Women Surgeon Leaders for the 21st Century

25 Jul 2014
By: SreyRam Kuy, MD, MHS
Part I: The Status of Women in Leadership Roles, Changing Culture and Leadership Training

“If you’re offered a seat on a rocket ship, don’t ask what seat! Just get on.” -Sheryl Sandberg, Chief Operating Officer of Facebook, from Lean in: Women, Work, and the Will to Lead

“When you ask women, they do want these things [leadership roles] and they want them as much as men do.” – Patricia Numann, MD, Former President of the American College of Surgeons and Association of Women Surgeons Founder

“I used to walk down the street like I was a super star… I want people to walk around delusional about how great they can be – and then to fight so hard for it every day that the lie becomes the truth.” -Stefani Germanotta, entertainer known as “Lady Gaga”
 A century ago Orison Marden published, “How They Succeeded: Life Stories of Successful Men Told by Themselves,” describing the leadership and career success stories of prominent late nineteenth century US leaders such as Alexander Graham Bell and John D. Rockefeller.  Among these profiled nineteenth century leaders was Helen Gould, an heiress, philanthropist and a law school graduate.  Ms. Gould remarked upon the confines of nineteenth century America upon opportunities for upward mobility available to women, “I do not see, for my part, how any child from the poorest tenements could ever grow up and develop into strong, successful men or women…  And it is harder on the girls than the boys!  The boys can go forth into the world and probably secure a position… but the poor girls have so few opportunities.”  And yet, she had the prescient foresight to say, “But I don’t think it matters much what a girl does so long as she is active, and doesn’t allow herself to stagnate.  There’s nothing, to my mind, as pathetic as a girl who thinks she can’t do anything.”  A century later, the first woman to be inducted as president of the American College of Surgeons proved that “girls” can indeed do anything. 
Dr. Patricia Numann remarked on leadership roles that “When you ask women, they do want these things and they want them as much as men do.”  Clearly, there is a wealth of talent among women surgeons.  What is the status of women in leadership roles in medicine today?  And, what are the resources to assist women medical students, surgical residents and surgeons in advancing in leadership roles in their hospitals, communities, universities, and professional organizations?
The Status of Women in Leadership Roles in Medicine
In 1960, only 5% of medical students were women.[1]  Today, at least half of medical students are women.  Has the advancement of women in leadership roles in medicine kept up with the growth of women entering medicine?  In a cohort study of all US medical school graduates from 1979-1993, women were more likely than men to pursue an academic career (10% more women than would be expected with proportional representation of men and women, with women significantly over-represented among medical school graduates entering academic medicine).[2]  However, the percentage of women who advanced to associate or full professor were significantly lower than their male counterparts.  The percentage of women medical school faculty members holding full professorship has grown slowly over the years, from 7% in 1978 to 15% in 2005.(Nattinger)  This is in contrast to the fact that 30% of male faculty have held the rank of full professor consistently over this time period and that in 2005 only 11% of department chairs were women.  
Some of the factors that have been suggested for this gender disparity in leadership roles in medicine include less preparation for an academic career, fewer resources at the beginning of the career such as salary disparity either due to sexual discrimination or ineffective negotiation, lack of mentoring, less supportive institutional environment, and societal norms dictating home life and child care responsibilities which impact career trajectory.[3],[4],[5]  To close the gender leadership gap, a multifaceted approach is necessary.  A number of strategies have been suggested.  Changing the culture of medicine, disseminating knowledge about resources for leadership training, increasing awareness of promotion criteria, improving mentoring of junior women surgeons and developing negotiation skills are several other avenues that empower women surgeons in emerging as leaders in academic and organized medicine. 
Changing the Culture of Medicine
Valantine and Sandborg describe one institutional model which aims to change the academic culture to allow integration of work-life balance and flexibility policies into the promotion process, such as parental leaves and tenure clock extensions, which would enable institutions to better recruit and retain the best and brightest of both women and men.[6]  Fried et al. describe another multifaceted institutional intervention to address career advancement obstacles faced by women faculty.[7]  By targeting problem identification, leadership involvement, education of faculty, mentoring, reduction of isolation and increased integration of women faculty into the scientific community, they reported a significant increase in the number of women promoted to associate professor rank over a 5 year intervention period.  Other institutional change frameworks emphasize the need to increase the visibility of women and the work they do by tracking and publishing institution specific data on women in leadership positions and valuing women’s relational skills by training deans and other administrators to look for and recognize the value of women’s behind the scenes relational expertise in collaboration.[8]  The National Institute of Medicine (NIH) developed a tool to assess if an institution has a Culture Conducive to Women’s Academic Success (CCWAS).[9]  The CCWAS consists of four elements, equal access, work-life balance, freedom from gender biases and supportive leadership.  This can be a valuable tool for institutions seeking to reinvigorate their culture to enable women to flourish in academic medicine.      
Leadership Training
Sonnino describes valuable resources available for professional development and leadership training, available on the Association of Women Surgeons Website[10]and the American Journal of Surgery.[11]  These opportunities of professional development described include courses provided by the AAMC (Association of American Medical Colleges), the ELAM (Executive Leadership in Academic Medicine) program for women, ACPE (American College of Physician Executives) Leadership Development Program, Harvard University MBA training programs, and the Robert Wood Johnson Foundation Fellowships.  ELAM offers senior women faculty at medical and dental schools a year-long fellowship training experience to enable them to develop the skills need to competitively seek higher level administrative positions at academic medical centers.[12]  Research has demonstrated that women physician who participated in ELAM were more successful than non-ELAM women physicians in attaining department chair or Dean level positions.[13] 
Leadership training needs to begin early, in medical school and residency training.  Taking an active leadership role to enable effective teamwork and patient care during residency medical school is the training grounds the future surgical leaders.[14]  The American College of Surgeons hosts an annual Residents as Teachers and Leaders Course at their national headquarters in Chicago, Illinois at no cost to surgical trainees.[15]  Residents are taught effective teaching skills including learning how to give feedback to learners, establish time for teaching, and seeking teaching opportunities in the operating room and on the wards.  Residents are also taught techniques for successful leading such as conflict resolution, integrating diverse working styles, and leading productive teams.  The American College of Surgeons also has course of practicing surgeons, Surgeons as Leaders: From Operating Room to Boardroom.[16]  This three day course teaches surgeons about consensus building, changing culture, conflict resolution, emotional intelligence in order to have personal insight, and practical translation of leadership principles into daily action.    
By incorporating a multifaceted approach of fundamental change in institutional culture, leadership training, negotiation skills, development of mentoring relationships and awareness of promotion criteria, hopefully we can one day see more women surgeons following in the footsteps of Dr. Numann in leading our hospitals, communities, and professional societies.  Check out next month’s AWS newsletter to learn read the second segment of this two part article, “Women Surgeon Leaders for the 21st Century: Part II – Negotiation Skills, Developing Mentorship Relationships, and Promotion Criteria”.
Parting Thoughts from Women Leaders

“Always aim high, work hard and care deeply about what you believe in.  And when you stumble, keep faith.  And, when you’re knocked down, get right back up and never listen to anyone who says you can’t or shouldn’t go on.”

– Hillary Rodham Clinton, Former US Senator, First Lady and Secretary of State

“I always did something I was a little not ready to do.  I think that’s how you grow.  When there’s that moment of ‘Wow, I’m not really sure I can do this,’ and you push through those moments, that’s when you have a breakthrough.” 

–Marissa Mayer, Chief Executive Officer of Yahoo

“As a leader, I am tough on myself and I raise the standard for everybody; however, I am very caring because I want I want people to excel at what they are doing so that they can aspire to be me in the future.”

–Indra Nooyi, Chief Executive Officer of PepsiCo

SreyRam Kuy, MD, MHS was born in Cambodia, grew up in Oregon, graduated from Crescent Valley High School as Valedictorian, and attended Oregon State University where she earned dual degrees in Philosophy and Microbiology.  Dr. Kuy’s passions are healthcare policy, physician leadership and health services research.  After college she worked as a Kaiser Family Foundation Barbara Jordan Health Policy Scholar in the Senate, writing speeches and policy briefs for Senator Tom Harkin on women’s health, coverage for breast cancer screening and treatment, and health care instrument safety.  She attended medical school at Oregon Health Science University, then finished general surgery residency in Wisconsin.  She earned her master’s degree in health services research at Yale University School of Medicine as a fellow in the prestigious Robert Wood Johnson Clinical Scholars Program.  She is also a writer.  Her first book, Soul of a Tiger, describes her family’s survival during the Cambodian Genocide known as the Killing Fields.  Her second book, 50 Studies Every Surgeon Should Know, will be released in 2015 by Oxford University Press and describes seminal research in the surgical field.  Dr. Kuy is an assistant professor of surgery at Louisiana State University and the Overton Brooks Veterans Affairs Medical Center.    

[1]Hamel M, Ingelfinger J, Phimister E, Solomon C.  Women in Academic Medicine – Progress and Challenges.  NEJM. 2006;355:310-312.
[2]Nonnemaker L.  Women Physicians in Academic Medicine: New Insights from Cohort Studies.  NEJM. 2000;342:399-405.
[3]Nattinger A.  Promoting the Career Development of Women in Academic Medicine.  Arch Intern Med.  2007;167:323-324.
[4]Bickel J, Wara D, Atkinson B, Cohen L, Dunn M, Hostler S, Johnson T, Morahan P, Rubenstein A, Sheldon G, Stokes E.  AAMC Paper:  Increasing Women’s Leadership in Academic Medicine: Report of the AAMC Project Implementation Committee.  Acad Med.  2002;77(10):1043-1058.
[5]Allen I.  Women doctors and their careers: what now?  BMJ. 2005;331:569-572.
[6]Valentine H, Sandborg C.  Changing the Culture of Academic Medicine to Eliminate the Gender Leadership Gap: 50/50 by 2020. Acad Med. 2013;88(10):1411-1413.
[7]Fried L, Francomano C, MacDonald S, Wagner E, Stokes E, Carbone K, Bias W, Newman M, Stobo J.  Career Development for Women in Academic Medicine.  JAMA.  1996;276:898-905.
[8]Morahan P, Rosen S, Richman R, Gleason K.  The Leadership Continuum: A Framework for Organizational and Individual Assessment Relative to the Advancement of Women Physicians and Scientists.  Journal of Women’s Halth.  2011;20(3):1-10.
[9]Westring A, Speck R, Sammel M, Scott P, Tuton L, Grisso J, Abbuhl S.  A Culture Conducive to Women’s Academic Success: Development of a Measure.  Acad Med. 2012;87(11):1622-1631.
[10]Association of Women Surgeons.  https://www.womensurgeons.org/CDR/AJSprofdevleadershiparticle.pdf.  Accessed 6/10/2014.
[11]Sonnino R.  Professional development and leadership training opportunities for healthcare professionals.  The American Journal of Surgery.  2013;206:727-731.
[12]Richman R, Morahan P, Cohen D, McDade S.  Advancing Women and Closing the Leadership Gap:  The Executive Leadership in Academic Medicine (ELAM) Program Experience.  Journal of Women’s Health & Gender Based Medicine.  2001;10(3):271-277.
[13]Dannels S, Yamagata H, McDade S, Chuang Y, Gleason K, McLaughlin J, Richman R, Morahan P.  Evaluating a Leadership Program: A Comparative, Longitudinal Study to Assess the Impact of the Executive Leadership in Academic Medicine (ELAM) Program for Women.  Acad Med. 2008;83:488-495.
[14]Kiesewetter J, Schmidt-Humber M, Netzel J, Krohn A, Angstwurm M, Fischer M.  Training of Leadership Skills in Medical Education.  GMS.  2013;30(4).
[15] American College of Surgeons.  Residents as Teachers and Leaders Course.  http://www.facs.org/education/residentsasteachersandleaders.html.  Accessed 6/10/2014.
[16]American College of Surgeons.  Surgeons as Leaders: From Operating Room to Boardroom.  http://www.facs.org/education/surgeonsasleaders.html.  Accessed 6/10/2014.  

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