Academic Medicine Gets a Poor Report Card—What Are We Going to Do?

When I was growing up, report cards were very important in our family. Expectations for performance were based on our parents' estimation of our capabilities. Reasons for meeting those performance expectations were known and ranged from getting into a good college to justifying the expense of tuition to not disappointing our parents. Grades were awaited with great anticipation and scrutinized not only for academic performance but also for indications of effort and positive progress. Good grades were recognized; bad grades, discussed. The most serious discussions were reserved for reports that indicated a lack of positive progress or effort. When necessary, remedial plans—everything from set study hours to tutoring to loss of privileges—were put into place. In this Commentary, I share my thoughts about another type of report card. Seven years ago, the AAMC formed a committee to determine why the number of women selected for leadership positions in academic medicine was failing to keep pace with either the desire to achieve gender balance or the availability of talented women.1 A plan of action was proposed, including the formation of a project implementation committee. This month's Academic Medicine includes this team's findings in the form of a report card entitled “Increasing Women's Leadership in Academic Medicine: Report of the AAMC Project Implementation Committee.” In this Commentary on the report, I consider four questions: (1) Why should we in academic medicine care about our performance in this area? (2) What does the report card say about our progress? (3) What should we consider as we develop remedial plans to improve our performance? Finally, (4) What will a good report card in this area include? WHY CARE ABOUT FULL INCLUSION OF WOMEN IN THE LEADERSHIP OF ACADEMIC MEDICINE? The report notes three reasons for the full inclusion of women in academic medicine: principles, pragmatism, and prevention. In its report, the committee emphasized the second of these reasons, the pragmatic business arguments for full inclusion. I agree that these arguments are compelling. Corporate America has concluded that the single most important asset of any organization is its people.2,3,4,5 People are the source of the knowledge capital, the initiative, and the hard work that make the difference between a successful enterprise and one that is not successful. Particularly in this time of change, academic medicine must recruit, retain, and make full use of the most talented people available. Women now make up almost 50% of students entering medical school and, as such, compose half of the potential pool from which academic medicine can draw its future leaders. We cannot remain blind to the potential, and the needs, of this group. Corporate America has also demonstrated that diversity in leadership is related to substantial advantages. As a group, women bring a new and valuable skill set to leadership positions. The organizations in which women have achieved such positions find their communication styles, teamwork capabilities, and leadership methods enhanced and improved. Organizational capacities are increased. Fuller inclusion of women in academic medicine may lead to the fuller inclusion of other minority groups, as well as to the fuller inclusion of men who possess styles of leadership different from the traditional norms. It is important to note that this is not a zero-sum game: fuller inclusion of other groups does not eliminate or minimize the substantial influence that traditional leaders and leadership styles have brought, and will continue to bring, to the table. The business arguments for full inclusion of women and for increases in the numbers of women in leadership positions are compelling. However, it is important to note that the other two reasons that the report gives for the increased participation of women in academic medicine, principles and prevention, also have considerable merit. In particular, one of the principles—that fostering full participation of women is the right thing to do—is a fundamental one. Medicine is an inherently moral undertaking, and those of us who are charged with training future generations of physicians and inculcating the medical ethic can ill afford not to do the right thing. It is our good fortune that in this situation the principles and the pragmatic align. We may stress the pragmatic but must also articulate the principles. A GOOD OR BAD REPORT CARD? The implementation report presents a variety of quantitative and qualitative information about women's movement into the medical profession, and particularly into senior faculty ranks and leadership positions in academic medicine. The report documents that we have successfully modified admission policies to allow equity in admission to the profession as a whole. In addition to their entrance into medical schools and their successful negotiation of national hurdles to licensure, women can be found, at least in small numbers, in all medical and surgical specialties. In some disciplines, in fact, women constitute the majority of new practitioners. Women have chosen careers in academic medicine, and some women have attained, and been successful in, leadership roles as division chiefs, department chairs, and deans. At the same time, women remain underrepresented in most surgical and medical specialties. After statistical controls for work hours and publications, studies still show that women are less likely to be promoted than are men with similar academic records. Women account for only 8% of medical school chairs and for less than 10% of medical school deans. The committee report challenges the opinion still held by some that women's leadership in academic medicine is a pipeline issue that will resolve itself with time. But national data and studies at individual schools demonstrate that women have been entering the academic medicine pipeline in sufficient numbers for enough years to justify much greater representation in senior faculty ranks and leadership positions.6,7 The problem is not entry into the pipeline but rather the impeding of women's progress by a number of blockages and leaks in the pipeline. Actually, the “pipeline” metaphor cannot adequately represent a process as dynamic as career development. Whatever metaphor we select, the report makes clear that only minimal forward progress has been made. In 15 years, the proportion of women who are full professors increased by only 1%. Some medical schools have never had a woman department chair. Of concern is the report's suggestion that women may be rejecting careers in academic medicine. The annual rate of faculty attrition is higher among women than among men. Female medical school graduates are no longer more likely than male graduates to enter academic medicine. In effect, women may be voting against such careers with their feet. The committee concludes that progress within academic medicine over the last 25 years is “incomplete and inadequate.” In fact, this is a very poor report card. How many applicants would be accepted to our schools and residency programs if their report cards demonstrated a level of success in their pursuits similar to that demonstrated by academic medicine in this report card? I suspect not many. HOW DO WE IMPROVE OUR PERFORMANCE? The recruitment of women into academic medicine depends on the presence of female role models who have been successful in their ascent through the career track. Retention of women faculty members will require their promotion to higher academic ranks and positions of greater responsibility. Both recruitment and retention require that women have the skills necessary to succeed, and that the environment be one in which they can succeed and one in which they want to succeed. So what do we do about this “incomplete and inadequate” progress? What plan can be put in place to improve our performance? A recent report identified three leadership development strategies that are commonly used in academic medicine: (1) professional workshops for individual faculty members, (2) fellowship programs designed to foster leadership, and (3) attempts to effect organizational change.8 All three means should be employed. We should look beyond the boundaries of our own institutions, and beyond academic medicine as a whole, as we develop solutions. Many organizations, particularly business corporations, have dealt with the challenges and enjoyed the benefits of expanding women's opportunities for leadership. Their programs can be used as templates and modified as appropriate. Their experiences can also provide valuable evidence of the benefits that accrue to institutions that do the hard work of facilitating women's leadership. The first two methods, professional workshops for individual faculty members and fellowship programs in leadership, are directed at the development of the individual faculty member. I hope that the report will stimulate an analysis of how institutions are developing their greatest asset—the people who work in the institutions—and specifically (for the purposes of this Commentary) of how we are developing our faculty members and department leaders. In many institutions, faculty development—of men and women at all levels—is woefully inadequate. Faculty development programs should be an integral element of lifelong learning to which faculty members and institutions must mutually commit. These programs must be offered to women and men, be developmentally appropriate, and be geared to the specific work and challenges of the faculty members. Faculty members must take responsibility for their own self-development and participate actively when opportunities for learning occur. Programming should include senior faculty members and college leadership. For example, the report alludes to the important role of department chairs in promoting women's leadership in academic medicine. Programming directed at developing and leading diverse teams can provide chairs with the valuable skills they need to play this role effectively. Some academic health centers have begun institution-based programs that train groups of faculty members in leadership and business skills in an attempt to help both the faculty members and the institutions navigate the rough waters of academic medicine today. For example, the University of Kentucky (UK) has created a Certificate in Medical Management Program that targets mid-level faculty members for intensive training in leadership and business skills.9 Although some of these skills may have been traditionally considered male strengths (e.g., those in the area of finance), others emphasize skills in which women traditionally have special expertise (e.g., in teamwork). The networking that occurs among colleagues in these settings can both foster culture change and increase skills. A number of program graduates have been given opportunities to exercise their new skills, thereby bringing value to the organization and to the individual faculty member. The third component of leadership development, organizational change, is considered crucial for effecting institutional change and for providing women with more opportunities to move into leadership positions. To be sure, changing institutional culture is difficult, but faculty development programs targeted at senior leadership can have an impact on culture while increasing participants' skills. For example, Dr. Emery Wilson, dean of the UK College of Medicine, recently engaged faculty members from the UK Gatton College of Business and Economics to conduct a year-long leadership development program for a College of Medicine group that included the dean, department chairs, and associate dean staff. Over the year, this group participated in exercises that included visioning, team building, and strategic planning. Initially greeted with skepticism by some, the program ultimately achieved wide buy-in. If such programs include discussions of the benefits of diversity and exercises for skill building in leading diversity, they can have a positive impact on the whole culture. Cultural improvements begin with a careful review of institutional policies and practices. Many institutions are in the process of evaluating their systems of faculty appointment and promotion. In most cases, this evaluation grows out of concerns that existing systems no longer work in academic medicine's current environment rather than out of gender equity goals. However, changes in appointment and promotion practices afford an excellent opportunity to affect organizational culture in the areas of diversity and leadership advancement of women. I comment on four areas that should be addressed: expanded definitions of scholarship, new views of faculty—institution relationships, explicit requirements for success, and increased accountability on the part of leaders and the institution in terms of faculty success. Many institutions are reevaluating the definition of scholarship. Academic medicine has long emphasized the scholarship of discovery—usually, individual discovery. The scholarship of discovery is, and will always remain, crucial to the contributions that academic medicine makes to society, as well as to the intellectual vitality of individual institutions. However, there has also been broad recognition that much of the research done in academic medicine— particularly in clinical departments—is more closely associated with the scholarships of application and integration. Also, there is increasing attention to the scholarship of teaching. Failure to recognize and validate faculty members engaged in these forms of scholarship undermines important missions. This increased attention to four forms of scholarship has resulted from changes in science and in the work that is done in academic medicine. However, expanded definitions of scholarship may also have a positive impact on women's success. Some evidence suggests that women may be particularly interested in collaborative research projects that generate the scholarships of integration and application, and that they may be particularly adept at dealing with some of the complex issues that lend themselves to this type of investigation. Women are well represented among faculty members focused on education, and recognition of this type of scholarship may assist in their engagement and success in academic medicine. Many schools are also expanding their views of employment relationships with faculty members. Traditional agreements have worked, and will continue to work, for many faculty members. However, full-time status, short and inflexible tenure clocks, and other traditional arrangements are often inconsistent with the nature of our work in academic medicine and with the seasons of peoples' lives, be they men or women. For years, individual leaders have creatively circumvented dysfunctional institutional policies in individual instances. However, these individual arrangements are no substitute for and may actually delay institutional change. Slowly, modifications to traditional relationships, including rolling contracts, expanded tenure clocks, and less-than-full-time tenure-eligible positions, are being introduced across institutions. These modifications, made because of the increased complexity of academic medicine, will have a positive impact on women's—and men's—participation in and entry into senior positions. As we expand the types of relationships that faculty members have with the institution, several things are important. Rigorous standards of excellence must be adhered to. We must help faculty members as a whole to understand and appreciate the contributions made by each individual member. The work of all, as long as it is excellent and contributes to the institution's mission, should be valued. As the types of relationships between the institution and the faculty members expand, it becomes increasingly important that expectations become explicit. Many institutions have revised, or are in the process of revising, their appointment, promotion, and tenure (APT) documents to define previously nebulous terms, outline pathways to promotion, and provide examples. Some institutions are developing methods by which faculty members can document their contributions to the various missions of the institution.10 It is impossible to define everything, and it is important that APT procedures retain some flexibility. However, this clarity in expectations and the use of tools to document performance can be of great value. Although all faculty members may benefit from such revised procedures, women and members of underrepresented minorities may be particularly benefited. Clarity eliminates some of the current need for extensive networks to help locate promotion rules and then decipher the code words found within them. Performance documentation helps ensure that achievements, including promotion, are recognized by all as the result of the faculty member's contributions and not “because she's a woman.” Other important mechanisms to facilitate cultural change include systems for gathering information and enhancing the accountability of institutional leaders. Regular surveys of faculty members and exit interviews with those who depart can provide college leadership with valuable insights into a variety of issues, including perceived barriers to success. When the information garnered through these sources results in action, it can have a dramatic positive impact on organizational culture. Of course, persistent inaction can have the opposite effect. Some institutions are incorporating the recruitment of diverse faculty members and the success of junior faculty members into the performance evaluations of chairs and center directors. Such processes underscore the institution's commitment to faculty members and encourage department chairs' personal involvement in the success of their junior faculty members. Of course, there will continue to be faculty members who do not succeed. But evaluating leaders, in part on the basis of their abilities to recruit and foster the success of a diverse faculty, and detecting those whose patterns of faculty development are inconsistent with institutional goals will allow the use of targeted interventions designed to bring about positive change. A final point worth considering is the current work-life movement that is affecting many corporations, not-for-profit institutions, and some institutions of higher education. The work-life movement incorporates the philosophy that a well-functioning life outside the work environment contributes to optimal work performance. Our faculty members—and young physicians and scientists considering academic medicine—are placing increased importance on balance and integration between their work lives and their personal lives. Attention to these desires can have a positive impact on the institution and may particularly facilitate women's success. WHAT WILL A GOOD REPORT CARD LOOK LIKE? I have concluded that academic medicine's report card on the advancement of women is disappointing, and I have recommended mechanisms for improvements. What should our report card look like ten years from now? How will we know whether we have succeeded? Quantitative measures of success should include substantial increases in the numbers of women in academic medicine and in high-level faculty and administrative positions. Analysis of the entering cohort of assistant professors for the next three years should demonstrate that women and men have been promoted in equal percentages. Attrition rates for men and women should be equal and should be below current levels. Explicit statements of expectations for promotion and clear mechanisms for documenting performance should be commonplace. Qualitative indicators will also be important in that report ten years from now. We should hear numerous stories of successful women leaders and the value they have brought to their institutions. In those instances in which a woman leader is not successful, we should hear that failure described as an individual failure rather than as women's failure. Finally, and most important, I hope that such qualitative analyses will show that all of us (women and men) who are privileged to work in academic medicine are experiencing the joy and fulfillment in our work that we expected when we entered the profession, and that these analyses will also demonstrate our conviction that our institutional systems are contributing to that joy and fulfillment.