanova Kavalcikova, and Chris Martini; and (ii) medical educationalists: Debra Lee Klamen, Heeyoung Han, Leslie Clasina Smith, Shelley Parr, Pat O’Sullivan, Paul de Roos, and Sonia Vaida. For translations, the authors thank Beatriz Noronha, Denis Pizhin, Jekaterina Jagodzinska, Laure Robert-Tissot, Tatjana Dill, David Berger, Alicia Del Moral Olmo, Italiana di Alejandro Bernasconi, Philippe Dubois, and Societa Anestesia Analgesia Rianimazione e Terapia Intensiva. The authors also acknowledge the following (i) supporting international societies: European Airway Management Society and American Society of Regional Anesthesia and Pain Medicine; Italiana di Anesand (ii) supporting national societies: Societa tesia Analgesia Rianimazione e Terapia Intensiva (Italy), New Zealand Society of Anaesthetists (New Zealand), South African Society of Anaesthesiologists (South Africa), Oman Society of te Marocaine Anesthesia and Critical Care (Oman), Socie sie Re animation (Morocco), Nigerian Society of d’Anesthe Anaesthetists (Nigeria), Kenya Society of Anaesthesiologists (Kenya), Finnish Society of Anaesthesiologists (Finland), Armenian Society of Anaesthesiologists and Intensive Care Specialists (Armenia), Bulgarian Society of Anaesthesiologists (Bulgaria), Sociedade Brasileira de Anestesiologia (Brazil), Romanian Society of Anaesthesia and Intensive Care (Romania), Turkish Anaesthesiology and Reanimation Society € € sthesiologie, (Turkey), Osterreichische Gesellschaft fu ¨ r Ana ~ ola Reanimation und Intensivmedizin (Austria), Sociedad Espan n y Terape utica del Dolor (Spain), de Anestesiologı´a, Reanimacio te Franc¸aise d’Anesthe sie et de Re animation (France), and Socie Nederlandse Vereniging voor Anesthesiologie (Netherlands). The authors also acknowledge the collaborators, who are listed in the Supplementary material.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.bja.2019.12.022.
References 1. Eurostat. Healthcare personnel statisticsdphysicians. Available from: https://ec.europa.eu/eurostat/statisticsexplained/index.php/Healthcare_personnel_statistics_-_ physicians#Healthcare_personnel. [Accessed 1 July 2019] 2. Galley HF, Colvin LA. Next on the agenda: gender. Br J Anaesth 2013; 111: 139e42 3. Jefferson L, Bloor K, Maynard A. Women in medicine: historical perspectives and recent trends. Br Med Bull 2015; 114: 5e15 4. Baerlocher MO, Hussain R, Bradley J. Gender patterns amongst Canadian anesthesiologists. Can J Anaesth 2006; 53: 437e41 5. Association of American Medical Colleges. Graduates of U.S. medical schools by sex. academic years 1980e1981 through 2018e19. Available from: https://www.aamc.org/ download/493700/data/factsdatachart4.pdf. [Accessed 20 December 2019] 6. Jena AB, Khullar D, Ho O, Olenski AR, Blumenthal DM. Sex differences in academic rank in US medical schools in 2014. JAMA 2015; 314: 1149e58 7. Sege R, Nykiel-Bub L, Selk S. Sex differences in institutional support for junior biomedical researchers. JAMA 2015; 314: 1175e7 8. Amrein K, Langmann A, Fahrleitner-Pammer A, Pieber TR, Zollner-Schwetz I. Women underrepresented on editorial boards of 60 major medical journals. Gend Med 2011; 8: 378e87 9. Ramakrishnan A, Sambuco D, Jagsi R. Women’s participation in the medical profession: insights from experiences in Japan, Scandinavia, Russia, and Eastern Europe. J Womens Health (Larchmt) 2014; 23: 927e34 10. Kuhlmann E, Ovseiko PV, Kurmeyer C, et al. Closing the gender leadership gap: a multi-centre cross-country comparison of women in management and leadership in academic health centres in the European Union. Hum Resour Health 2017; 15: 2 11. Grogan KE. How the entire scientific community can confront gender bias in the workplace. Nat Ecol Evol 2019; 3: 3 12. Toledo P, Duce L, Adams J, Ross VH, Thompson KM, Wong CA. Diversity in the American society of anesthesiologists leadership. Anesth Analg 2017; 124: 1611e6 13. Honorato MC. Gender and leadership positions in anaesthesiology: take on the challenge 2018. Available from: http:// newsletter.esahq.org/gender-leadership-positionsanaesthesiology-take-challenge/. [Accessed 1 July 2019] 14. Haller G, Delhumeau C, Mamie C, Zoccatelli D, Clergue F. Gender difference in career advancement and job satisfaction in anaesthesia: a cross-sectional study. Eur J Anaesthesiol 2016; 33: 588e90 15. Fahy BG, Culley DJ, Sun H, Dainer R, Lutkoski BP, Lien CA. Gender distribution of the American Board of Anesthesiology diplomates, examiners, and directors (1985e2015). Anesth Analg 2018; 127: 564e8 16. Moeschler SM, Gali B, Goyal S, et al. Speaker gender representation at the American Society of Anesthesiology annual meeting: 2011e2016. Anesth Analg 2019; 129: 301e5 17. Miller J, Chuba E, Deiner S, DeMaria Jr S, Katz D. Trends in authorship in anesthesiology journals. Anesth Analg 2019; 129: 306e10 18. Bissing MA, Lange EMS, Davila WF, et al. Status of women in academic anesthesiology: a 10-year update. Anesth Analg 2019; 128: 137e43
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19. Bismark M, Morris J, Thomas L, Loh E, Phelps G, Dickinson H. Reasons and remedies for underrepresentation of women in medical leadership roles: a qualitative study from Australia. BMJ Open 2015; 5, e009384 20. Lyu HG, Davids JS, Scully RE, Melnitchouk N. Association of domestic responsibilities with career satisfaction for physician mothers in procedural vs nonprocedural fields. JAMA Surg 2019. https://doi.org/10.1001/jamasurg.2019.0529 21. Ibarra H, Ely R, Kolb D. Women rising: the unseen barriers. Harv Bus Rev 2013; 91: 60e6 22. Yang Y, Chawla NV, Uzzi B. A network’s gender composition and communication pattern predict women’s leadership success. Proc Natl Acad Sci U S A 2019; 116: 2033e8 23. Fisler N, Sweitzer BJ, Wurz J, Kleiman AM, Stueber F, Luedi MM. Achieving gender parity in acute care medicine requires a multidimensional perspective and a committed plan of action. Anesth Analg 2019; 129: 1778e83 24. World Bank. The World Bank data: GNI per capita, atlas method. Available from: https://data.worldbank.org/ indicator/NY.GNP.PCAP.CD. [Accessed 20 December 2019] 25. Leslie K, Edgley C, Lee AC, Sellar A, Sgroi J, Toh R. Reporting of sex and gender in human studies published in anaesthesia journals. Br J Anaesth 2018; 120: 1128e30 26. Onajin-Obembe B, Haylock-Loor C, Filipescu D, et al. The gender gap. In: Duval Neto G, editor. Occupational wellbeing in anesthesiologistsvols. 309e54. Rio de Janeiro, Brazil: Brazilian Society of Anesthesiology; 2018 27. Baltar F, Brunet I. Social research 2.0: virtual snowball sampling method using Facebook. Internet Res 2012; 22: 57e74 28. Zdravkovic M, Berger-Estilita J, Sorbello M, Hagberg CA. An international survey about rapid sequence intubation of 10,003 anaesthetists and 16 airway experts. Anaesthesia 2019. https://doi.org/10.1111/anae.14867 29. Akoglu H. User’s guide to correlation coefficients. Turk J Emerg Med 2018; 18: 91e3 30. Watling CJ, Lingard L. Grounded theory in medical education research: AMEE guide no. 70. Med Teach 2012; 34: 850e61 31. Bryant LD, Burkinshaw P, House AO, West RM, Ward V. Good practice or positive action? Using Q methodology to
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Handling editor: Cynthia A. Wong
CLINICAL INVESTIGATION
Perceptions of gender equity in departmental leadership, research opportunities, and clinical work attitudes: an international survey of 11 781 anaesthesiologists ~ es6, Marko Zdravkovic1,2, Denisa Osinova3, Sorin J. Brull4, Richard C. Prielipp5, Claudia M. Simo Joana Berger-Estilita7,*, and Collaborators 1
Department of Anaesthesiology, Intensive Care and Pain Management, University Medical Centre Maribor, Maribor,
Slovenia, 2Faculty of Medicine, University of Maribor, Maribor, Slovenia, 3Department of Anaesthesiology and Intensive Care, Jessenius Faculty of Medicine in Martin, Comenius University Bratislava, University Hospital Martin, Martin, Slovak Republic, 4Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA, 5University of Minnesota Medical School, Minneapolis, MN, USA, 6Department of Anaesthesiology, ^ ncer Do Estado de Sa ~ o Paulo, Faculdade de Medicina da Universidade de Sa ~ o Paulo, Hospital Sı´rio Libane ^s, Instituto Do Ca ~ o Paulo, Brazil and 7Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Sa Switzerland *Corresponding author. E-mail: [email protected]
Abstract Background: Women make up an increasing proportion of the physician workforce in anaesthesia, but they are consistently under-represented in leadership and governance. Methods: We performed an internet-based survey to investigate career opportunities in leadership and research amongst anaesthesiologists. We also explored gender bias attributable to workplace attitudes and economic factors. The survey instrument was piloted, translated into seven languages, and uploaded to the SurveyMonkey® platform. We aimed to collect between 7800 and 13 700 responses from at least 100 countries. Participant consent and ethical approval were obtained. A quantitative analysis was done with c2 and Cramer’s V as a measure of strength of associations. We used an inductive approach and a thematic content analysis for qualitative data on current barriers to leadership and research. Results: The 11 746 respondents, 51.3% women and 48.7% men, represented 148 countries; 35 respondents identified their gender as non-binary. Women were less driven to achieve leadership positions (P<0.001; Cramer’s V: 0.11). Being a woman was reported as a disadvantage for leadership and research (P<0.001 for both; Cramer’s V: 0.47 and 0.34, respectively). Women were also more likely to be mistreated in the workplace (odds ratio: 10.6; 95% confidence interval: 9.4e11.9; P<0.001), most commonly by surgeons. Several personal, departmental, institutional, and societal barriers in leadership and research were identified, and strategies to overcome them were suggested. Lower-income countries were associated with a significantly smaller gender gap (P<0.001). Conclusions: Whilst certain trends suggest improvements in the workplace, barriers to promotion of women in key leadership and research positions continue within anaesthesiology internationally. Keywords: anaesthesiology; gender equity; gender gap; global survey; leadership; physician perception; research; work attitudes
Accepted: 20 December 2019 © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved. For Permissions, please email: [email protected]
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Editor’s key points Factors contributing to gender disparity in leadership and research in anaesthesiology have not been well defined. An internet-based survey was designed to investigate career opportunities in leadership and research amongst anaesthesiologists, and gender bias attributable to workplace attitudes and economic factors. Based on 11 746 respondents representing 148 countries, women were less driven to achieve leadership positions and were also more likely to be mistreated in the workplace. In addition, being a woman was reported as a disadvantage for leadership and research. A number of personal, departmental, institutional, and societal barriers in leadership and research were identified.
The last few decades have witnessed an increasing number of women active in medical professions across the world. Data from both Europe and North America1e4 indicate that there are more women than men physicians, with the proportion of women approaching 75% in some European countries.1 This trend will likely continue as the number of women medical students continues to grow.5 Although women make up a substantial proportion of the physician workforce, they are consistently under-represented in important governance positions. They are less likely to achieve academic promotion,6 submit and be successful in grant applications and research funding,7 and achieve key leadership positions.8e10 This concept has been described as the ‘leaky pipeline’.11 Anaesthesiology mirrors these broader trends,12e18 although most of the gender equity data in anaesthesiology are solely numeric,12,13,15e18 of small scale, and primarily explore North American practise. Whilst numeric data clearly document the problem, they do not provide insights into why these differences occur.13 Factors contributing to this gender disparity in anaesthesiology are commonly extrapolated from other medical fields19,20 or even other sectors, such as business administration.21,22 Current explanations are multifactorial with bias undoubtedly a major contributor19; however, many other factors likely contribute. Fisler and colleagues23 developed a multidimensional perspective on achieving gender parity, which has departmental and peer forces at its core. Therefore, focussing departmental efforts on improving gender equity will influence practising anaesthesiologists on a daily basis and will, over time, reach other healthcare sectors.23 However, there are scarce data about departmental opportunities and attitudes in anaesthesiology. To promote leadership, research, and clinical opportunities based on abilities rather than gender, a global assessment is necessary. With this international cross-sectional survey, we aimed to further define the current global perception of gender equity amongst anaesthesiologists, specifically in the areas of departmental leadership, research, and co-worker attitudes in the clinical workplace. We also explored the career aspirations and time spent on career advancing activities. Finally, we aimed to describe perceived barriers to leadership and research, and propose interventions to help improve gender equity. We hypothesised that (i) anaesthesiologists perceive identical career opportunities in leadership and research, independent of gender; (ii) career aspirations and time devoted
to career advancement are independent of gender; and (iii) anaesthesiologists experience gender-unbiased attitudes in the workplace and that there is no perceived gender bias because of economic factors as determined by national income groups defined by the World Bank in 2019.24 Gender equity and equality are two strategies to produce fairness. Gender equality represents the fair treatment of women and men, whereas gender equity denotes social justice providing resources to both men and women to support success in their careers.
Methods Ethics approval This international, internet-based, cross-sectional survey was approved by the Ethics Committee at the University Medical Centre Maribor, Maribor, Slovenia (Ref.: UKC-MB-KME-75/19). At the end of the survey, respondents were obliged to provide explicit consent for participation and data analysis.
Instrument development We developed the questionnaire based on three aspects of anaesthesiologists’ careers: leadership opportunities, research opportunities, and clinical work attitudes. All questions were aimed for the primary unit (i.e. department) where the respondents worked. A 46-item questionnaire was constructed in English (Supplementary questionnaire). Five items were compulsory, including confirmation of the work in the operating theatre as an anaesthesiologist, a question asking whether the respondent was the current head of a department (if affirmative, the set of questions on departmental leadership aspirations was skipped), gender, question about previous research experience (leading to two different sets of questions based on the response), and participant’s consent. Respondents were also asked to include their city and country of practise, although these were non-compulsory fields. Six of the 46 survey items were open-ended questions that explored respondents’ interest in various leadership roles, perceived barriers to leadership and research, suggestions for improving gender equality, and other comments. The terms ‘women’ and ‘men’ usually refer to gender (a cultural construct), whereas the terms ‘female’ and ‘male’ usually refer to sex (a biological construct).25 Because the survey was designed as a worldwide cultural survey, we have used the terms ‘women’ and ‘men’ throughout the paper, with the exception of the actual survey, in which we followed the feedback from the piloting process and used ‘female’ and ‘male’. We also used the word ‘gender’ throughout the paper as a reference to the roles, behaviours, and characteristics that a time-societal duality attributes distinctively to men and women.26 The draft questionnaire was piloted by 18 clinicians (trainees and consultants) from 10 countries and six professionals with background in medical education research and qualitative research methodology (see Acknowledgements). The English version was translated into French, German, Italian, Portuguese, Russian, and Spanish by native speakers, and translated back to English by a different native speaker. The back-translated English versions were compared with the original English version for accuracy. Inconsistencies were adjudicated by a third reviewer. The questionnaire was hosted
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Fig. 1. (a) Survey completion rate calculation and respondent exclusion flow chart. (b) World map of survey completion rate targets. Green indicates countries for which the minimum target number was reached, red indicates that the target was not reached, and grey indicates that no data were collected. Created at www.mapchart.net.
online at SurveyMonkey (San Mateo, CA, USA) with the restriction of one response per device enabled.
Survey distribution and sample size calculation As the primary mode of survey distribution was through social media using the ‘snowballing’ sampling technique,27,28 selection bias was reduced by aiming to collect between 7600 and 13 700 responses from at least 100 countries.28 This number was estimated from the World Federation of Societies of Anaesthesiologists (WFSA) data as representing 10% of each of the national society’s members, or as five responses per million population, with a ‘cut-off’ number of 500 (Supplementary Table S1). The survey link was primarily distributed through LinkedIn, Facebook, Twitter, and e-mail invitations, with supporting (inter)national societies e-mailing the link via their own mailing lists (see Acknowledgements for the list of supporting societies). Up to two reminders were sent.
theory30). Answer reduction was performed by JB-E and crosschecked by CMS. Both authors performed interim analyses, in clusters of 1500 answers, to check for saturation. Open-ended questions were analysed for common themes and categories through open coding. Open codes were reanalysed for duplications and overlapping themes. Final verification of categories was attained through peer debrief (MZ).
Results The survey was available for completion for a total of 6 weeks, from September 14, 2019 to October 26, 2019. Of 15 714 respondents who started the survey, 3968 (25%) were not included in the main analysis (Fig 1). The survey completion rate was 80.8%. We performed a separate descriptive analysis of the non-binary gender group of respondents (n¼35) because further statistical tests were not warranted because of a low overall number of respondents in this gender group.
Respondent characteristics Data analysis Surveys in which respondents did not indicate gender were excluded from the analysis. Responses from men and women were compared, as were responses from countries with high-, upper middle-, and lower middle-/low-income economies.24 Quantitative data were analysed using Pearson’s c2 statistics for contingency table analyses (two sided). We used Cramer’s V as the measure of strength of association (weak: >0.05; moderate: >0.10; strong: >0.15; and very strong: >0.25).29 Further effect size estimations were performed on two-bytwo contingency tables, and reported as odds ratio (OR) with 95% confidence intervals (CIs). Parametric data were reported as mean (standard deviation [SD]) and analysed with Student’s t-test. Significance was set at P<0.05. The statistical analysis was performed using SPSS Statistics 20 (IBM Inc., Chicago, IL, USA). The qualitative analysis of open-ended questions was performed by two authors (JB-E and CMS) using an inductive approach and a thematic content analysis (grounded
Of the 11 746 respondents from 148 self-identified countries (Fig 1), 1488 (12.7%) did not declare their country of practise. One hundred and eleven countries (75%) reached the calculated minimum target of respondents (Supplementary Table S2). There were 6030 (51.3%) women and 5716 (48.7%) men respondents, with the mean ages (SD) 41 (10) and 43 (11) yr, respectively (P<0.001). The respondent level of practise included 888 (7.6%) women and 1304 (11.1%) men trainees in the first and second halves of their training; 4166 (35.6%) women and 5351 (45.7%) men specialists had less than or more than 10 yr of experience. The proportion of men respondents was higher only within the ‘specialist for more than 10 yr’ group, whilst women predominated in the other three groups (P<0.001). The departmental gender structure analysis showed a mean women:men ratio of 0.48 (0.21) (Supplementary Fig. S1). When asked about family commitments, 3095 (51.4%) women and 3385 (59.5%) men reported having childcare responsibilities (OR: 1.39 95% CI: 1.29e1.49), favouring men; (P<0.001). In a subset analysis for level of practise, this
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difference emerged with trainees in the second half of training (36.8% men compared with 29.1% of women had childcare responsibilities; P<0.001), and continued in specialists for less than 10 yr (66.7% vs 56.2%, respectively; P<0.001) and in specialists with more than 10 yr of experience (64.9% and 61.5%, respectively; P¼0.01). We compared demographically the 2883 excluded respondents with the 11 781 included on two questions. (The response rate was insufficient for the other demographic questions.) The excluded respondents were younger (mean [SD] 39.8 [11.2] yr vs 42.0 [10.6] yr; t-test P<0.001) and a higher proportion of trainees than specialists (573 [28.7%] vs 2192 [18.7%], respectively; c2 P<0.001; Cramer’s V: 0.10).
Leadership and research When asked, ‘My gender is a disadvantage when competing for a leadership position in my department’, 1796 (34.6%) women agreed or strongly agreed compared with 198 (4.7%) men (P<0.001; Cramer’s V: 0.47 [very strong gender association]). In pursuit of research, the percentages were lower but still different from for men. When those who have done some research were asked, ‘My gender is a disadvantage when doing research at my department’, 402 (12.9%) women agreed or strongly agreed, compared with 104 (3.0%) of men
(P<0.001; Cramer’s V: 0.34 [very strong gender association]). For those who had never conducted any research, 263 (10.2%) of women agreed or strongly agreed compared with 59 (3.0%) men (P<0.001; Cramer’s V: 0.32 [very strong gender association]). Women aspired less frequently than men to taking a leadership position in their departments, but they manifested an equal desire for research and a higher desire for clinical work achievement (Table 1). Both men and women favoured sub-chair leadership roles in preference to becoming the head (chair) of their department (P<0.001 for both; Cramer’s V: 0.41 for women and 0.44 for men [very strong associations]). The desired sub-chair leadership roles were qualitatively assigned into five categories: research, education, patient safety, quality improvement, and clinical work. Men reported that they spend more time on career development activities (Table 1). Women were more likely to be the current heads of departments than the immediate-past head (OR: 3.00 [95% CI: 2.74e3.29]; P<0.001). Amongst 2304 (19.6%) respondents who were current or past heads of departments, 822 (35.7%) were women and 1482 (64.3%) were men. The barriers to taking the leadership position and in performing research were further explored qualitatively through open-ended questions; 3647 (31.0%) responded to the openended question on barriers to leadership and 3740 (31.8%) for
Table 1 Career aspirations in leadership, research, and clinical work for women vs men and work hours. Values are n (%) or mean (standard deviation). *c2 test reported comparing frequency distributions within 52 contingency tables. **Independent sample t-test. yA 5-point Likert scale was used, in which 1¼not important; 5¼very important for career plans. zIncludes clinical work, research/ academic work, and any leadership positions. Career aspect
Measurement scale
Women
Men
P-value (Cramer’s V)
Leadership Taking a leadership position in my department
5-point Likert scaley
2.90 (1.31)
3.17 (1.36)
Strongly agree Agree Unsure Disagree Strongly disagree Strongly agree Agree Unsure Disagree Strongly disagree
367 (7.1%) 715 (13.8%) 1525 (29.4%) 1445 (27.8%) 1143 (22.0%) 941 (18.1%) 1742 (33.5%) 1469 (28.3%) 651 (12.5%) 391 (7.5%)
426 (10.1%) 803 (19.0%) 1224 (28.5%) 994 (23.5%) 798 (18.9%) 814 (19.3%) 1579 (37.4%) 1054 (25.0%) 443 (10.5%) 331 (7.8%)
<0.001* (0.11; moderate association) <0.001** <0.001* (0.10; moderate association)
5-point Likert scaley
2.85 (1.30)
2.88 (1.31)
Strongly agree Agree Unsure Disagree Strongly disagree
376 800 723 425 288
338 573 536 316 217
5-point Likert scaley
4.32 (1.09)
4.26 (1.10)
<0.001* (0.05; no or very weak association) ¼0.001**
<20 h 20e40 h 41e60 h 61e80 h >80 h
277 (4.6%) 908 (15.1%) 3128 (52.0%) 1335 (22.2%) 370 (6.1%)
223 (3.9%) 597 (10.5%) 2892 (50.7%) 1465 (25.7%) 525 (9.2%)
<0.001* (0.09; weak association)
I would like to become the head of my department in the future (current/past heads of departments excluded)
I would like to take some other leadership role in my department in the future (excluded current/past heads of departments)
Research Doing research
I would like to do research in the future (amongst those who have not done any research so far)
Clinical work Doing clinical work
Time spent on career Average weekly hoursz
(14.4%) (30.6%) (27.7%) (16.3%) (11.0%)
(17.1%) (28.9%) (27.1%) (16.0%) (11.0%)
<0.001* (0.06; weak association)
¼0.033* (0.03; no or very weak association) ¼0.203** ¼0.166* (NA)
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research. For both questions, saturation was reached after the interim analysis of the first 1500 responses, and one author (MZ) cross-checked the remaining responses for coverage. The codes were sorted into four major themes (personal, departmental, institutional and governmental, and societal changes) and organised into a framework (Table 2); many overlapping codes between leadership and research were identified. All 3322 (28.3%) responses to the question, ‘Please suggest what could be done to improve gender equality in leadership, research, and/or clinical work at your department’ were analysed and categorised into four major themes: personal, departmental, institutional, and societal changes (Table 3). Overall, 411 (11.3%) reported no existing barriers for leadership and 489 (13.1%) for research, and 598 (18.0%) did not suggest strategies for gender parity because they did not perceive inequalities in their work environment.
Socio-economic factors Women anaesthesiologists perceived that co-worker attitudes towards them were worse than those perceived by men anaesthesiologists (surgeons [P<0.001; Cramer’s V: 0.20]; patients [P<0.001; Cramer’s V: 0.18]; nurses [P<0.001; Cramer’s V: 0.13]; anaesthesiology colleagues [P<0.001; Cramer’s V: 0.26]) (Fig 2). When asked, ‘Have you ever been mistreated at your workplace because of your gender?’ 2564 women (43.6%) and 374 men (6.8%) agreed (OR: 10.6 [95% CI: 9.4e11.9]; P<0.001). The sources of mistreatment were reported as surgeons (n¼1935), anaesthesiology colleagues (n¼1425), patients (n¼1165), nurses (n¼971), and others (n¼345). The most common in the latter category were the heads of departments or direct superiors (n¼165), administrative staff (n¼53), doctors from other specialities (n¼40), and patient relatives (n¼25). The mistreatment was reported 701 times (24.2%), and amongst the reported incidents, support was provided in 394 cases (56.1%). Amongst the non-reported mistreatments, support was provided in 872 cases (40.5%). In lower-income countries, women anaesthesiologists perceived their gender to be less of a disadvantage in taking the departmental leadership position or doing research (Fig 3). Similarly, they perceived better treatment from surgeons, patients, nurses, and anaesthesiology colleagues.
Non-binary gender respondents Of a total of 35 respondents identified as being a non-binary gender (mean [SD] age: 47.8 [12.5] yr), 23 were specialists with more than 10 yr of professional experience and 15 had childcare responsibilities in the home. Most respondents disagreed that their gender was disadvantageous for leadership roles (n¼24) or a research position (n¼27). Nine reported having been mistreated in the workplace because of their non-binary gender, mainly by surgeons or their supervisors.
Discussion Our data suggest that approximately equal proportions of men and women were interested in, and responded to, our survey. The data also show that women anaesthesiologists are equally driven to progress in research, slightly more at clinical work, but they are less focused on achieving leadership positions compared with their men colleagues. Although both men and women respondents perceived that their gender was a
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disadvantage when competing for a departmental leadership position or doing research, more women felt hindered. In addition, more women felt mistreated at their workplace by surgeons, patients, nurses, and anaesthesiology colleagues. Men appear to spend more time focused on career development activities. Overall, a positive trend towards gender parity was noted. Women were less interested in pursuing a leadership position. This finding is not new, and the reasons behind it have been usually attributed to the ‘motherhood penalty’31 (i.e. career breaks attributable to pregnancy, part-time work attributable to child-rearing, and emotional load attributable to household responsibilities). When explored qualitatively, other factors surface, including the absence of menattributed personal traits, the stereotypic assumptions of men leaders, or the ‘impostor syndrome’.32 This unconscious bias, despite western egalitarian beliefs, influences leadership in a top-down fashion and was equally shown by both genders.11,33 Being a woman is still viewed as a disadvantage; reducing hours or taking time off from one’s profession to start a family may hinder advancement towards an academic or leadership position.18 Interestingly, more men than women reported they had childcare responsibilities at home. This is consistent with a recent report that women surgery residents were less likely to have children.34 A possible explanation is that women choose not to have children to have more chances of a successful career. Our qualitative analysis shows that the paucity of mentorship programmes for women, gender discrimination in the workplace, lack of role models, and the heavy burden on family duties constitute the main obstacles to equality. Our survey also shows that the unconscious bias in anaesthesiology goes beyond the gender issue. Being foreign; from a different race, religion, or caste; or even from a different region in the same country were mentioned as barriers for academic and administrative progression. The limited existing data on this issue suggest that discrimination is significantly worse in ‘non-mainstream’ groups, particularly when individual characteristics are intersectional (i.e. being a disabled person of colour).11 As individuals, these minorities have limited power to confront these diversity issues; those in a position of power, capable of decision-making, need to be actively enlightened and involved on issues about discrimination.11,23 The equal interest in research between genders may be a reflection of younger women wanting to ascend in academia, combined with a recent burst of national and international institutional gender-equity measures.13,35e37 Another important piece of the puzzle may be the worldwide workforce generation shift. Millennials, born between the early 1980s and mid-1990s, are the majority of medical students, residents, and a small percentage of junior faculty.38 This generation is ‘deeply empowered, collaborative, and innovative’,39 and may change the paradigm of leadership and academic progression by actively choosing a ‘healthier’ workelife balance, therefore investing fewer hours in their career, and by facilitating an ‘accessible digital network’ and overriding many of the formalities associated with research. Finally, they are proactive, techno-savvy, kinaesthetic learners, and are drawn to organisations that offer an engaging, supportive, and nonhierarchical atmosphere.40 This generation may well be changing the focus of research as a necessary criterion for promotion to a genuine curiosity and improvement in healthcare.
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Table 2 Major themes derived from the qualitative analysis of open-ended questions on perceived barriers for leadership positions and research. The bold fonts span the domains for which the comments are relevant. *Research barriers only. HOD, head of department.
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Departmental
Institutional and governmental
Societal
Men preference unconscious bias against women (higher expectations of women leaders) Lack of role models Resistance to change generation gap: it has always been that way Clientelism / nepotism / cronyism / “Mafia”/ corruption / bureaucracy Androcentrism, gerontocracy, oligarchy & misogyny (“sect”, “old-boys club”) Centralization of decisions / abuse of power Job insecurity / fixed-term contracts Absence of available leading positions Crowded senior academics / low turn-over / poor investment in younger generation / no research culture* Conflicting interests from other (healthcare) professions Favouritism / lack of transparency in role attribution / being member of a political party Current trend to feminize leadership roles / strong gender equality measures (in some countries) Barriers from hospital management Intrinsic features Social instability Learning climate Decisions dominated by non-physicians Age, experience, impostor syndrome, personality Lack of (skilled) mentorship Coercive administration traits (undecisive, shy, confrontational, War Lack of academic development strategies perfectionist), burned-out, non-native speaker Lack of funding/support Career progression manipulation (lack of support Lack of skills: management, communication, Poor infrastructure* Devaluation slow progression) research* Poor journal access* of currency* Lack of networking opportunities Personal inertia, procrastination, unwillingness to Barriers from government Intrinsic Barriers do research* Inefficient ethical committees Paternalistic, non-democratic HOD leadership, HOD “Non-mainstream”: religious & caste Overly restrictive research regulations* not research-oriented* discrimination/racism/regionalism/gender or No national research structure* Leadership role comes on top of clinical duties/ need sexual preference biases, disabled/health issues, Research results do not please politicians* for extra commitment (overtime) foreign training, locum position, single parent, self HOD does not favour/hire women (including due to employed religious issues) Extrinsic competitors Lack of financial reward /undervalue of leadership Time management, peer competition, military and research obligations, unsupportive spouse, overambition, Need for additional political/administrative work publication pressure Coping with variations of servilism Gender-linked factors Leadership reserved for academics Lack of authority, absenteeism, career breaks (due to No time for own professional development pregnancy, family, childcare), “non-male” Lack of team effort for collecting data/following behaviour, “female” emotional overload protocols/obtaining patient consent* Poor statistical support, inadequate documentation,* no research protected time* Staff shortage, department not dedicated to research, lack of case-mix Extrinsic Barriers Highly competitive role (peer envy, mobbing) Private practice/clinical work associated with (financial) bonuses Inadequate distribution or absence of grant money* Feasibility due to pregnancy Structural and professional barriers between intensive care medicine & anaesthesiology Inaccessibility of collaboration with men-driven specialties
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Personal
Table 3 Major themes derived from the qualitative analysis of open-ended question on suggested strategies to overcome gender inequity in leadership and research. The bold fonts span the domains for which the comments are relevant. *Gender equality represents the fair treatment of women and men, whereas gender equity denotes social justice, giving both men and women the resources they need to be successful. CPD, continuous professional development. Personal
Departmental
Institutional
Societal
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Zero tolerance for discrimination e elimination of old mental models e education e raise awareness of gender discrimination e more transparency Have gender equity as a mission statement Be a role-model Change maternity leave policies (“equal paid leave for both parents”) be confident, speak-up, report Establishment of women quotas concerns, be rational, impartial, Establishment of gender equity groups and associations honest and respectful of others have work ethics, be professional Change the monetarist health system be up-to-date and invest in CPD Empower women e “allow women to participate in the same activities as men” Make Changes Start enlightenment programs/discussions on gender bias training and identification change your personal beliefs Stronger implementation of existing gender-neutral/equity rules use coaching Equality* measures Equality* measures improve gender bias in Changes in culture be a team-player equal work and research adopt meritocracy Surgery better education for change your place of work time ¼ equal funding have a gradual exposure to hospital benchmarking children in gender equity Do not take advantage of gender equal pay for equal work leadership funding for adequate staffing better education for women equal work ethics alone to attain a leadership role adapt roster to family involvement of national equal household chore equal rights or advance professionally commitments societies/medical associations distribution equal punitive measures (flexibility) create a psychologically safe Have role-models recruiting qualified women better access to childcare in the working environment democratic elections equal possibility to work workplace Changes in Medicine part-time, equal roster allow part-time re-entry after Design overhaul in Medicine equal maternity/paternity leave childbirth More women in conference networking enhancement allow and recognise home-based panels transparency in opportunities work (research) More women professors for leadership special working conditions Increase visibility of women during Expect a generational change pregnancy support facilities at work (laundry, take-away food, etc) merit-based rotating departmental leadership Mobbing reporting systems/ heavy punishments for inflictors Briefings & auditing of gender disparities Interprofessional learning/teambuilding Better communication and support between women Mentorship programmes for women/ men sponsors Gender-neutral job applications/ job interviews, transparent recruitment Be adequately funded/ have better academic support (more collaboration with universities) Adequate staffing
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Fig. 2. Men (black) and women (grey) anaesthesiologists’ perceptions of co-worker attitudes (treatment Better, Equal, or Worse) towards women anaesthesiologists compared with men. P-values of c2 statistics are reported for 23 contingency tables.
The high proportion of women who reported having been mistreated at work is alarming. Such a finding is consistent with a trend reported in critical care medicine, in which discrimination reports, including sexual harassment, were twice as frequent amongst women.41 Such forms of conduct have a negative effect on the self (including burnout and suicidal thoughts)42 and the team, and hamper career progression.43 All healthcare institutions must have a zero tolerance approach to discrimination (gender or otherwise) by issuing guidelines and enforcing accountability, with clear consequences for inappropriate behaviour. Such guidelines must apply equally to women, men, and non-binary genders. We also noted a smaller gender gap in low- and lower middle-income countries, mostly situated in Africa and in the Middle East. Albeit not directly related to the medical profession, data from the African Development Bank indicate a concern that traditions, such as early marriage and childbearing, may hold back women from entrepreneurship.26 Since 2003, African governments have made commitments towards women’s empowerment, instituted gender policies, and launched several large-scale initiatives towards equity.26 This almost 20 yr investment may be paying off. The
situation in the Middle East is more difficult to assess; although highly heterogeneous in income, Arab countries have the lowest woman-participation rate in active life, despite various efforts towards education equality. This seems to have less to do with religion than with social conduct, reinforced by the legal system.26 Overall, these countries appear to have progressed the furthest in terms of gender equality, which may be the reason for the smaller perceived gender gap. There are several limitations to our study: (i) the sample was neither random nor homogeneous across the globe; (ii) we could not control for the possibility that each participant replied more than once (although we allowed only one response per device, and used a relatively short collection time period); (iii) respondents who were previously impacted by gender bias were probably more motivated to reply; (iv) some collaborators were accused of ‘spreading a feminist survey’, which may have influenced the response rate in some countries; (v) the exact response rate cannot be determined, but instead we calculated the completion rate (>80%) and we achieved the precalculated minimum target number of respondents; (vi) the survey was fully anonymous, and
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Fig. 3. Women perception of gender bias from respondents from high-income (filled circles), upper middle-income (diamond), and lower middle-income/low-income (triangle) countries. a) The upper three panels are perceptions of gender being a disadvantage for taking a leadership position at the department or for doing research (amongst those who have done some research and those who have not). b) The lower four panels are perceptions of attitudes towards women anaesthesiologists in the clinical workplace. P-values are reported for c2 statistics on 33 contingency tables.
therefore, we were not able to precisely characterise the nonresponders; (vii) more insights about childcare responsibilities could have been provided with additional questions about the identity of the primary caregiver; (viii) the membership of an affiliated national organisation in the WFSA is voluntary, so it is possible that the total number of anaesthetists per participating country was underestimated; and (ix) we did not reach the minimum target number of responses in several Asian countries and in the USA, probably because of survey fatigue and site blocking. Finally, some aspects of gender issues were not included in the survey, because these would have increased the length of the instrument and probably lead to a lower response rate. Nonetheless, this survey summarises the responses of nearly 12 000 international anaesthesiologists, and provides an unprecedented, large-scale assessment of the prevailing attitudes of overt and implicit gender bias within anaesthesiology around the world. In addition, it increases visibility of disparities and contributes to raising awareness of several types of discrimination in anaesthesiology. Two major strengths of the study include (i) the wide global, multilingual coverage made possible by social media, which increased the efficiency of recruitment efforts, which is a new and welcomed current trend in research33; and (ii) the possibility of
opting out of the analysis at the end of the survey, rather than inferring consent from survey completion.28 In summary, we characterised current gender inequity perceptions amongst anaesthesiologists globally. Whilst some trends suggest improvements in the workplace, we have reconfirmed the perception of an extensive network of barriers to promotion of women and men in key leadership and research positions within our speciality. More importantly, the analysis of suggestions for gender parity improvement has yielded a range of strategies, which can be considered and hopefully implemented by practising anaesthesiologists in their departments. Accepting the goal of zero (gender) discrimination and universal tolerance, our findings should contribute to better targeted departmental interventions to overcome barriers for all genders and improve attitudes in the workplace. One of the essential prerequisites is merit-based rotation of availability of leadership and research positions, which was found to be the key factor for healthy business development and innovation.
Authors’ contributions Study conception/design: MZ, DO, JB-E, SJB, RCP. Survey design: all authors.
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Data acquisition: all authors. Data analysis: MZ, JB-E, CMS. Writing paper: MZ, DO, JB-E, SJB. Revising paper: all authors. All authors approved the final version of the paper.
Declarations of interest SJB has intellectual property assigned to Mayo Clinic (Rochester, MN, USA), has received research funding from Merck & Co. (funds to Mayo Clinic), and is a consultant for Merck & Co. (Kenilworth, NJ, USA); is a principal and shareholder in Senzime AB (publ) (Uppsala, Sweden); and is a member of the Scientific Advisory Boards for ClearLine MD (Woburn, MA, USA), The Doctors Company (Napa, CA, USA), and NMD Pharma (Aarhus, Denmark). RCP serves on the speaker’s bureau for Merck Co, Inc., and is a consultant for Fresenius Kabi. Other authors have no conflicts of interest to declare.
Acknowledgements For piloting the questionnaire, the authors thank the following (i) anaesthesiologists: Andreja Moller Petrun, Mirt Kamenik, Jozica Wagner Kovacec, Domen Kogler, Marko Lokar, Katarina Katja Primozic, Bogdan Zdravkovic, Barbara Pecovnik, Pieter Mertens, Maria Lurdes Castro, Tina Heidi Pedersen, Beatriz Noronha, Ross Hofmeyr, Thomas Chloros, Filip Depta, Jana Sendreyova, Natalia Bogdanova Kavalcikova, and Chris Martini; and (ii) medical educationalists: Debra Lee Klamen, Heeyoung Han, Leslie Clasina Smith, Shelley Parr, Pat O’Sullivan, Paul de Roos, and Sonia Vaida. For translations, the authors thank Beatriz Noronha, Denis Pizhin, Jekaterina Jagodzinska, Laure Robert-Tissot, Tatjana Dill, David Berger, Alicia Del Moral Olmo, Italiana di Alejandro Bernasconi, Philippe Dubois, and Societa Anestesia Analgesia Rianimazione e Terapia Intensiva. The authors also acknowledge the following (i) supporting international societies: European Airway Management Society and American Society of Regional Anesthesia and Pain Medicine; Italiana di Anesand (ii) supporting national societies: Societa tesia Analgesia Rianimazione e Terapia Intensiva (Italy), New Zealand Society of Anaesthetists (New Zealand), South African Society of Anaesthesiologists (South Africa), Oman Society of te Marocaine Anesthesia and Critical Care (Oman), Socie sie Re animation (Morocco), Nigerian Society of d’Anesthe Anaesthetists (Nigeria), Kenya Society of Anaesthesiologists (Kenya), Finnish Society of Anaesthesiologists (Finland), Armenian Society of Anaesthesiologists and Intensive Care Specialists (Armenia), Bulgarian Society of Anaesthesiologists (Bulgaria), Sociedade Brasileira de Anestesiologia (Brazil), Romanian Society of Anaesthesia and Intensive Care (Romania), Turkish Anaesthesiology and Reanimation Society € € sthesiologie, (Turkey), Osterreichische Gesellschaft fu ¨ r Ana ~ ola Reanimation und Intensivmedizin (Austria), Sociedad Espan n y Terape utica del Dolor (Spain), de Anestesiologı´a, Reanimacio te Franc¸aise d’Anesthe sie et de Re animation (France), and Socie Nederlandse Vereniging voor Anesthesiologie (Netherlands). The authors also acknowledge the collaborators, who are listed in the Supplementary material.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.bja.2019.12.022.
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Handling editor: Cynthia A. Wong