Women comprise half of the scientific and medical workforce, yet still hold a minority of leadership positions. Here I discuss the barriers to gender equity and offer a new approach to address the problem.
Gender inequities in science and medicine have long been on the institutional radar, culminating in the 2018 report from the National Academies entitled Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine (1). This study found that harassment was so serious that it held women back in their careers; the report also listed five factors that create conditions for harassment in science and medicine: (i) perceived tolerance for sexual harassment, (ii) male-dominated work settings (men in positions of authority with women in subordinate positions), (iii) hierarchical power structure, (iv) symbolic compliance with Title IX and Title VII, and (v) uninformed leadership that lacks intentionality and focus on gender equity. The damaging effects of harassment and gender bias cannot be denied or ignored if we are to achieve the equitable workplace we need and stop wasting talent. My research focuses on gender, but making systemic gender bias visible sheds light on other forms of discrimination as well. The solutions required to deal with gender bias have a wider applicability to addressing the experiences of other underrepresented groups.
As of now, gender bias of all kinds continues, and it can be easily seen and measured in the second point on the report's list—lack of women in leadership positions in academic medicine. It has been assumed that the “leaky pipeline” of women moving up in their career paths will gradually change all by itself, but numbers do not lie, and that myth has been disproven: Those numbers have not changed even though for decades at least half of the graduates of U.S. medical schools have been women (2). A 2020 article in The New England Journal of Medicine with lead author K.P. Richter finally blew the “wait and see” argument out of the water (3). Although most reports have simply counted the number of women leaders, Richter and her team controlled for the number of women in the field—the actual number of potential candidates. They found that over a 35-year period, women physicians in academic medical centers were less likely than men to be promoted to the rank of associate or full professor or to be appointed to department chair, and there was no apparent narrowing in the gap over time. As the National Academies report notes, moving women into leadership positions is an important part of systemic transformation; if harassment and bias are reasons why few women advance to leadership, then removing obstacles to women's advancement is where intervention must happen.
In order to understand what stops women from moving up the ranks, I carried out an Institutional Review Board (IRB)–approved study where I interviewed, in person, more than a hundred women and men in academic medicine and analyzed what they said about their experiences. This qualitative research shows how gender bias functions at the ground level and how it holds women back. The detailed descriptions of women's experiences are shocking, but they also offer promising ideas about how to intervene. This article reviews the scope of the problem of lack of female leadership and suggests specific remedies for challenging the culture of gender bias in the moment when it happens.
THE “LEAKY PIPELINE” DOES NOT EXPLAIN THE PROBLEM
According to the National Academies report, more female leadership would constitute a key systemic change. The numbers show, however, that many women are leaving academic medicine rather than moving up into leadership. Not surprisingly, being harassed diminishes job satisfaction; moreover, when individuals report harassment (which they rarely do), they note that their experiences are minimized or normalized, and those they tell do nothing (inaction) or the women are retaliated against. Even the few women who do make it to top positions often find that their effectiveness is limited by sexism that operates insidiously and often invisibly.
In other words, simply waiting for women to mature into viable candidates for these positions will not work if we ever hope to see a proportionate number of women leaders. As of this writing, there are only seven women directors (one of whom is “interim”) of the 71 NCI-designated cancer centers in the United States. Internationally, the data are no more promising. Clearly, more active intervention is required to remove the gender bias that holds women back.
WHY DIVERSITY, EQUITY, AND INCLUSION POLICIES HAVE LIMITED IMPACT
Most institutions have acknowledged the need for change by developing diversity, equity, and inclusion (DEI) policies and initiatives to enhance diversity, but these policies are not working as planned. As previously noted in a 2020 “Science and Society” piece on racial diversity in academic medicine, diversity policies are necessary but not sufficient, because they do not address the kinds of daily examples of discrimination that I discuss here in relation to women (4). Systemic bias is intersectional: Overlapping bias based on gender, race, ethnicity, sexual orientation, etc. intensifies the overall effects of discrimination. Most publications to date point out the tension between discrimination and harassment policies that idealize equity and ignore the reality of the experiences of women and communities that are underrepresented in medicine (UIM).
One common approach to increasing the diversity of leadership is to require that a specified number of search committee members for these leadership jobs are women and/or individuals who are UIM, with the expectation that diverse committees will identify diverse leaders. Institutional administrators and professional search firms may also explicitly instruct search committees to identify women and UIM candidates and highlight the role of implicit bias to mitigate its impact during the search process.
Yet even when such policies are in place, men are still more likely to get the position. Many women I interviewed felt that they were considered in searches simply to allow the institution to “check the box” and believed that their candidacy for a top job was never taken seriously. It is easy to follow the letter of those policy requirements without having an intention to follow the spirit.
It is important to acknowledge that gender bias is not restricted to men. As the ingenious study performed by Moss-Racusin and colleagues nearly a decade ago showed us, women scientists were as likely as their male colleagues to offer a lab manager job to “John” rather than “Jennifer,” even though the two curriculum vitae were identical except for gender (5). Gender bias is clearly complex and deep-seated for many of us.
The lack of change since the National Academies report was published makes clear that outrage and institutional policies alone are not working effectively to address the problem. We need a new kind of intervention to recognize and deal with what is happening all around us, every day—we need a new way to end bias.
WHAT REALLY HAPPENS: QUALITATIVE RESEARCH
In early 2019, I embarked on an IRB-approved, qualitative research study to better understand the underlying factors that result in the persistent underrepresentation of women in leadership positions in academic medicine. I traveled around the United States and carried out in-person, recorded interviews with 52 men and 52 women at 16 different academic medical centers. I intentionally selected institutions from different regions of the country, including public, private, top-tier, and lower-ranked institutions. Although each university hosts a unique culture, I did not hear any substantive differences from interviewees across institutions. I concluded the study when I no longer heard new themes emerging from the interviews (this is known as saturation). The majority of individuals interviewed were full professors (64%), although men were more likely to have achieved this faculty rank (71% vs. 58% of women interviewees). Over half held a leadership position (57%), although more leaders were, of course, men (36% of men vs. 23% of women interviewed were deans, department chairs, or center directors).
I spent 2020 analyzing the results, and to date we have published three articles in the peer-reviewed literature focused on gender differences in mentoring, women's experiences with promotion and tenure, and men's and women's views on gender inequities in professional networking (6–8). This research demonstrates that one of the most insidious and ubiquitous forms of gender bias is the expression of outmoded gender stereotypes that designate women as less qualified or worthy than men. This double standard—rarely recognized or acknowledged—means that men and women are judged by different measures, a practice that disadvantages women at every turn and also makes a mockery of the claim that medicine and science operate as a meritocracy. But when we look at examples of this double standard, we see not only an expression of implicit bias but also an opportunity to challenge it and perhaps change the system. We cannot address systemic bias unless we can make it visible, but when we choose to call it out in the moment it happens, we can make a powerful intervention. That is what I describe in this article.
Women Are Assumed to Be Less Capable of Holding Power than Men
The interviews yielded many examples of women being judged on qualities that had nothing to do with their resumes. One woman described how the leadership position she was interviewing for about a decade ago was spontaneously downgraded during her interview! She said, “I was interviewing for the director of the cancer center at [X], and the dean decided during the interview that he was interviewing me to be the associate director for basic research.” Two other women learned during their interviews for leadership positions that the job had already been offered to someone else from outside the institution. In addition to being disappointed, they felt “humiliated,” and one woman left the institution shortly thereafter. When a different woman did not make the final cut for a department chair position, she was given this feedback: “‘Don't ever show up to an interview with a backpack.’ I was supposed to have a purse or a briefcase.” Comments about women's appearance or dress are signs of the double standard; they are rarely applied to men.
A female dean who works at an institution where the hospital president is also a woman reported, “In a meeting, we were discussing the challenges of recruiting women to leadership positions. A [male] department chair said, ‘Women just don't want to be leaders.’ I'm in the room, and the hospital president is there too. We're both his boss, and he said that. And nobody said anything in response.” This man's bias was freely expressed and not challenged despite its obviously faulty premise.
When women did become leaders, they often found that their power was diluted compared with their male peers. One woman was recruited to a leadership position where her predecessor scooped up most of the resources when he advanced to a more senior role at the university; she told me, “I'm not exactly the boss, ‘cause he's the boss.” As she had spent the funds given to her when she was hired to recruit and retain faculty, she stated, “I've used my package, so the power will either be refreshed or it won't.” About a year after our interview, she left the institution. In another instance, a woman department chair was asked by the human resources (HR) director “to do a personality test when I arrived…they told me it would help me become a more effective leader.” But she was taken aback by the critiques they offered about her style and personality. Only later did she learn that two male chairs hired around the same time were not put through the same process, and she concluded, “One of the biggest enemies for women in power in academia is HR.” But because HR is charged with ensuring compliance with institutional DEI policies, what is a woman to do when she is subjected to gendered scrutiny?
Over and over again, the women I interviewed related stories of making a point in a meeting, being ignored, and then hearing a man make the same point a few minutes later to great acclaim. Is the woman simply not worth listening to?
Women Are Expected to Embody Old Stereotypes of Femininity
Several women described their experiences serving on search committees for leadership positions where it was clear to them that women candidates were assessed differently from men. One woman (a full professor) described being on a search committee for a department chair: “It was shockingly eye-opening to me. The person who got the job [a man] was not even on the committee's radar screen; he got on the list because the CEO insisted. In addition, women were asked questions differently from the way men were asked questions…in all instances, the issue of the woman's capability was called into question.” Another woman (an associate professor) said, “The chair of the search committee criticized the woman finalist as not being ‘warm and fuzzy,’ but the personality of the man who was offered the job was never discussed.”
Neither of these women on the search committee spoke up at the meeting. The full professor found that other women on the committee weren't upset, so she said nothing. The associate professor felt too intimidated, saying, “I work with these people and didn't want to be labeled as ‘difficult’; it was just easier to go along.”
The “warm and fuzzy” requirement came up again and again in the interviews, often couched in terms of a woman having “sharp elbows” or being “too abrasive” to be a good leader. The problem is not women's ability to lead, it is men's (and sometimes women's) unwillingness to be led by women. One man told me how he advised a female division chief in his department to soften her edges because she “clashes” with strong (male) personalities: “We tell her, ‘You can't say certain things, even though you're a woman; you shouldn't say, “That was a stupid idea,” even if it was a bad idea—instead you could say, “I would think about it differently.”’ We've tried to rein in some of that, so others don't feel like she's exerting too much authority over them.” He acknowledges that men are uncomfortable with this woman but cannot quite see how he is actually circumscribing her authority. Where a man would be seen as authoritative, the woman is viewed as authoritarian.
The Stigma of Motherhood
Many interviewees, both men and women, recounted experiences that reveal the intensity of the double-standard mentality around motherhood. Some women spoke about being ignored, passed over for opportunities that could advance their careers, and denied resources that were offered to their male colleagues (even those who were less accomplished) because they were mothers. In contrast, many men in leadership positions believed that they acted fairly and saw the paucity of women leaders as a result of a woman's decision to prioritize family over career. They assumed that this was a freely chosen decision, “natural” rather than problematic, and therefore not their responsibility. The claim that a woman who has children can no longer be expected to devote herself to her career seemed to require no further thought from those who expressed it: The gender stereotype that women should be the primary caregiving parent remained unexamined and unchallenged. Nor did male leaders consider that family-friendly policies might ease the caregiving burden for parents of both sexes.
One woman reported that when she had her third child, her chair said, “You have too many children—being a mother will hold you back.” Yet her male peers seemed to advance regardless of the number of children they had. Another woman recounted that when she told her chair that she was pregnant, he responded “I think very highly of your work ethic, but I don't want it to be a precedent that it's okay to have children during residency.” It was clear that the ban on having children during training only applied to female residents. Another woman was told by an institutional leader, “‘Science is hierarchy, and you shouldn't aim for the top because you're a woman, and you have kids.’ When I pointed out that my successful mentor had kids, he said, ‘Well, his wife stays home with them.’”
The burden of motherhood was often referred to obliquely: One male department chair seemed truly baffled about why women leave academic medicine but speculated that it was due to women not being willing to work “crazy hours” for little money doing research after clinical training. He said, “That is the critical window. It happens obviously when people are having families, when people want some flexibility in the lab; no matter what policies we put in place, if you take 6 months’ leave, the field moves on and not being in the lab affects that, even if we support that however we want.” The suggestion is that that women with children cannot participate in that important career moment, so it is no surprise that their careers are limited. Yet of all the women I interviewed, not one said she did not want a leadership position, and few of them saw having children as an obstacle.
These anecdotes highlight that despite clear institutional policies designed to recruit and advance women, people's perceptions of gender roles covertly (and sometimes overtly) impede a woman's appointment to leadership positions. Even when they are advanced, women continue to be stymied by gendered expectations and power grabs. Not only do policies alone fail to address the problem or create change, they illustrate an overt institutional commitment that is blind to the daily experiences of many people who work there. This is why top-down institutional DEI policies have not been sufficient to address bias.
NEW INTERVENTIONS TO CHALLENGE THE STATUS QUO OF GENDER BIAS
As the stories I heard from the interviewees illustrate, implicit bias works on a very mundane level, and that is where we can intervene more effectively. One key to fixing problems is recognizing them when they appear and responding immediately. In the words of the late John Lewis, “When you see something that is not right, not fair, not just, you have to speak up.” Challenging bias in the moment it happens has a number of advantages:
It makes visible a pattern that has been denied and thus helps women realize that the problem is systemic rather than individual; this makes it easier for women to speak up.
It encourages people to reflect on their own implicit biases, which they may not have recognized.
It prompts a reexamination of a potentially biased decision, such as the decision to hire a man over an equally qualified woman.
The ability to call out bias publicly depends on one's place in the hierarchy. Anyone can initiate a one-on-one conversation with a more powerful person, asking politely for clarification of a problematic comment. Those who have more power and job security can safely challenge bias publicly, in the moment. We need both forms of response. Private conversations encourage mindfulness and reduce defensiveness; public responses may make people uncomfortable, but they are necessary to create a new community culture. Namely, a culture in which people can speak up without fear of retaliation and where there is education around respecting everyone's point of view.
Change requires awareness. One man I interviewed, a center director, waxed eloquent about how his wife is silenced or minimized in her departmental meetings, stating, “I've been sensitized to the situation because of my wife.” However, when I asked how he handled it when one of his female faculty suffered similar indignities, he stared blankly and said, “I have to say I have not seen that, so it either hasn't happened or I've been oblivious.” Simply asking him that question in the interview prompted self-reflection that may affect his awareness of gender dynamics at his next meeting. However, it is stunning that he was unable to make the connection between his wife's experiences and those within his own department.
Experiences of empathy can go a long way. One interviewee shared a strategy where women and men were in a group training experience, and the men were charged with reading out loud the women's written experiences of discrimination and harassment. “It was heartbreaking. Saying the words out loud, publicly—it was horrifying to know that this is what women experience.” This is a particularly persuasive way to make the effects of bias visible.
What we need is a language, a lexicon, that allows us to talk openly about what happens, when it is happening, so we can develop consistent practices to mitigate discrimination and harassment. Our best way out of this quagmire is to develop strategies to respond as soon as someone says something that reveals implicit bias. It may be difficult, but if the biased culture of academic medicine is to change, we have to get more comfortable with feeling uncomfortable. We need both the language to talk about bias and a “space” where that bias can be discussed without fear of retaliation.
As we work toward normalizing these conversations in our professional venues, we can leverage the power of social media as an important tool for change. Increasing awareness and uplifting one another and our communities matters.
No disclosures were reported.