See Article, page 1171

It sounds like a broken record, and it is how almost every article published on gender equity in medicine begins. Something like…There have been equivalent numbers of men and women enrolled in medical school for over 20 years, yet women in medicine remain underrepresented in leadership. Despite more studies continuing to confirm this frustrating fact, consistent and positive change for women in leadership seems elusive. When a 2000 landmark study from New England Journal of Medicine,1 which originally demonstrated that women physicians in academic medical centers were less likely to be promoted than men, was repeated in 2020,2 it came to the same conclusion. Furthermore, the authors compared the 2 study cohorts and found no narrowing of the promotion gap over a 35-year period. During the COVID pandemic, women in all sectors experienced increasing pressures and challenges related to home and personal responsibilities and suffered significant burnout. Recent data from a McKinsey report3 are even more concerning for women in health care who have had fewer opportunities to work remotely, have experienced a greater demand to prioritize work over family and personal life, and take fewer days off than women in non-health care jobs. While this mentality was initially celebrated by health care institutions and executives touting the hero status of their workers, far-reaching negative effects including burnout and attrition threaten to cripple the progression of women and especially women of color to health care leadership positions.4

Thus, in this issue of Anesthesia and Analgesia, we prepared for that same disappointment as we read that hauntingly familiar language in Harbell’s introduction of “Women representation in anesthesiology society leadership positions.”5 The authors examined the percentage of women holding professional society leadership positions in 13 anesthesiology societies in 2021. Society leadership positions comprehensively included presidents, vice presidents and/or presidents-elect, immediate past presidents, secretaries, treasurers, assistant secretaries/treasurers, board of directors, council members, and committee chairs. Compared to the percentage of women anesthesiologists in the workforce, the percentage of women holding any society leadership position was significantly greater. Three subspecialty societies showed especially interesting results: the Society for Pediatric Anesthesia (SPA) and the Society for Obstetric Anesthesia and Perinatology (SOAP) had the highest percentage of women leaders, which may stem from having a high proportion of women anesthesiologists in those subspecialties; the Society for Cardiovascular Anesthesiologists (SCA) had a significantly higher proportion of women leaders as compared to their number of women members. Importantly, the authors found a statistically significant increase in the percentage of women presidents over a 40-year period. While other studies of subspecialty professional societies have demonstrated results to the contrary,6,7 in our own profession of anesthesiology, which has lower gender diversity compared to other specialties,8 Harbell et al is showing us positive results. These results echo the trends first reported by Bissing et al,9 where despite disparities in the highest ranks of academic anesthesiology, there were increasing numbers of women anesthesiologists as full professors, program directors, grant recipients, and on Board of Directors. In anesthesiology, it seems we are making some progress toward gender equity.

With smiles on our faces and hope in our hearts, the question is: “What does this progress mean?” We asked ourselves: “Where else have we seen progress?” In health care, studies show better clinical outcomes for patients who have women physicians.10–12 However, the business world has the best data on the progress, benefits, and need for women in leadership positions. Ten years of consistent data demonstrate a clear correlation between organizational diversity and financial performance, and the American business sector has accepted that this correlation is not just coincidental. Increasing women in leadership enhances employee morale, satisfaction, and teamwork, boosts productivity and work ethic, promotes innovation, augments profitability, and contributes to better branding, image, and reputation.13 While the World Economic Forum’s 2022 Global Gender Gap Report indicates that it will take 59 more years for the United States to close the gender gap, the business world knows the economic importance of closing this gap, as it could add 12–28 trillion dollars to the global Gross Domestic Product.14 The percentage of women leaders in the C-suite has risen from 20% to 26% in 5 years, and senior-level women are being promoted at a higher rate than men.3 Business’s bottom line is money, and having women leaders is better for business.

Perhaps, Harbell’s positive results indicate that anesthesiology is recognizing that deliberate representation of women in leadership is better for improving the future of our profession, the care of our patients, and ultimately the finances.15 Alternatively, perhaps we are at last seeing a numerical effect, with a larger denominator, as the proportion of women entering anesthesiology 20 years ago was higher than the proportion 30 years ago.16 However, we cannot rest back, solely focusing on the numbers of women leaders in anesthesiology, and simply say, “things are getting better.” We must keep the momentum going. How do we ensure continued, increasing representation of women leaders in anesthesiology and in health care? How exactly do we commit to gender equity? Perhaps the pendulum may need to swing to the other extreme to find where equity will exist. As Ruth Bader Ginsberg famously said, “When I’m sometimes asked ‘when will there be enough’ [women on the Supreme Court] and I say, ‘When there are nine,’ people are shocked. But there’d been nine men, and nobody’s ever raised a question about that.” To achieve gender equity in anesthesiology and health care leadership, we need to identify the persistent obstacles hindering the development and advancement of women to these roles.

The business world is eager to promote the few women who managed to get to the top, knowing it improves the bottom line, but it has not adequately fixed the obstacles to early promotion that create the long-term gap. Medicine also has a “broken rung” or as we more commonly hear a “leaky pipeline.” Within 6 years of completing residency training, 40% of women physicians either reduce work hours or leave medicine altogether.17 Three-quarters of the remaining 60% are considering part-time work or leaving medicine. That is a massive red flag that the private health care model is not amenable to working women. Some obstacles to early promotion identified in anesthesiology include implicit bias, the motherhood penalty, imposter syndrome, fewer opportunities for networking, promotion, and mentorship, unequal pay18 harassment,19 and lack of family-friendly benefits. Accordingly, what are the specific actions we can take to keep women from dropping out of the race? At this point, we need more than data; we need disruption and deliberate investment at all levels, both departmental and institutional.

At the departmental and institutional levels, our leaders first must mitigate the stagnation in the pipeline. Currently in anesthesiology, our residencies consist of one-third of women residents; in 2022, there are 2255 women of 6600 total US anesthesiology residents.20 Increasingly, more women medical students are choosing surgery and surgical subspecialties over anesthesiology. We must examine the reason for this rise in interest in other perioperative specialties, and our educational leaders must work to level up the number of women entering our field. Second, and with equal focus, there should be increased sponsorship, promotion, and focus on women at each stage of their career to prevent attrition. Supporting this, a recent qualitative study of women leaders in anesthesiology found that early-career, high-value mentorship, and sponsorship were important factors in leadership acquisition.21 Investing in young physicians makes a difference. Women at more junior stages must envision a future path and know the role models who can help ensure progress. We must also empower, and not forget, women at the midcareer stage, as the concept of “Jennifer fever” has described when early-career women receive professional focus and sponsorship by more senior colleagues and superiors.22 As women advance to midcareer and gain experience and competence, the intentional support wanes, possibly because midcareer women are seen as more of a threat to the senior colleagues’ careers, and they may be dismissed, undervalued, marginalized, and, passed-over for opportunities.22,23 Finally, departments and institutions must protect women at the senior level from burnout and promote their role as mentors.

National programming and opportunities for professional development for women in medicine include the AAMC Early-Career and Mid-Career Faculty Leadership Development Seminars, SPA Women’s Empowerment and Leadership Initiative, and Drexel’s Executive Leadership in Academic Medicine. These programs can be replicated on a more local level also; for example, author E. B. M.’s institution provides programming for women and underrepresented in medicine faculty (ALICE and ADVANCE-UP), and the anesthesiology department hosts a program called Academy for Building Leadership Excellence. Women students, residents, and fellows must be able to see women assistant professors be promoted to associate professors and then full professors, director, or vice chair roles, along with institutional and external committee and board members, without working twice as hard. To accomplish this, women, in both academics and private practice, must be heard, and their needs must be acknowledged by leaders prioritizing cultural change and redesigning systems to interrupt bias. Many women experience bias and barriers to advancement not only because of their gender but also because of other aspects of their identity, including race, sexual orientation, and disability; these women must be considered, recruited, or solicited when filling open leadership positions. This is more than educational training and inspirational speakers, and it requires financial investment and open engagement by leaders. This means implementing systemic policies to standardize hiring and promotion processes, to encourage a reasonable workload, to maintain clear work-home boundaries, to provide flexible work hour options (ie, job-sharing and part-time positions), to support the additional mental load, caregiving, and domestic responsibilities that women carry, to share available benefits that reduce mental and physical health burdens (ie, employee assistance, stress management, and counseling programs), and to ameliorate the daily microaggressions and harassment. At times, these missions seem overwhelming, but these must be deliberately focused on to advance and experience the benefits of women in leadership positions in health care and anesthesiology. Otherwise, we will continue to struggle to retain women physicians in anesthesiology, let alone promote women to leadership positions within our specialty.

Fundamentally, Harbell et al’s5 study reminds us that women are just as ambitious as men. Women desire leadership roles in our specialty and are finding ways to get there, perhaps outside of their institutions or departments and starting at the small or medium society level. Future study of societies, such as SPA, SOAP, and SCA, that are promoting women to leadership roles may help identify good practices for other societies and groups to implement. Despite the progress we see in these numbers, there is a lot more needed to maintain the momentum. We need to remove the obstacles in women’s paths, or we risk losing not only our current women leaders but also the next generation of leaders. Our young physicians and students are even more ambitious, and value specialties prioritizing equitable, supportive, and inclusive cultures. This is not the time to pat ourselves on the back and toast in congratulations. This is our call to action.

DISCLOSURES

Name: Elizabeth B. Malinzak, MD, FASA.

Contribution: This author helped write and revise the editorial.

Name: Julie L. Huffmyer, MD.

Contribution: This author helped write and revise the editorial.

This manuscript was handled by: Edward C. Nemergut, MD.

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