Literature review
Leadership in Obstetrics and Gynaecology
Background
Prior to commencing this project a systematic search through relevant literature was performed to establish the current landscape on gender and leadership in O&G. With only seven articles addressing this issue, the search was subsequently expanded to consider gender and leadership more broadly within with medicine.
Method
Searches within PubMed, Google Scholar, and the individual journals ‘Gender & Society’ and ‘Gender Issues’ were conducted. The PubMed and Google Scholar databases were chosen for their high utilisation in medicine, and individual journals for their high impact factor within the field of gender.
Articles included in this review were English language papers published between 2000 and 2017, with the key-words: ‘gender’, ‘leadership’, ‘medical leadership’, ‘gender bias’, ‘gender schemas’, ‘positive discrimination’, ‘gender equality’, ‘gender quota’, ‘glass ceiling’, ‘medicine’, ‘obstetrics’ and ‘gynaecology’.
Articles were included if they referred explicitly to obstetrics and gynaecology, medical leadership, gender equality, the ‘glass ceiling’, gender bias or implicit bias. Articles concerned with sex and gender differences in health and illness were excluded from the review. Following initial synthesis of the literature, further articles were added if they met the criteria but were published after the initial review, or if they increased the depth of the analysis within the subsections of the review.
The SALSA analytical framework (Search, AppraisaL, Synthesis and Analysis) was employed to examine all articles considered for review (147). Articles were compiled into an EndNote database and abstract were reviewed. Those relevant to the topics of ‘leadership in medicine’, ‘leadership in obstetrics and gynaecology’, as well as ‘solutions to the gender leadership gap’, were read in full. Those articles fulfilling the considerations of robustness (validity and reliability) and applicability were included (148).
Leadership in Medicine
Where are the barriers to leadership?
The earliest level of leadership in medicine begins in medical school. Within this student setting Wayne et al found that when leadership opportunities arose, fewer female students volunteered to become leaders (149). This gender bias was eliminated after implementing interventions, suggesting curriculum reform could increase female student leadership. Limiting the generalisability of this study was the inclusion of only first year students, with the study’s strength in its explicit methodology, structured approach, and reproducibility. Further research in the area would benefit from investigating whether the leadership gap persists through all levels of medical school or self-corrects over time.
At medical specialist level a number of barriers have been identified for women desiring medical leadership (47). Van de Brink notes ‘gender practices’ are common barriers for women seeking leadership (150). These include: exclusive ‘male’ network practices, the view of women having lower levels of leadership commitment, and perceived ‘less appropriate’ leadership styles. This study did not address the question of ‘leadership desire’ among responders. Setting the scene with this would allow the reader to acknowledge the relevance of barriers for female specialists seeking leadership. This was subsequently addressed by Pololi et al. In this large and systematic study on leadership aspiration, male and female specialists held equal levels of leadership aspiration (115).
At an institutional level Dannels et al surveyed US and Canadian medical school deans on organisational culture and policies regarding women in leadership (151). Acknowledging the increasing gender equity in ‘mid-level’ leadership positions, their findings supported previous reports that ‘time alone’ was not sufficient to ensure advancement of women to ‘senior leadership’ positions. Instead intentional strategies, not just a ‘critical mass of women’, must be considered within organisations, if leadership gender equality is to be achieved (152-154).
What are the barriers within leadership?
There are many historical justifications for the gender leadership gap in medicine including: (i) not enough women or women not staying in positions long enough to reach leadership roles (‘pipeline argument’), (ii) women not seeking leadership positions for family reasons, and (iii) women being less likely to be ‘natural’ leaders. All of these have been refuted in the literature as being inaccurate representations of the barriers to leadership (155-157). Instead many examples of ‘glass ceilings’, ‘leaky pipelines’, and ‘sticky floor’ barriers remain for female specialists seeking medical leadership (15, 29, 30, 34, 91, 158), with these and many other studies reinforcing the existence of reversible gender leadership barriers. Included in this is the study by Bismark et al (97). Here 30 medical practitioners in leadership roles were interviewed in an effort to identify preventable gender-related barriers (including internalised, interpersonal and structural elements) for women seeking leadership roles. Although limited by a small sample size, this study yielded similar results to that of Yedidia and Bickel (159), with each identifying reversible gender leadership barriers.
Once in leadership positions, the literature reveals female medical specialists are less likely to advance at the same rate or receive equitable financial compensation for their leadership role (160-164). This gender pay difference remains even with adjustments for age, experience, speciality, hours worked, academic rank, measures of research productivity and clinical revenue (165). Although some of these studies are limited by financial self-reporting, there is no evidence of systemic gender-related inaccuracies. Those with objective measures are strengthened by their robust methodology, standardised approach and reproducibility.
What solutions exist for leadership equality within medicine?
Within the United States, the Association of American Medical Colleges (AAMC) began assessing the landscape for women in academic medicine in its first step towards challenging institutional gender leadership inequality (166). Gathering data from public documents, the AAMC explicitly detailed the leadership gender gap of the world’s largest medical population, and subsequently stipulated compulsory curriculum strategies aimed at addressing this inequity (113, 167). Although ‘top’ leadership positions remain male dominated, many medical institutions, having adopted the AAMC strategies, have now achieved proportional gender leadership representation (168). Building on the AAMC report, Valentine and Sandburg subsequently published their ‘ABCC solution’ aimed at improving leadership opportunities for female specialists in medicine (169). Their paper highlighted the benefit of an individualised framework to support successful careers, family responsibilities, and personal interests (170). By challenging the traditional ‘ladder system’ to leadership and re-culturing the workplace, Valentine and Sandburg anticipate a 2020 50/50 leadership gender balance within institutions adopting their program.
More recently Spalluto et al (171) published the results of their LIFT-Off program (31). This program, designed to improve understanding and opportunities for women seeking leadership within radiology, showed a statistically significant improvement in access to faculty development and advancement opportunities, as well as improved clarification of expectations about the path to career advancement. With only a single faculty involved and only a 1-year follow-up data the study has many limitations, but does create a low cost and potentially sustainable educational model for other medical departments seeking solutions to the leadership gap.
In summary, the literature on leadership in medicine suggests women face barriers from medical school, through to specialist practice. Reduced levels of perceived capability, capacity and credibility are amongst the barriers women may face when seeking medical leadership (97). Both medical schools and some specialist colleges (113, 171) are promoting interventions to achieve gender leadership equality.
Leadership in Obstetrics and Gynaecology
O&G leadership in Australia
Very little has been published on gender leadership equality within O&G in Australia. The first publication came in 2010, when the first female professor of O&G in Australia documented her journey from student in 1967 to specialist (172). In a stimulating piece, Professor Caroline de Costa reflected on being one of only seven female specialists amongst ‘several hundred’ male specialists in the early 1980s. The second publication came in 2012 with the publication of de Costas’ RANZCOG annual scientific meeting oration. With females making up 80% of trainees but only 14% of the RANZCOG board, she highlighted the gender leadership inequality, and discordance between female membership and leadership (173). Despite further feminisaton over the last five years, this statistic persists today (9). Although no other author has directly addressed the O&G gender leadership gap in Australia, the international literature is growing (10-14, 19).
O&G Leadership Internationally
The international literature, predominantly out of the United States, provides a broader insight into the trends and barriers to female in leadership in O&G.
One of the earliest publications on the feminisation of O&G and gender leadership gap came from Vicki Seltzer (10). Published in 1999, this article reported on 25 years of data on the gender landscape of O&G in the United States, revealing an increasingly feminised specialty, but ongoing gender leadership gap. This article provided a comprehensive reflection on the many overt, often unintentional inequities that exist for women in O&G, with the articles greatest strength the many suggested solutions to minimise gender leadership inequality. These included supervision and mentoring, providing childcare facilities. and ensuring gender diversity on committees, with most remaining relevant today.
In an article published by Wise et al in 2003, O&G faculty from Canadian medical schools were invited to participate in a questionnaire on academic promotion (11). Responses in this study revealed; women were less likely to be promoted to professor, were more likely to perceive promotion barriers, and ranked mentoring as the top solution to the gender leadership gap. Strengths of this study included the explicit and transparent methodology, the standardized approach, the high response rate, the matched gender distribution of responders and wider membership, and the study’s reproducibility.
In 2015 Hofler et al investigated gender and leadership in O&G academic departments within the United States (12). Their findings revealed a clear gender leadership gap, with males holding the majority of leadership roles. Within leadership female specialists were more likely to hold ‘educational leadership’ roles, with males holding more traditional ‘head of department’ leadership positions. Strengths of this study were the transparent and reproducible methodology, as well as enormous breadth of data revealing the gender leadership gap within O&G in the US. In 2016 Hofler et al went on to compare the O&G leadership gap with other medical specialties within the United States (13). Here they found women were significantly under-represented among department chairs for all medical and surgical specialties. Despite O&G experiencing one of the largest feminisations over the 23-year period, the ‘pipeline’ of females entering the specialty in residency in 1990 had not resulted in the expected gender leadership diversity.
Most recently Ricciotti et al (14) published results from a cross-sectional observational study outlining the gender of department-based and educational leaders within O&G across the United States. This 2012-2013 snapshot of the gender leadership landscape revealed an underrepresentation of females as fellowship directors, a proportionate representation as residency program directors, and overrepresentation as medical student clerkship directors. A geographical variation in leadership was noted, suggesting a possible cultural variation in gender views and leadership. As seen previously (174), this study again noted the overrepresentation of women in medical ‘educational’ leadership roles.
This more focused review of the literature on O & G leadership is limited in number, but does provide evidence that O&G is not dissimilar to many other medical specialities with regards to the gender leadership gap. The authors within this cohort provide some insight to the barriers and potential solutions to the gender leadership gap, but none have addressed this within the speciality of O&G.