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WHEN Professor Kirsty Forrest moved to Australia from the UK in 2013, she thought she was moving to a country that had well and truly tackled historical gender bias.
“I had just heard the misogyny speech by [then Prime Minister] Julia Gillard and I thought ‘they are all over it in Australia, they will be great, there will be great gender diversity,’ but then I came here and I thought ‘oh no’,” said Professor Forrest, who is Dean of Medicine at Bond University.
From casual references to “chicks” in the community to gendered feedback on her communication style, such as “grumpy” or “too assertive”, Professor Forrest soon realised that there was a long way to go before unconscious gender bias was a thing of the past.
Professor Forrest was commenting on a Perspective in the MJA, in which Professor Helena Teede wrote that despite decades of gender parity in medical school admissions, under-representation of women in senior medical leadership positions persisted.
Professor Teede, Executive Director of the Monash Partners Academic Health Services Centre, wrote: “The age-old argument that this is due to a time-lag or pipeline effect clearly no longer applies.”
Professor Teede said work was underway on a program to better support the advancement of women to medical leadership roles. The program would incorporate systems, organisation and individual-level strategies and provide a roadmap with measurable and benchmarked outcomes.
In Australia, around 30% of deans, chief medical officers or college medical board or committee members were women, she wrote, while 12.5% of large hospital chief executive officers were women.
In an exclusive InSight+ round-table podcast, Professor Teede and colleagues said the barriers to women attaining leadership positions had attenuated but were still “very much alive and well”.
“Those barriers are not so much explicit, but more ‘unconscious bias’, and they exist at a systems and policy level, at an organisational level, and at an individual level,” Professor Teede said. “With the much greater awareness, there is now a strong desire by both male and female leaders, organisations, and policy makers to overcome some of those barriers and make sure we progress, support and enable women to attain their leadership and career goals and optimise work–life balance.”
Professor Teede wrote in the MJA that the barriers to women’s career advancement could be characterised under three themes: capacity (women juggling careers while shouldering a disproportionate amount of the domestic and family load), perceived capability (the confidence women may hold in their ability to lead), and credibility (the linking of traditionally masculine values to leadership credibility).
All three themes resonate with Professor Imogen Mitchell, Dean of Medicine at the Australian National University (ANU) Medical School.
She said the issue of perceived capability was a real issue for women, and one with which she had grappled personally.
Before she applied for the prestigious Harkness Fellowship in Health Policy and Practice, Professor Mitchell sought the opinion of her respected mentor, former Chief Medical Officer Professor Chris Baggoley.
“I said to him, ‘I am not sure that I am the right person for the Fellowship’, and he said ‘ you are definitely the right person, you should never underestimate how much of an impact you have had’,” said Professor Mitchell, who went on to win the Fellowship in 2013.
“I think a lot of women need that push, and I think that [encouragement] is needed much more than is currently given for the up-and-coming female leaders, whether that be in [clinical medicine] or academia.”
Professor Mitchell has also found that, in some instances, she has had to modify her communication style to ensure that her view is being heard.
“I know there are certain males who will not respond to me and I sense that it is because I am a woman,” Professor Mitchell said. “I then have to use different strategies to influence their thinking [and may have to communicate] through a male who is of significant standing to help persuade them that what I am saying is in fact the right thing.”
Issues of unconscious bias are not peculiar to Australian medicine, and Professor Teede pointed to a recent issue of The Lancet describing the loss of women’s potential as a “leaky pipeline”. US researchers also recently reported in JAMA Open that the proportion of female corresponding authorship on oncologic randomised controlled trials (17.9%) was below that of the proportion of female academic oncologists, which ranged from 27% to 39% in the study period.
Professor Mitchell said the dominance of men in leadership roles was still stark. While she had never been a believer in targets and quotas, she said there could be a role for targets in forcing organisations to consider workplace structures. She said the ANU was part of the Athena SWAN (Scientific Women’s Academic Network) charter, and such initiatives encouraged organisations to reflect on gender diversity.
Professor Michelle Leech, Head of the Medical Course at Monash University and Deputy Dean at the Faculty of Medicine, Nursing and Health Services, said women graduating 30 years ago would have seen very few female leaders in medicine, but there had been a gradual increase in recent years.
“We are lucky at Monash because we have a female vice-chancellor, a female deputy vice-chancellor (education), a female executive dean, and I am head of the medical course,” Professor Leech said. “You can see a pipeline stretch ahead of you of all women leaders.”
But, she added, until gender parity in leadership positions was reached, there was still a perception that the “top positions were for men”.
Professor Leech said a range of strategies – formal and informal – were needed to support women into leadership roles. “You need plenty of role modelling, and mentorship, and support, and this can start very early,” she said, noting that encouraging women to take on student leadership roles can plant the seed about leadership opportunities early on.
She said Monash also had a “senior women shadowing program” that exposed potential leaders to the range of different leadership styles.
“You can’t just leave it to chance; you have to do something active to promote and enable it.”
Professor Forrest welcomed formal moves to address gender inequity in leadership. She said of the 23 medical deans in Australia and New Zealand, only five were women.
“And that’s the same as it’s been in the past 25 years,” she said. “There is no progress, or very slow progress.”
She dismissed oft-repeated claims that women were not interested in taking on leadership positions.
“That’s rubbish,” she said. “I suspect many women say that to themselves in the end because the system has made it so difficult for them to get there. The data are there about the inequity. Now we have to move forward and do something.”
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No one ever requests their blood count to be done by a human, rather than a machine.
No one ever requests their refractive surgery be done purely by a surgeon’s slow and imperfect hand, rather than the 17 seconds of the latest generation of machine.
How many of us trust the examining hand of the highly-trained, postgraduate university qualified intern, rather than a CT or MRI of our loved one’s head injury? Or the intern’s opinion of the ECG rather than the machine’s own printed report?
It parallels the airline industry, where the robot welds the plane better than a human can, and the computer flies the plane better than a human pilot. The AMA campaigns for Autonomous Emergency Braking – it’s safer. Driverless cars are now a reality, and approaching consumer-level availability. The machines make fewer errors than we do, it’s a matter of time before the legal liability for those errors is resolved.
We all give lip service to doctors having a well rounded personality, life outside medicine etc, but if we are exsanguinating we want the friendless loser who hangs around A&E and sleeps in the hospital, to attend to us without delay. TV’s autistic ‘The Good Doctor’ is a desirable archetype. There has traditionally been a preponderance of men in those roles, possibly with a biological as well as sociological bias.
The ideal doctor is literally a faultless machine which always makes the right decisions and performs the right actions, never has a sick day or parental leave, has no life outside the hospital and no distractions. A Coulter counter, a Lasik, a Da Vinci.
My old boss John Solomon had been Wallaby captain in the 1950s, while an O&G trainee, and lamented in the 1980s that such an extracurricular commitment would be impossible. Now there are more compulsory courses, time-based competencies, and demands of the career. In the 1950s you could get away with returning from a test match with a dislocated shoulder, but this century Dr Bawa-Garba discovered that if you return from maternity leave with imperfect clinical acumen, you will be prosecuted.
Perhaps, as I raised in comments on MJA Insight 24 July 2017, the worst bias is that anything unpaid, including giving birth or caring for ones own children, is not seen as proper work. Only 24/7 commitment to the job counts, irrespective of gender.
Last century we went from the hand-sewn and hand-steered plane of the Wright brothers, this century gender bias will become irrelevant as the machine doctor never forgets to order the serum lactate or to prevent unauthorised dispensing of antihypertensives. There will be no need for a Professor of Medicine when the von Neumann machine has no human students to teach, just as Wilbur and Orville Wright’s great-granddaughters don’t get to make aeroplanes by hand.
In the meantime, Professor Forrest should be glad to get “gendered feedback on her communication style, such as “grumpy” or “too assertive””, because the masculine gendered feedback translates those terms as “angry” and “bullying”. Sackable offences.
I have never wanted to be defined by my gender. In anaesthesia I never am. Now the kids are older I do feel more comfortable in stepping up to roles as I feel I can commit myself having lived the “young children rearing juggle”. I whole heartedly agree with Karen Price too. Equality is a society issue as we want our children to not only be inspired from role modelling in the workplace but to benefit from having parents able to invest time in the child.
We have been here before: MJA Insight 25 September 2017.
Michael Keane dealt very calmly with these issues from an alternative perspective.
Perhaps we should start with definitions which is part of the problem. People are using the terms inequity and inequality interchangeably. Using the term inequity and quoting numbers in the same sentence? They are most definitely different. And female gender? Female is a sex. Notwithstanding, as a white Anglo-Saxon male from the UK I can certainly vouch that discrimination in Australia is alive and kicking. The consultant interview, as an example, is merely a vehicle for sanitising the prejudices of the local cronies. With 4 university degrees (one higher) and 3 surgical fellowships are your seriously judging my ability to do the job in a 30 minute interview? And RACS proudly announce they’ve kicked the habit!!!!
Would agree with #9: this is not about bias, but about involvement in a significant project of any type outside medicine. And even then, it is not about a perception of lack of commitment, but simply an inability to juggle multiple roles and feel that one can do justice to them.
The literature from Scandinavia cited by Karen at #2 is indeed interesting. Norway mandated gender targets in the mid-2000s for public AND private company boards. The targets were indeed met in accordance with the legislation, but what was seen was a select number of women holding multiple board positions across several companies, whereas as men were more numerous, but held fewer positions.
The most common ‘other’ project is child-rearing, the responsibility for which still falls more on the woman. Sometimes ‘leaning in’ is just not that attractive.
In a 40 something year career I have experienced good and bad leaders of both sexes. All I want in a position of leadership is someone who is the most likely to do the job well – be it female, male or even LBGT etc. Am I a bigot, sexist or whatever for thinking this?
The current healthcare system was established last century and a lot of its structure and processes reflect what were considered societal norms 50 years ago. However times have changed and with the increased numbers of women graduating from medical school, much needs to be done to ensure that their talents are not wasted. Some of this will require legislation, a lot of this requires policy changes within Professional societies (eg addressing the issues that allow inequity to continue), as well as at the relevant levels of the healthcare system (where a considerable amount of work is required). Resourcing adequate maternity leave remains an issue but so is resourcing adequate paternity leave. Implicit bias is a real issue within the healthcare system and one can only wonder whether the failure of the system to evolve and change is also one of the contributing factors to other issues such as for example burnout.
Then there are the other issues of communication styles (gendered language) in the work place, implicit bias impeding the career progression of some (for example the recent US publications of where residents were being awarded different work rating scores according to gender-with the women scoring less), failure of women to secure leadership positions. Yes there is much that needs to change but this involves the leadership of the wider system and not just the women.
Echo the above, I left ICU partly because looking after my son while my partner slept after working nights meant I couldn’t attend teaching on my rostered days off.
My supervisor made a particular point of me not being a good senior reg because I wasn’t there on my days off.
Did they give a flying that it was to be present at home. Nope. Bet he wouldn’t have said that if was a female.
As a male, I have experienced bias too.
I have always been a hands-on father. When I left work early to pick up children from day care, I was told that I was “not serious about” my career.
I deny that this is a gender issue. I consider that it is much more a bias against those who have an involvement outside their professional life.
Hell’s Bells. The Head of State of Australia is a woman, the State Premier is a woman, the CEO at our hospital is a woman, the Director of Medicine is a woman, my boss is a woman. Actually the male approach to women is best seen in the movie “Titanic”. Women and children first. Six millionaires died rather than take lifeboat places before women.
The statistics speak for themselves. Merit is plentiful in women too, opportunity is not. Glass ceiling based struggles are no doubt ‘alive and well’
Including women against women.
Such a wonderful article. I have always had an innate drive to make a positive difference in the world around me. I have always been ambitious. I have the capacity and through growth mindset have the perceived capability, but I couldn’t adequately describe the ongoing barrier/resistance I frequently encountered. As a short, youthful looking (aka cute), bubbly, enthusiastic, soprano voiced female doctor, thank you for articulating the reason for this resistance. Now I know what this barrier is (ie perceived credibility), I can take steps to mitigate this bias. Thank you, I have a path forward.
Change needs to happen for women much earlier in their career path when the divide in career trajectory starts when women take time to have children. this has a major impact and some women never have the strength and energy to even try to get back to a leadership role. Structural change in employment practises needs to be made both for men and women as without the support of men it will continue to be a struggle.
Overtly and covertly
It’s a complicated discussion and not confined to implicit or explicit bias. There are structural impediments within our culture too. National tax payer funded childcare is one. School hours and after school care another. School holidays and the precarious balancing of work and home for couples. There is gender discrimination for men too in nurturing and looking after their families with respect to the unpaid labor roles. The workplaces have simply not addressed the changing work practices of the people and is still rolling around in yesteryears conceptualisation of two workers. One paid in full time work. And one unpaid in full time work at home.
The Lancet article in 2004 by Dame Carol Black talked about the confidence and visibility of women at the ubiquitous after hour meetings attendances as being a part of this whole.
There are layers of structural and personal bias and assumptions that are simply outdated and not fit for purpose. From the literature in Scandinavia it appears the attitudes don’t change until the legislation does. Enabling parents to equally take on caring roles (children, Christmas, birthdays, the old, and the sick)
The pipeline is there. The qualifications are there. The confidence and desire to progress are there. Men are expressing desire to be a present Father for their kids so the population seems ready.
Time for policy and legislation to catch up.
I was told that my application for promotion from senior lecturer to Associate Professor at UNSW would be unlikely to be successful because I had shown no evidence of leadership. Many of my previous registrars are now A/Prof despite having published far less, provided far less education and having made no significant impact in medicine.