Friday, March 21, 2014

Challenges for Women in Academic Medicine and the Question of Leadership

“The world will be saved by a Western Woman.” - His Holiness, the 14th Dalai Lama at the Vancouver Peace Summit, 2010

His holiness stated this on stage with three Nobel peace laureates: Mairead Maguire, Jody Williams and Betty Williams. Also at the table was Mary Robinson, most beloved of all Irish presidents and a tireless human rights activist. Susan Davis was there too. Her humanitarian work has impacted the lives of millions in Haiti, Bangladesh, Afghanistan and several African countries.

Women, it is well known in the developing world, are less a credit risk and take monies made in a small business and invest in their families, their communities and their countries. Women do not start wars (with the exception of Catherine the Great and Margaret Thatcher). Women, in the Dalai Lama’s opinion, have more compassion and care for those who suffer. That is why he believes that Western Women, highly educated and motivated for change, will save the world. In this era of healthcare, I believe that Women, have a unique role to play in caring for our patients, our trainees and our colleagues as the environment changes. I believe that we have a very unique opportunity to steward our profession during “these “uncertain and changing times.

In academics, how does one start a “traditional academic career?” You go to the “right” medical school, then the “right” residency, followed by the prestigious fellowship. At some point along the journey, you obtain a mentor in the focus of your field of study – clinical, scientific, or academic. As a woman, your mentor doesn’t have to be gender specific. In fact, my first (and current) mentor is Dr. Jesse Meredith at Wake Forest University – not to be confused with his son, J. Wayne Meredith, MD, the Chair of Surgery at Wake Forest. Dr. Meredith Sr. is one of the surgeons who trained and performed surgeries in the day of portal hypertension decompressive surgeries. When TIPS (transjugular intrahepatic portal caval shunts) do not work or are not possible, those with “open” surgical experience in those types of surgeries are few and far between.  Sometimes, in my line of work, I need someone to talk to about these types of problems. He has always been there for me with advice, before I was a transplant surgeon and afterwards. He is who set the tone for my career: patient first.

The mentor can certainly help direct your career, and the relationship with the mentor certainly does not have to be formal. I believe that we are always training and there are always lessons to learn from whoever is around you if you are aware and take the time to notice.

Having said that, where does one go from formal training? First: job, grants, clinical experience, promotion, tenure, and then perhaps, leadership? This is where the “glass ceiling,” or perhaps lack of opportunity, becomes a reality for most mid-level to senior women, not only in surgery, but medicine.

When you review the 2012 AAMC report Women in US AcademicMedicine and Science: Statistics and Benchmarking Report, it is clear that despite women being greater than 50% of all medical school students, we have not progressed in numbers statistically equivalent in progression in academic rank or leadership positions. Currently, there are only three sitting chairs of surgery that are women in the United States, with the departure of Dr. Julie Freischlag and Dr. Nancy Ascher from their respective chairs.

Why have women not progressed in similar achievements in the academic hierarchy in similar numbers occurs for many reasons. I am certainly no sociologist, and a full discussion of the many pressures that women face in academics is beyond my talk, however, I can only speak from my own experiences and observations over the past twenty years in academic surgery.

Medicine as we know it is undergoing a significant number of changes with the Accountable Care Act and the call for “value” in healthcare from patients, payers and CMS, as well as many other changes in the fundamental way we as healthcare providers perform the business of Medicine. For-profit healthcare, loss of private practices, hospital ownership of physician’s time and effort, vertically integrated healthcare systems, are all new and frightening for medical leaders on all levels. I believe that the instability in the current healthcare environment leads Healthcare Leadership to choose leaders with whom they are “comfortable “ and “ familiar” with, as opposed to leaders who don’t look like them and perhaps possess demographic characteristics they have never worked with in an executive environment.

I know that there are other factors in these choices: variations in experience, additional training, women not understanding the “language of leadership”, opportunities, and mentorship, and frankly, women’s choices. Leadership in academic medicine is different than leadership as defined by business, in my opinion. Whether it is the day-to-day operations of caring for patients, the pressures of working for organizations that often have conflicting agendas (research, patient care, teaching, administration and making enough money to support the missions), the politics of being in academic medicine – leadership, as defined in business, is different than that observed and defined in medicine. I do not believe that this should be the case, and leadership should be just that- Leadership.

“True leadership is less of a title or a position, it is more of a state of “being.” It is about courage and risk taking and not so much about politics and walking a “safe” line. Leadership is about standing up for what is important to you – patients, trainees, your research or science, mentorship and having the vision to bring your Department/Division/group of partners along with you.  It is about sacrificing your career for the forward motion of your organizations and its members – the concept of “servant leadership.” It is eventually about your legacy and the legacy of the organization under your direction. Not empire building and certainly not about money.

So, if this is a track you want to pursue, the first thing one needs to do is to assess what you have available to you to make this happen and what you need to acquire. What resources do you have? What skills do you have and potentially need? What are your challenges? First, you must learn the language of leadership and have a vision for what you want to achieve. Think globally not locally.

There are resources available to you for your leadership training and development. 35% of AAMC accredited medical schools have monetary support for the standard Group on Women in Medicine and Science (GWIMS). These monies are intended for women faculty promotion and provide development opportunities for those selected faculty members. Departments and Divisions often have funds set aside for faculty training and development. If there are no monies available at your institution at that level, the Dean’s office or Hospital may possess funds available for leadership training. See the table below for some options and costs for those training opportunities.

Other options for leadership development include formal mentorship opportunities (if not available for you locally) in national societies such as the American College of Surgeons and the Association of Women Surgeons. A searchable mentor database has been developed for AWS members.  

I have found personal coaching and assessment very valuable and now have a relationship with a psychologist who specializes in helping women find their way to leadership. Personal coaching is an expensive option. However, it is about you – your skills, your challenges and your issues and allows you to have an objective ear for your concerns. I have found this assessment and support, invaluable.

I would suggest that now is the right time to pursue leadership opportunities. The challenges that Healthcare Reform presents allows us that opportunity and the business literature is full of articles and assessments regarding women as leaders. While it is unfair to all of us to stereotype a “typical” woman leader, Forbes Magazine at a conference in 2012, published an article regarding women’s leadership characteristics including: empathy, curiosity, collaboration – as well as – an open, information sharing style vs. hording of knowledge. Women are also described as highly adaptable leaders. The perfect skills to have in the changing health care environment.

While you are preparing for whatever leadership role you desire (section, division, department chief or dean role or even a chief medical officer in industry), here are a few suggestions from lessons I have learned along the way (mostly from mistakes).

1. First, always lead yourself.

Have a routine for basic self-care (exercise, diet, meditation, yoga, religion, etc.). Practice finding that work/life balance – whatever that looks like for you. Be extremely mindful of the resource that is you. Don’t waste your energy on people, issues or activities that do not “feed you” and only drain you. People depend on you – family, patients, and colleagues. Preserve yourself for what matters to you. Become the leader you would like to be. Have unquestionable integrity, and fairness. Lead by example. Be on time for the OR, keep your charts up to date, and be on time for clinic. Have a sense of humor, and remember most of the time, “it” isn’t all that important usually. We, as surgeons, know what is really important. Never hold a grudge – easier said than done, but work at it. Be the best surgeon you can be.

2. Have peer credibility.

Possess and practice the four A’s of Surgery – accountability, availability, affability and ability (usually in that order of priority). If you are friendly and available, you will go a long way with garnering the support and, if not admiration, the respect of your colleagues. Remember, it is your colleagues that you are hoping to lead in some fashion as you move forward.  Be supportive to the people who work for you: nursing staff, administrative support staff, and especially trainees. Never be demeaning, hold people accountable but communicate and educate.

3. Most importantly, fine tune your inter-personal and communication skills.

Moving forward in academics is about relationship building. Note, I did not say politics. Learn people’s names and listen to staff (you usually can find out the “real” story about any one issue by listening.) Work on building your reputation of being friendly, approachable and most importantly, effective. Never lose your temper and if you do, do not say anything that could be repeated out of context that makes you look worse.

I have observed over the years, that women in the operating room (for example); do not enjoy the same level of understanding from the staff when tempers are lost. There is no room for immaturity or lack of insight into how a tiff in the OR could potentially ruin or significantly delay your potential promotion into a leadership position until you have been judged to be “mature.” Most importantly, never single out an individual with your tirade. It has to be about the issues.

4.  Have a constructive way to resolve conflict on any level.

Always start your resolution process with a clear mind and a calm heart (as hard as that might be). Remember it is about the issue, not the person, even if it has to do with the person’s behavior. It is about being disruptive, for example. Always resolve issues face-to-face and refrain from the immediate email reflex. A short meeting with a published agenda and planned follow up is critical. Ignore the urge to call someone’s boss. Be deliberate, be about the issue and follow through.

5.       Set your priorities.

Refer back to #1. Preserve the resource that is you for the things and efforts that you think are important. Other people will have an idea of what they want for you, but you have to be very clear in your own direction and avoid busy work (i.e. committee that are not important, and do not accomplish anything for example). Avoid being the token appointment to any committee or organization unless you feel it is something that you think is worthy of your time and effort. Be extremely organized using whatever tools work for you. The personal coach for me has been extremely useful in this particular issue. Prioritize your office, and time – clinical administrative and teaching. If research is important to you, set aside protected time for your efforts. This of course, may require negotiation and follow through. You cannot do research and have a clinic the same day.

6.       Disarm the tenure clock and collaborate.

In order to progress in the hierarchy of Medicine, one must be productive in a research area and/or publish. Not all of us should be, or can be, an NIH funded basic science researcher. However, that doesn’t mean that all of us in academic medicine cannot be productive.

One of the issues in retaining women faculty is the issue to promotion and tenure. Certainly, some institutions have more rigorous promotion and tenure requirements than others. However, all academic programs have some minimum requirement for contribution to the literature and some have a time limit for application for promotion and tenure.

If and when you make the decision to have a child, and you are in the academic setting, know your own institution’s maternity policy. Apply for leave, in anticipation of your leave, in an early and timely fashion and do not leave this application to anyone else. I have had Division Chief’s lose these types of applications on their desks – never reaching their intended destinations. If you are planning a child or you are a very busy clinical surgeon, it is critical for your academic success to collaborate with academically productive people. You as a clinician can contribute much needed clinical expertise to (as my example) an Outcomes Research group. By collaborating, instead of being on your own, your work can continue when you do take leave, or you become very busy.

7.       Hone your administrative skill set.

Currently, I am in the throes of a Corporate Finance class as part of a Master’s in Health Administration Program. Why? As a Division Chief and as the former interim Chair of Anesthesia at my institution, I was responsible for budgets to the Dean, determining salaries based on productivity, bonuses and contract negotiations with Hospital organizations for services provided. I was blessed with a wonderful business manager; however, I felt that I needed more precise information about what I was doing, hence my return back to school for the MHA.

It is imperative if you are to be a leader in academic medicine especially in the current environment that you understand the finances of what it is that you do. You need to know diagnostic codes, reimbursements, documentation requirements and your own regulatory environment. You must have a trustworthy business manager but they are often hard to find and may have been “institutionalized” meaning they may not be open to new ideas about how to do your business. You often have to mentor them as much as your partners and trainees. If you cannot read the P & L statement or an income statement, take the time to talk to your business people and learn about how overhead is allocated and what the lines on your P & L statement mean. It is important. Profitable divisions and departments have the ability to grow and develop. If you are not comfortable with any of this perhaps you too will find yourself back in school for an MBA or an MHA. It isn’t surgery, after all.

In conclusion, I hope my hard learned lessons have been useful. I have learned over the years, that keeping one’s own CV is important, make sure you know what you are doing (i.e. do an executive summary) and look at yourself and your career annually to make sure you are on the track you want to be. Use your friends to help you on your way.

I would never be where I am, or more importantly who I am and how I am, without the Association of Women Surgeons and my mentors there. To be the 2014 Kim Ephgrave Visiting Professor is one of the highlights of my career. Thank you again for this honor.

“I learned all kinds of things from AWS members and staff about challenges in our various family and professional situations, and AWS gave meaning to my own hard learned lessons as a vehicle for sharing them with others.” - Kim Ephgrave, MD

A few references for your perusal:

 Dr. Betsy Tuttle Newhall 
Professor of Surgery, and Urology
Division Chief of Abdominal Transplantation
Surgical Director for UNOS, Kidney and Kidney Pancreas Program
Saint Louis University



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