Stefan De Hert, ESA President
Maria Cristina Honorato Cia, Council member Spain
The last decades have witnessed a steadily increasing number of women professionally active in medicine. Yet, gender parity is still not reflected in medical leadership. What is holding women back from leadership roles in medicine and is there a way to make a difference?
Recent reports indicate that most of the EU member states have a higher number of female than male physicians. The highest percentages (60% or more of the total number of physicians) were recorded in the Baltic States, Romania, Slovenia, and Croatia, with women accounting for almost 75% of the total number of physicians in both Estonia and Latvia. Based on these numbers, one might conclude that – at least in medicine in Europe – gender balance is achieved and that discussions about female representation in medicine have become obsolete.
Such conclusion is unfortunately unwarranted. Despite women constituting a substantial proportion of the physician workforce, they are consistently underrepresented in positions of leadership and prestige.1-5Data on the situation in the field of anaesthesiology are scarce, but there is no a priori reason to expect any difference from other fields in medicine. Recent data from the US do indeed confirm female under-representation in leadership positions.5
So how is the situation in Europe and by extension within our own European Society of Anaesthesiology? To investigate this question a survey was launched among our members to get information about their gender, country of residence and work, their professional position, work conditions, and their involvement in leadership positions and representation functions.
At the same time, a questionnaire was sent to the presidents of the European national societies requesting information on gender distribution in their leadership positions.
Here we present the results of these investigations.
The survey was sent out to the active (n = 4,869) and affiliate members (n = 1,813). We received 1,234 responses, which represents a response rate of about 18%. Gender of the responders was the same (49.5% male and 50.5% female).
Substantially more women than men work part-time (29% women vs 12% men). The majority of responders work in public hospitals (men: 78%, women: 82%). Twelve percent of the male responders and 11% of the female responders work in private practice and 9% and 8%, respectively, work in a combined practice. The monthly income is shown in Figure 1. Substantially more men than women are in the higher income range (5,000–10,000 € and > 10,000 €). It is not certain whether this difference can be solely related to the fact that more women are working in a part-time employment model. It might be of interest to further unravel the underlying reasons for this difference.
Figure 1. Monthly income (Euros).
Previous studies seem to indicate that differences in specialty, part-time status, and practice type are not sufficient reason to explain the disparity.6-8Additional explanations that have been proposed are: differences in negotiating skills, lack of networking opportunities, the glass ceiling effect, and even implicit or explicit bias and discrimination.9-12Recent data have suggested that a portion of the earning gap may simply be related to the fact that women seem to prioritize payment less than do men.13
The results on professional position are shown in Figure 2. The disparity in leadership positions is striking. There are twice as many men than women in a position of professor and hospital medical director and even 3 times more men in the position of head of the department.
Figure 2. Leadership positions.
A similar fraction of men and women are involved in clinical and basic research (42% male and 38% female for clinical research and 20% male and 21% female for basic research). However, when we look at public representations such as giving lectures at national meetings (men 70% and women 30% of responders), at international meetings (men 18% and women 11%), and at representations in various scientific and other committees (men 29% and women 19%), this equal distribution has completely disappeared.
These observations are in line with previous publications reporting that the number of women promoted to the rank of associate and full professor were much lower than expected.3,14Also, female medical students and physicians perceive more difficulty in finding mentors than do their male colleagues.15
Questionnaire to the national societies
Eighteen national societies responded to the questionnaire, which represents a response rate of 53%.
In the period from 2005 until now, only 28% of the national societies’ presidents were female. In five of the responding countries, there has never been a female president in the observation period and in one country all presidents have been female.
The current national societies’ board positions consist of 63% men and 37% women. Committee chairs are 41% women and 39% of committee members are female. Finally, 61% of the responding societies report actively encouraging women to participate but only 16% have a real active gender balance policy.
And what about the European Society of Anaesthesiology?
Table 1 summarizes the gender distribution within the different member types of the society. Of note, for some memberships the information about gender is rather scarce. For the three main categories of membership: active, affiliate, and associate, there is a higher representation of men. Interestingly, this distribution is opposite in the group of trainees and medical students, who represent the younger generation.
Table 1: Gender distribution within the different member types of the European Society of Anaesthesiology.
% gender distribution is calculated on the total number with gender information (column 3).
What is the gender distribution of the attendees at our main scientific events? For the Focus Meeting 2017 in Tel-Aviv, we had 380 delegates. Of these 67% were men and only 33% women. For Euroanaesthesia 2018 in Copenhagen, we had 5,419 participants about whom we have gender information and it seems that the numbers are a little more in equilibrium with 58% men and 42% women. This means that for both our main scientific events we seem to attract more men than women. The question is: why?
Let us now have a look at the gender distribution of our abstract presenters and the faculty at Euroanaesthesia 2018. We had a total of 1002 abstract presenters, of whom 51% were female and 49% men. This means there is a more or less equal distribution in gender of those – mainly young persons – who are at the beginning of their career and eager to communicate their findings to an audience. Interestingly, however, when we look at the gender distribution of the faculty, the picture changes completely. Of a total of 491 speakers, only 19% were female. What has happened with this initially equal distribution of speakers? Why, once established authorities are involved, have women disappeared and the vast majority of the faculty is male?
Is this an isolated problem related to our congresses? Unfortunately not. Let’s have a look at the gender distribution of our major governing structures. Currently, the Board of Directors of the ESA is composed of 8 men and only 1 woman, the council of 24 men compared to 13 women, and the National Anaesthesiologists Societies Committee of 27 men and 7 women (though this is not directly related to ESA, since they are the national representatives/society presidents).
As apparent from Figure 2, this gender disparity is also present in all our committees, except for the Trainee Committee, which has a 50/50 gender distribution. Of note, the secretariat at the ESA headquarters in Brussels counts a majority of women: 23 vs. 14 men.
Where to go from here?
These numbers clearly indicate that those continuing to claim that there is no problem of gender equality within the field of medicine and specifically anaesthesiology have a wrong, or at least biased, perception of the reality. There is indeed gender equality at the beginning of a medical career (students and trainees), but at the level of leadership position there is still a striking under-representation of women.
Identifying a problem is not that difficult. It is much more challenging trying to identify the underlying mechanisms for the issue and find potential solutions.
A first question to be answered is whether there should actually be a gender diversity at organizational level. While this may seem a completely obsolete question, we should not forget that it took until about half a century ago to have universal voting rights for women in all European countries and in Saudi Arabia even only in 2015. Nevertheless, the first article of the Universal Declaration of Human Rights clearly states that “All human beings are born free and equal in dignity and rights”. Moreover, there is clear evidence that diversity in the workforce is associated with improved organizational performance and seems vital for improving outcome in healthcare.16-18
What are the reasons for this disparity of women in leadership positions? It is beyond the scope of this contribution to analyse this question in depth but some comments may be appropriate. Differences in gender values and ambitions are frequently invoked as a reason why fewer women than men reach the higher levels of medical positions.3Obviously, the responsibility for child care still is mainly borne by women and the issue of balancing career and family seems to be important for the European female physicians.19Also, it has been reported that women with academic careers are less likely to have children or be married. Of those women who are married, a higher percentage of their spouses are working full-time outside the home, when compared to men.20In other words, it seems that the conflict between family responsibilities and the availability for leadership roles still may be an important causal factor.1
Starting from this observation, possible approaches to the problem might be for women to figure out how to maximize their time available for professional work.1However, equally – if not more – important is the fact that administrators and leaders in the various medical specialties make a concerted effort to integrate family considerations into their organizational strategies.1-3,21Obviously, the latter is important for both women and men.
Referring back to the observation that female medical students and physicians perceive more difficulty in finding mentors than their male colleagues,15it would seem logical to develop specific mentorship programs.1,4
However, such measures are only supportive. Is there any need for a more structured approach? Organizational decisions to go for equal recruitment and to set clear targets seem to be successful in closing the gender gap.4
Very recently, Leslie et al. proposed a 10-item rule for improving female participation in anaesthesiology leadership,22highlighting the importance of collecting information, having a structured approach to solving the problem, and finding ways to support both female office bearers and candidates. Among the proposed policies, there is a specific suggestion towards making the work environment and approach more family friendly. They famously finish their paper asking organizations to take the pledge, and thus commit to taking this issue seriously.
The ESA Board of Directors is taking on the challenge and is actively taking steps to address this problem. Currently the ESA has vacancies for leadership positions in different committees within our society. It is now our turn to take the pledge. This is the time to stand up: apply, encourage, support, and, very importantly, start this conversation in your work place, hospital, clinic, wherever. If we want to get rid of gender inequality within the society, this is the opportunity for everyone to help shape the future of our society: TAKE THE PLEDGE AND COMMIT. How will you help shape the future for gender equality?
- Morton MJ, Sonnad SS. J Nat Med Ass2007;99:764–71.
- Ramakrishnan A, Sambuco D, Jagsi R. J Women’s Health2014;23:927–34.
- Arrizabalaga P, Abellana R, Viñas O, Merino A, Ascso C. Gac Sanit2014;28:363–8.
- Kuhlmann E, Ovseiko PV, Kurmeyer C, et al. Hum Res Health2017;15:2.
- Toledo P, Duce L, Adams J, Ross H, Thompson KM, Wong CA. Anesth Analg2017;124:1611–6.
- Baker LC. N Engl J Med1996;334:960–4.
- McMurray JE, Linzer M, Konrad TR, Douglas J, Shugerman R, Nelson K. J Gen Intern Med2000;15:372–80.
- Tracy EF, Wiler JI, Holschen JC, Patel SS, Ligda KO. Gend Med2010;7:350–6.
- Rotbart HA, McMillen D, Taussig H, Daniels SR. Acad Med2012;87:98–104.
- Fried LP, Francomano CA, MacDonald SM, et al. JAMA1996;276:898–905.
- Tesch BJ, Wood HM, Helwig AL, Nattinger AB. JAMA1995;273:1022–5.
- Levine RB, Lin F, Kern DE, Wright SM, Carrese J. Acad Med2011;86:752–8.
- Weaver AC, Wetterneck TB, Whelan CT, Hinami K. J Hosp Med2015;10:486–90.
- Nonnemaker L. N Engl J Med2000;342:399–405.
- Sambujak D, Straus SE, Marusic A. JAMA2006;296:1103–15.
- Cohen JJ, Gabriel BA, Terrell C. Health Aff2002;21:90–102.
- Wallis CJD, Ravi B, Coburn N, Nam RK, Detsky AS, Satkunasivam R. BMJ2017;359:j4366 doi: 10.1136/bmj.j4366
- Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. JAMA Intern Med2017;177:206–13.
- Mayoroba T, Stevens F, Scherpbier A, van der Velden L, van der Zee J. Health Policy2005;72:73–80.
- Sonnad SS, Colletti LM. Surgery2002;132:415–9.
- Mobilos S, Chan M, Brown JB. Can Fam Phys2008;54:1285–6.
- Leslie K, Hopf HW, Houston P, O’sullivan E. Anesth Analg2017;124:1394–6.