Female medical leadership: cross sectional study Editorial by Showalter

Introduction

The Norwegian labour market has adjusted to the increased proportion of career women with an equal opportunities policy of positive sex discrimination in favour of women and improved social benefits. Dual career families are now the norm rather than the exception; current employment rates for women and men in Norway are 56% and 70%, respectively. Maternity leave has improved, and working women are entitled to full cash benefits for 42weeks or 80% benefits for 52weeks, and men are entitled to 2weeks' paternity leave. The public day care coverage is 60%, and parents are allowed 10days' paid leave a year per child for illness in children. Despite this liberal equity policy and an increase in the number of women working, relatively few women hold positions of leadership in industry, business, or the public sector, including health care.1

Up to the 1990s, when the proportion of women among medical students reached 50%, women had the advantage of positive sex discrimination in medical schools. Now, though universities use this to increase the proportion of women in academic posts, there is no such policy in the appointment of hospital doctors and public health positions.

Data from Finland suggest that female physicians are largely excluded from decision making in medical research,2^–4 but few studies have explored the relation between specialty and career choices and female leadership in medicine. As the purpose of the Norwegian equal opportunities policy has been to favour women in the workforce and strengthen their participation in all employment positions to obtain equity, it is of interest to study the extent to which female Norwegian doctors have succeeded in reaching senior positions.

With data on specialty and occupational status of Norwegian physicians we examined the distribution of female and male leaders with respect to age and type of job. We then estimated the probability of leadership for different categories of female and male physicians. Finally, we explored whether leadership among female hospital physicians is related to the proportion of women in the specialty.

Methods

Results

Of all physicians in the study, 28% were women. The mean age for women was 40.5years and for men 46.5years. The proportion of male physicians who were leaders was 14.6% (95% confidence interval 14.0% to 15.4%) compared with 5.1% (4.4% to 5.9%) for women. The mean age for female leaders was 49.7(48.6to 50.7) years and for male leaders 52.8(52.4to 53.3) years. Table 1 shows the numbers of physicians in the different age and job categories and the corresponding proportion of leaders.

The probability of being a leader was estimated by a logistic model with sex, age, and job categories as additive covariates. Table 2 gives the estimated probabilities of leadership for the different combinations of age and job situation. As some of these groups are quite small the confidence intervals are correspondingly wide —for instance, the 95% confidence interval for the estimated probability of 0.39for female academics over 54years was 0.21 to 0.63whereas the corresponding interval for the male probability of 0.57was 0.42to 0.72.The age gradient, assumed to be the same for men and women, was significant as was the sex effect, with an adjusted odds ratio of 2.0(1.6to 2.4) in favour of men.

A possible period effect (that it is easier for female physicians to reach leadership now than, for example, 10to 15years ago) was explored by including the interaction of women under 45years versus men and older women in the above model. This covariate had no significant effect, however, and the estimated probabilities in table 2 remained almost the same.

The 2033women currently employed in hospital medicine were included in a logistic regression analysis of the possible impact of proportion of women in different specialties on the probability of female leadership. Covariates were age, the proportion of women in the specialty (squared), and a dummy variable for specialist or non-specialist. All three covariates showed significant effects, with t values of 7.13,4.0,and 3.45,respectively. The figure shows the estimated probabilities of leadership for five major specialties plus the female dominated specialty of child psychiatry by using this model. There was a slight increase in probability of leadership with increased proportion of women, but the differences between the groups were not significant.

Estimated probability of leadership for 50 year old female specialist working in hospital in six different specialties with varying proportions of women. Derived from logistic regression model with 2033 hospital based female physicians

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Discussion

Although the present study on careers of female physicians shows that few women reach senior positions, an encouraging finding, considering the steady increase in female medical graduates, is that the proportion of women in any medical specialty may be a determinant for female leadership. Nevertheless, there was no increased probability for leadership positions among the new generation of female physicians.

Because the medical career structure has been slow to adapt to the changing profile of medicine5 it has been questioned whether female physicians have the same opportunities as their male colleagues or if they are exposed to barriers which mean that they are likely to have a secondary role. 3^–5 In addition to individual constraints such as family preferences and lack of leadership ambitions,6^–8 attention has been drawn to structural constraints as the explanation of why female physicians who aspire to top positions meet invisible barriers. Deficiencies in career advice and counselling from patrons and colleagues may contribute to the “glass ceiling” effect on women's upward mobility.9^–11 According to Kanter, who studied the impact of organisational characteristics on internal labour market patterns, the gradient of the existing sex ratio in a corporation is a strong predictor for career opportunities for women.12 She argues that women in a minority are exposed to exaggerated attention and lack of integration, reactions that will not appear in groups with less skewed sex ratios. Hence the size of the female minority group has to be sufficient to achieve the positions necessary to change the organisational structure.12 The fact that the relation between female leadership and the proportion of women in the specialty is positive supports this view if we are willing to equate the specialty union with Kanter's organisation.

Despite the recognition of dual careers, a policy of equal opportunity, and improvement of crèche facilities, the present study shows that women still do not reach senior positions as easily as men. The few female leaders in the study worked in public health and female supported hospital specialties. General practice and community health are deemed less prestigious than hospital career jobs, 3 13 and women report less interest in academic careers and leadership than men. 14 15 Even though the proportion of women in medicine is increasing, women tend to have employment characterised by routine work and low salary. 2 3 5 16 The progress towards parity remains slow and in certain sex stereotyped specialties, such as surgery and general medicine, women still comprise a tiny minority of the most senior grades. 2 3 16^–18

Without disregard of discrimination issues, the underrepresentation of women in positions of authority may reflect some systematic, underlying effect whereby women simply do not choose to take on heavily committed senior positions. Because it is difficult to get away from the traditional linking of age to grade so prevalent in medicine5 women face a trade off between career posts associated with power and influence and family and emotional responsibilities. Although marriage and children are traditional constraints on the careers of female physicians, other factors, such as long hours and on call, impose considerable strain on relationships because careers of partners also have to be taken into account. 5 19 Even in dual career families, women are traditionally in charge of caring work.19 The present study suggests that female physicians give priority to emotional and family commitments at the expense of power and influence on medical decisions. A reassessment of the traditional linkage between career advantage and age is needed in the medical career structure. More part time opportunities and flexibility of careers would make it possible to give familial commitments precedence and subsequently make a preference shift towards influential medical positions.