Podcast: Gender equity at the senior leadership level
Transcript
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Kirsten Patrick Medicine has an inequity problem especially at the senior leadership level. The factors and causes are complex, although well documented, despite our understanding of the size of the problem actually getting to gender equity is tricky, although it's important, not least, so that we can optimize creative problem solving of complex problems in the health system. I'm Dr. Kirsten Patrick, executive editor for the Canadian Medical Association Journal. Today I'm talking to Professor Andrea Tricco and Dr. Ainsley Moore, two of the authors of an analysis article, that outlines practical ways of advancing gender equity in medicine. The article is published in CMAJ. I've reached Andrea in Toronto and Ainsley and Hamilton. Welcome to CMAJ Podcasts.
Andrea Tricco Hi, thank you so much for having us. It's a real pleasure to be here today.
Ainsley Moore Hi I'm Ainsley and it's a pleasure to be here. It really is an honor and privilege to share with you today and your listeners.
Kirsten Patrick So I'd like to start off with each of you telling our listeners a little bit about who you are. Andrea?
Andrea Tricco My name is Andrea Tricco, and I'm a scientist at St. Michael's Hospital at Unity Health Toronto. I'm also an associate professor in the Dalla Lana School of Public Health at the University of Toronto, and I've been conducting research within the gender equity realm for the last couple of years.
Kirsten Patrick And Ainsley?
Ainsley Moore Hi I'm Ainsley. I'm a family doc. I'm on faculty with the department of family medicine as an associate clinical professor of medicine at McMaster University. I also serve as vice chair on the Canadian taskforce on preventive health care. And I am passionate about women's health, reproductive health and reproductive health rights.
Kirsten Patrick It's great to have you with us today. So let's go ahead with deconstructing this article for our listeners. Andrea, there've been other recent articles calling out the problem of gender inequity in medicine. Can you explain what your goal was in writing this particular article?
Andrea Tricco Yes, absolutely. So before I begin describing that, I do want to mention that gender is a multifaceted concept. And usually when we think about gender, traditionally, it has been more from a binary perspective. So we usually think of it as male and female. And most of the research is focused on the the binary division for gender. However, we want to note that gender is not binary. And so it's actually a continuum. So so just to note that, something important for us to keep in mind when we're reading the article, in that we were talking about their research and is very focused on male versus female. However, when in real life, gender is actually not binary, in terms of the goal for the papers. So basically, what we wanted to do is we wanted to summarize some of the excellent research that has been conducted on gender and equity within medicine. And the focus that we wanted was to focus on the solutions because we wanted to share these solutions with those working in the field. So we wanted to bring a bit more attention to the issue. However, putting the real appreciative lens on it, and then really focusing on what can we do now.
Kirsten Patrick I think it's always a lot easier to describe the size of a problem than to think about how do we solve this problem. So I think this article is great from that point of view. It gives lots of practical ideas of what we should actually be doing to solve the problem. Ainsley, what is the scale of gender inequity at the leadership level in medicine?
Ainsley Moore Yeah, it is easier to think about scale and size than to get at the nuts and bolts. But thinking about the scale, or the scope of the problem, you can think about how entrenched a problem is, how far back what the historical roots are, and you can look at how wide spread or what the breadth of a problem is. Looking back historically, you know, we know that that women have outnumbered men in Canadian medical schools for well over a quarter of a century now, but as, as you mentioned, Kirsten, our Canadian studies consistently identify these gaps in medical leadership not only in research medical leadership, but also in clinical leadership and medical education. And a really good example of the scale, when you look at the last 150 years of the Canadian Medical Association, there have only been eight women presidents out of 152. So that's just kind of a snapshot picture of the history of the depth, that if you look at medical education, it's even more entrenched, resistant to change. So look at the upper levels of medical education training, the first woman dean of a faculty of medicine, it took 117 years to get there. And it didn't occur until 1999. Considering there only been a total of eight out of 152 deans and that's... to think about when medical schools were established in Canada, so that's over 170 years ago, there have only been eight today so far. There's other metrics, so if you look at these these metrics that are key to achieving leadership success. So in thinking about the problem that way, there's a really interesting study from 2018 that looked at presenters at medical grand rounds in two Canadian cities, institutions, Toronto, Calgary, and what they found was that there were substantially fewer women presenters at these medical grand rounds, well below what you'd expect, well below that proportion that I talked about a female med students and residents in the program. And so the talent is here, the problem here is that medical grand rounds, as we know, they are opportunities. You showcase your research, you're presenting your expertise. And your identify yourself as a resource. Those metrics are key, because they're important outlets for recognition. They're the materials that we use and measures that we use as we submit our applications to go forward for tenure and promotion. But the other problem is, you know, grand rounds are opportunities for role modeling, and for connecting to others. So that's an important gap. The other like critical gap that sits connected to leadership success relates to national research funding competition. So this happens at both the scientist level as well as the project level, there's again, a big gender gap in terms of who is successful with those grants. And of course, that feeds the whole, the whole machinery, grants, publications, supervisees, in strength of your CV and your application to move forward in the Senate, with tenure. I mean, those are some pictures or glimpses of the scale of the problem. We know there's gender gaps in pay in Canadian medicine. But that's not specifically, you know, identifying leadership gaps. Although they're connected.
Kirsten Patrick It's great to have those snapshots because what you're saying is this is not a minority problem. This is a problem where women are now equally represented within the whole medical workforce. They're just not rising to the levels of leadership on the whole that men are. Andrea, in the article, you talk about the importance of considering the intersection of gender and race, when evaluating inequity. Can you explain what you mean by that?
Andrea Tricco Yes, absolutely. So what researchers have found is that focusing on gender is not enough. So we have to go beyond gender. And we have to actually consider all facets of people's lived experiences. And in order for us to do this, we have to look at all the factors that one would go through in their lives. And this is helpful, because it can help us to understand the root of the problem, and for us to identify potential solutions. So So in particular, we do need to think about and focus on the intersection with the systems of power and privilege and oppression, these need to be considered. So in any research relationship, or within any organization, we have these informal and sometimes formalized systems of power, as well as privilege and oppression. And until we fully understand this and understand what goes on, you know within relationships and within organizations, we can't bring about change. So so consistently, within research, we found that inequities are further increased when gender intersects with other factors. And a good example is race is because if we think about race, racialized women as an example, they experience challenges and and actually in an exaggerated way, and this has actually been termed a double jeopardy of race and gender bias. So unfortunately, when we have gender combined with other factors, it actually exacerbates the problem. So until we understand the intersectionality, and understand all these factors very, very well, we won't be able to get to those solutions that we really need to move things forward. So one example would be the systemic and structural issues of racism, this would actually contribute to racialized women who would experience more significant poverty as a child as well as an adult, and they would experience more financial hardships, or the death of a spouse as well as looking after aging parents. So again, when we see gender is intersecting with other factors, it just exacerbates everything. And we won't be able to fully understand this until we look at the whole entire picture. So we need the context, in order for us to to move forward. Unfortunately, the issue is that we often don't collect intersectionality data, we don't collect it very well. So so that's a problem in the primary studies. So when we look at the medical literature, not only is it being collected in the primary studies, but then if we're trying to synthesize it, so I do a lot of work within knowledge synthesis as an example. So if I want to do a systematic review, it's very challenging for me to look at intersectionality, even though I would like to, because it's never been fully reported in the primary studies. And so not only with that, we don't collect a report on the data within our organizations. So we don't know the extent of the problem. And meaning that we can't really address it. So until we realize the importance of this, and until we are committed to collecting data on this, we really won't be able to get to those solutions that we we desperately need within medicine.
Kirsten Patrick So it seems to me that you're saying that even though I was saying, Oh, it's easier to outline the size of a problem than it is to outline the solutions, it's actually not always easy to really get at the size of the problem, because the problem is complex, and we don't collect the right data to be able to sketch it out. It also sounds like you're saying that some that we need to look at this in a in a kind of an individual way. So it's not a one size fits all solution to getting to equity in medicine, it's more like we need to understand the particular challenges or hurdles or whatever that individual women face and, and help them to overcome those. Ainsley, where do you think the problem starts with gender and equity? What contributes to this gender inequity in leadership roles beyond what you've already highlighted?
Ainsley Moore So probably it's going to help to just go back for a minute and think about gender norms and clarify that concept. So gender norms are society's expectations, assumptions about how men, women, boys, girls behave in it, you know, their assumptions about all aspects of life, how we communicate dress, what roles we take on what we're expected to take on. And it defines dynamics within relationships. And, and so these determine life trajectories, they determine employment opportunities, advancements, etc. And so think about where it starts, that's a good place to sort of recognize that. But another main recognition that's key to figuring out where this starts is to think about gender equity as a fundamental human right. And gender equity is really a process. Gender equity gets you to the outcome, it gets you to gender equality. And that's equal treatment in all aspects of society without discrimination. So where does it start? It starts early, starts in childhood, and all the influences that we're exposed to in our lives. But it becomes exacerbated as we move forward. And, and certainly we see that in medicine, the systems supported by gender norms, perpetuate and continue differentials, gaps in gender and leadership. So it starts with society, but it's perpetuated by our systems and our structures. And these are, these are the systems and structures that are in place in medical education, medical practice, as well as academia. The higher you go up in the leadership ladder, the greater the inequity becomes. There's only 24% of full professors in medicine that are women. Andrea mentioned how gender intersects with race and culture that further exacerbates those challenges higher up. The systems are in place and they reward metrics that just don't favor the capacity that don't favor currently, women in positions trying to get to higher levels of leadership. We know that women face disproportionate exposure to disruptive behaviors and harassment, and those serve to entrench existing power structures. It's pretty challenging to come forward with concerns. It's easy to put your head down and just keep going. And it's easier to not expose yourself to more risks as you as you advance in your career. And so there's another level of this, like we've understood exposure to macro level, disruptive behaviors and the impact they have. But there's a new fledgling area that's looking at microaggressions. And these are interpersonal or private level interactions that really reflect sort of micro invalidations micro insults. They're indirect, they're more subtle, but they're expressions of judgment and prejudice, and they're different, they're constant, they're insidious, and they have an impact on whittling away in turn, you know, self esteem. And they can serve to limit women's interest in being hired or going forward for a promotion, as well as competence in going forward. So it means the way the system values work, care. If you look at the gender pay gap, the specialties that women tend to dominate psychiatry, pediatrics and family medicine, those are at the lowest end of the net income scale. And, and male dominated specialties, like cardiology, diagnostic radiology, ophthalmology, they're disproportionately much, much higher income generating specialties. So, you know, it's how the system rewards work. There's a lot of factors, I'm just hitting on the high level ones that are impactful and easily to communicated.
Kirsten Patrick You're talking about things that are set up at the system level, that kind of impede women's progress in medicine. And so it strikes me that the way that we work towards gender equity will be about dismantling some of those structures or changing them. Andrea, what are some of the ideas that you've put forward in the article that you'd like to highlight for listeners about how we actually practically gets to gender equity in medicine?
Andrea Tricco Yes, completely agree. And it is not about women leaning in, as you're alluding to, as well, as well, just repeating what Ainsley mentioned that, you know, this, this issue is very, at the very highest level in all levels. And definitely, we need structural changes to occur. So we're not asking women to lean in here, it's more about breaking down structural and cultural barriers, and men need to be involved. So actually, everyone needs to be involved, society needs to be involved, for us to actually see some of these changes. So as we mentioned earlier today, we need solutions that are contextualized to multiple levels. So we need to think about the organizational level, we need to think about the team level, we need to think about the individual level. So in order for us to see the gains and the changes, it's really a focus on holistic and multi faceted solution at all levels of medical organizations. So as you mentioned, we did bring up many, many different interventions in the article and potential solutions. And we're not saying that one approach is better than the other, we feel that our range and multifaceted and holistic approach would be best. So beginning with thinking about the quantification of the problem. So unfortunately, as we said, sometimes we may know information on gender. But oftentimes, it's just binary. It's not all the genders. And also oftentimes, we don't have any other additional intersectionality data. So we don't have the intersection of gender and other factors, as we mentioned previously, such as Indigenality as well as race, as big examples. So we need to have an idea of what the problem actually is. And unfortunately, this hasn't been a real focus until recently. And we just don't have the data. So it's hard for us to make a very contextualized solution when we don't know the extent of the problem. So we're suggesting that we have annual reporting on a very basic minimum on gender as well as intersectionality. And this is a good start, because it can help to increase the awareness of the issue. However, that is not sufficient on its own. And unfortunately, when you look at the literature, most of the interventions that have been researched or studied, have focused on increasing awareness and so increasing awareness is actually not enough. It's just the tip of the iceberg. So we need to go much, much deeper. So we need to think about things such as career flexibilities, so thinking through non gendered parental leave schemes as an example, how do we increase the visibility recognition and representation. So building off of some of the issues that Ainsley was mentioning previously. So how can we provide all genders with opportunities for presenting at medical grand round as an example? How can we give them opportunities to speak with the media, right? So we're seeing during COVID, I'm seeing a lot of my male colleagues in the media, and I'm seeing a lot less of my female colleagues as an example, how do we highlight the achievements of everyone? How do we provide opportunities for everyone? And also thinking through about opportunities for mentorship and sponsorship, so thinking about formal programs where we link up mentors, with mentees? So this is something that my Institute has been thinking of and been working on in the last couple years as an example, because having a mentor is so important within academic medicine, and within medicine, so having a mentor will help. And how do we make sure that we have equal opportunities for all genders to have supportive mentorship as well as sponsorship, which goes beyond mentorship, and it really is important. Other examples would be something like financial support. So there are some national funding bodies internationally that have come up with these lotteries. Instead of doing the whole peer review process, they actually run a lottery. And so you were randomly assigned to whether your grant is successful or not. This is a way because as Ainsley alluded to, as well, before, with our Canadian Institutes of Health Research, we looked at the grants and researchers have found that there is some gender bias in the scientists that are funding as well as at the project level. So when we do this kind of lottery, what happens is, the attempt or the focus is to try to reduce the potential for gender bias that may occur. And hopefully, we're moving towards more behavioral and systemic changes. So thinking about role modeling, modeling equity principles, by leaders of all of our organizations, seeing more different diverse leaders there that can be role models, having diversity in our hiring panel. So making sure that not only is everyone aware of the processes and aware of the potential biases that can happen when we're selecting candidates for organizations, but making sure that our panel themselves are diverse, so that people can relate and feel welcome and feel safe. And also so that we are able to hire diverse candidates. Oftentimes, when they've done research into this, they find that like, tend to hire like, right. So I hire this person, because I can relate to them. And I see myself in them. So it's very important for us to make sure that we have hiring panels that are diverse. One example that I did want to highlight today is the Athena scientific woman's academic network, or the SWAN, Athena SWAN initiative. And this one is very multifaceted, and they include several different interventions. So some of the examples would be things like monitoring and looking at different statistics and looking at the issues over time, career transition planning, they also have items related to flexible working. And there's also a big focus on organizational and cultural changes. So the Athena SWAN initiative is something that has actually gained great popularity around the world and was being worked on in here in Canada as well. And when they have evaluated it has found some good outcomes such as increased satisfaction of different genders, and in particular women. This is focused on a woman's initiative. So it has been shown to increase satisfaction, which is great. However, one limitation that has been found with Athena SWAN is that the people who tend to be the main beneficiaries of this program are white and middle class women. So we believe that the Athena SWAN initiative is fantastic. And it definitely is bringing us further along, however, it is not sufficient on its own. And again, we need to get back to the intersectionality focus again and thinking about how can we make sure that everyone wins. And how can we make sure that we provide equal opportunities to everyone, regardless of your gender, regardless of your race, Indigenous status, disability status, regardless of any of those intersectionality factors, we want to make sure that everyone is being provided with equal opportunities. Hopefully, this will lead to equal satisfaction in the workplace. And also, as we discussed in the article, you know, we do believe that having diversity does help. And you know, we've seen that female representation for example, on corporate boards, or as well as hospital boards, it can result in more thoughtful decision-making as well as less corruption. And also there have been many studies showing that women who are physicians, they actually provide high quality patient care. And in particular, they, some research has found that it led to better quality of care for diabetes, lower rates of mortality, hospital readmissions, emergency department visits, etc. So it's definitely needed. We need gender equity in medicine. But not only do we need to think about gender, we need to think about intersectionality. And again, how can we make our teams are more diverse? How can we make medicine more diverse? And hopefully increase patient care?
Kirsten Patrick How can women who are rising in their medical careers help others to do the same?
Ainsley Moore If you look at the gains that we have made, I think we would have to acknowledge, at least honor the role of informal mentorship that, you know, if we look at our careers, key individuals that have supported our pathways.
Andrea Tricco Absolutely, and our mentors and our sponsors. And it's just a real privilege and so wonderful to have the opportunities to have the sponsorship and mentorship from many leaders in the field. So that's definitely a real plus.
Kirsten Patrick Well, I've had great mentorship from both women and men that have helped me to advance and so I couldn't agree more. Thank you, Ainsley and Andrea, for joining me today on the podcast. It's good to have you discuss this really important article.
Ainsley Moore Thank you, Kirsten.
Andrea Tricco Thank you so much.
Kirsten Patrick I've been speaking with Dr. Ainsley Moore and Professor Andrea Tricco. To read the article they've co authored visit cmaj.ca. Also, don't forget to subscribe to CMAJ Podcasts on Soundcloud or a podcast app and let us know how we're doing by leaving a rating. I'm Dr. Kirsten Patrick, executive editor for CMAJ. Thank you for listening.