Gender gap in anesthesiology leadership

Myron Yaster MD, Judit Szolnoki MD, and Nina Deutsch MD

I’m a believer in the bell-shaped curve and how it applies to pretty much everything.  For example, I was an invited speaker at a meeting several years ago and I asked the members of the audience to stand if they were just “average” pediatric anesthesiologists.  Virtually no one stood.  I then asked the members of the audience to stand if they were “an above average” pediatric anesthesiologist.  Perhaps not surprisingly, virtually everyone stood.  I asked everyone to look around and pointed out that this was simply impossible.  Only 5-10 percent could be above or below average.  This didn’t mean that being average was bad or that the care they provided wasn’t excellent, it just meant they couldn’t all be above average.  The bell-shaped curve…

Why do I bring this up?  Today’s PAAD and its accompanying editorial once again looks at the underrepresentation of women in positions of leadership in anesthesiology and what internal and external factors are common in women who have achieved leadership positions.  There is no question that these are important issues, but these and previous articles we’ve discussed in the PAAD miss some very important issues, 2 of which stand out to me.  First, being a woman does not equal being a good leader. Like men they will fall into a bell-shaped curve, some great, some terrible, and most in-between. What can’t be minimized is the lack of opportunity and the numbers to fill that curve, the focus of the articles in today’s PAAD.  Thus, as important as it is to have more women in leadership positions, I think it is more important to promote good leaders whether they be men or women.  Second, in today’s article the women interviewed were those who successfully maneuvered and became department chairs or leaders in professional societies like the ASA and ABA.  But what about the women who didn’t succeed?  Why did they fail or what roadblocks prevented them from succeeding? 

I’ve asked 2 friends, colleagues, and mentees, Dr. Judit Szolnoki at Nemours Children’s Heath and Dr. Nina Deutsch, past president of the Society for Pediatric Anesthesia and a founder of WELI to assist me.  Myron Yaster MD

Editorial

Emily A Vail  and  Meghan B Lane-Fall.  How Did They Get There? What Perspectives From the Top Tell Us About Developing Women Leaders in Academic Anesthesiology.  Anesth Analg. 2023 Jan 1;136(1):2-5. PMID: 36534712

Original article

Ellen R Basile, Heather Byrd, Melissa Powell-Williams, Javier J Polania Gutierrez, Efrain Riveros-Perez.  Gender Gap: A Qualitative Study of Women and Leadership Acquisition in Anesthesiology.  Anesth Analg. 2023 Jan 1;136(1):6-12. PMID: 35550391

The study by Basile et al.1 is based on “26 semi-structured qualitative interviews conducted with women leaders in academic anesthesiology.”2  “The study used a constructivist grounded theory approach, an established qualitative research method that employs iterative surveys, interviews, or focus groups to collect the perspectives of study participants and “construct” a theory a priori to explain a process or phenomenon of interest.”2, 3 I (JS) love qualitative research methods: qualitative research seeks answers to “how” and “why” questions that are difficult to put in “numbers” for the more familiar quantitative research.

“Among medical specialties, anesthesiology stands out as a specialty in which there are large disparities in the representation of women in leadership. In anesthesiology, positions of leadership in academics and national societies are overwhelmingly male dominated.”1  And yet many women have succeeded and have acquired positions of leadership.  How did they do it? 

“The authors found that the respondents’ insights coalesced into 4 themes: personality traits, leadership preparation, gender-related considerations, and leadership acquisition. While some identified factors (including adaptability, perseverance, family concerns, and experiences of gender bias) were personal and potentially less generalizable, respondents also noted the value of external activities, such as self-promotion, networking, and formal leadership training during their careers. Respondents also identified two related resources, “high-level mentorship” and “sponsorship”, as crucial factors for leadership development and attainment of leadership roles.”2

“It is important to note that this window into leadership is limited in part by the absence of perspectives from women who applied for but did not attain leadership roles, those who are in early stages of their careers (eg, junior faculty and trainees), and those who left anesthesiology and/or academic medicine. By focusing solely on those who have achieved high-level leadership roles, the study may also reinforce perceptions of exceptionalism facing individuals who have objectively thrived for decades in a challenging environment. That is, these women leaders may be viewed as intrinsically different from peers without leadership roles. When women leaders are rare but visible, this misperception serves to reinforce the myth that qualified women don’t need or benefit from systemic career development support. It also isolates women leaders from peers and risks intimidating junior colleagues and mentees who view leadership roles as unattainable without extraordinary skills or extreme personal sacrifice.”2 While I (JS) agree that the perspective of non-leader women are missing from the study I disagree that the study implies “extraordinary skills”: these leaders were at the right place at the right time with the right support. So, in my mind it comes down to when the right time is for an individual, where the right place is and of course, and the support they receive.

“The 26 participants in this study1 provided detailed descriptions of how they perceived themselves, their journey to leadership roles, and the obstacles they overcame”.  Both Basile et al and Vail stress the importance of sponsorship and networking in career development. This jives with previous PAADs that discussed the importance of the Society for Pediatric Anesthesia’s WELI program which at its core is a sponsorship and networking program.4  They also underline the importance of self-promotion, perseverance, and grit. When we are talking about these traits I must throw in the concept of “followership”. I (JS) believe that active, engaged, critically thinking followers will have the best opportunities to engage with their leaders and be offered the right opportunity. Therefore, my advice is to be the right kind of follower to a leader who you can follow and believe in.

Going back to Myron’s introduction, what is not discussed in this article and editorial is what makes a good, great, or bad/terrible leader (the bell-shaped curve).  We think this is as, or even more important, than gender of the leader or how they achieved a leadership position.  There are entire consultant industries and hundreds of books and articles on leadership.  We (MY, ND) were fortunate that we had mentors in our lives who stressed the qualities of what makes a great leader more than how to get a leadership position.  Although there are many strategies, we all think the most important, stressed by Myron’s former chairman, Dr. Colleen Koch, and my (ND) current chairman, Dr. Genie Heitmiller, is to be a “servant” leader. Servant leadership is a leadership approach that puts serving others above all other priorities. Rather than managing for results, a servant leader focuses on creating an environment of trust in which their team can thrive and get their highest-impact work done.  This is a bottom up rather than a top-down approach.  The worst leaders are narcissists, who are autocratic leaders who primarily look out for themselves.   Thus, we think finding servant leaders is ultimately the most important characteristic that one should look for in searching for a department chair or division chief.  It trumps gender, diversity, academic productivity, grants, or race.

Let us know what you think and we’ll post in a future Reader response.

References

1.           Basile ER, Byrd H, Powell-Williams M, Polania Gutierrez JJ, Riveros-Perez E. Gender Gap: A Qualitative Study of Women and Leadership Acquisition in Anesthesiology. Anesthesia and analgesia. Jan 1 2023;136(1):6-12. doi:10.1213/ane.0000000000006073

2.           Vail EA, Lane-Fall MB. How Did They Get There? What Perspectives From the Top Tell Us About Developing Women Leaders in Academic Anesthesiology. Anesthesia and analgesia. Jan 1 2023;136(1):2-5. doi:10.1213/ane.0000000000006241

3.           Chun Tie Y, Birks M, Francis K. Grounded theory research: A design framework for novice researchers. SAGE Open Med. 2019;7:2050312118822927. doi:10.1177/2050312118822927

4.           Schwartz JM, Markowitz SD, Yanofsky SD, et al. Empowering Women as Leaders in Pediatric Anesthesiology: Methodology, Lessons, and Early Outcomes of a National Initiative. Anesthesia and analgesia. Dec 1 2021;133(6):1497-1509. doi:10.1213/ane.0000000000005740

5.           Kelley, R. (1988). In Praise of Followers. Harvard Business Review, 66, 142-148