Keywords

FormalPara Chapter Objectives

  • Describe the gender inequity in career advancement for women in academic careers

  • Emphasize the importance of gender climate as a modifier of professional isolation

  • Identify factors that contribute to workplace isolation and proposed solutions

Vignette

An early career African American physician has a thriving clinical practice at an academic institution but has limited insight into promotion strategies. She is often asked to participate in hospital committees and recruit patients for studies but feels like a “token representative” in these activities. She is one of the few women in her department and the only underrepresented minority (UIM) faculty member. Her chairman is cordial and meets with her to review her relative value unit (RVU) success but dismisses requests to meet and discuss research ideas and pathways to promotion. He values her clinical contributions to the department and includes her in the photo opportunities to highlight diversity but never engages her in a plan for further career development.

She is so busy clinically and with committee work that she never has the opportunity to activate her ideas about institutional initiatives, develop new investigative strategies, or partner on publications. Junior-level male faculty are hired with similar credentials but are given protected time to pursue academic and professional interests. She discovers in casual conversation that they have higher salaries despite what she knows to be equal or less clinical productivity. The chairman meets regularly with male faculty to discuss career interests, possibly due to their common shared experiences. She was surprised to receive a smaller clinical bonus that academic year and wonders if this was related to her attempt to discuss the differences in faculty support between her and her male colleagues she observed with her chairman.

Introduction

Women have become increasingly prevalent in medicine. According to the American Association of Medical Colleges, the percentage of women medical school graduates has increased from 7% in 1967 to 46%.in 2016 [1]. In 2018, there were more women than men matriculating at United States medical schools [2]. Despite this trend, gender gaps in career choices still exist across many specialties. Women are most widely represented in the specialties of pediatrics, internal medicine, and family medicine and less likely represented in fields such as surgery [1]. Underrepresented minorities represent only a quarter of women medical school matriculants [3]. Defined by the AAMC in 2004, an underrepresented minority in medicine (UIM) means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population [4]. While the overall trends of women in medicine are improving, there are still significant differences in pay, academic rank, and leadership [5].

Despite the increase in the number of female medical graduates, few women choose academic medicine. Only 27% of medical school faculty are women with medical degrees (MDs) [1]. Among women who develop academic careers, few earn tenure and rise to the level of senior leadership. While women represent 51% of clinical instructors, they represent only 20% of all full professors with MDs [1]. Women represent only 15% of department chairs. In addition, women represent only 16% of all medical school deans; most instead hold midlevel or associate dean positions [6, 7].

This lack of parity in female advancement in academic medicine has been documented extensively in the literature [1, 8, 9]. While women may develop thriving clinical practices and excel at teaching, these attributes tend to be weighed less favorably toward promotion, as compared to more traditional scholarly activity, such as research publications. Historically, women have had lower numbers of peer-reviewed research publications, driven initially by the smaller number of women in medicine [10, 11]. As the number of women in academic medicine has risen, the proportion of women authors has also increased, including those with first authorship roles [12]. In some specialties, when adjusting for the number of years in practice and stratifying by rank, women publish at equal rates to men [13, 14]. Despite similar trends in productivity, the outcomes are not equal. Female faculty who publish at a similar rate to their male colleagues in the same specialties still have discordant career trajectories, with many women plateauing at the rank of associate professor [1, 8, 9, 14].

According to a survey performed by Carr et al., there are five overarching barriers women face in academic career advancement: (1) a perceived wide spectrum in gender climate, (2) lack of parity in rank and leadership by gender, (3) lack of retention of women in academic medicine (the “leaky pipeline”), (4) lack of gender equity in compensation, and (5) a disproportionate burden of family responsibilities and work-life balance on women’s career progression. Survey respondents noted that the “gender climate” differed by academic rank for women, with lower ranks being perceived as more welcoming for women as compared to more isolating senior ranks [8, 15].

The remainder of the chapter will focus on the gender climate in academic medicine, with a specific focus on the impact of professional isolation on this climate. It will also explore ways to recognize the sequelae of isolation as well as steps needed to address it.

Isolation in Professional Careers

Isolation is defined as the state of being in a place or situation that is separate from others [16]. Isolation related to workplace interactions is most often described in the educational, sociological, and business literature. Isolation can interfere with collaboration and professional development. Inadequate support structures, including mentorship, may impede insight, feedback, and professional growth. According to a Harvard Business Review survey, solitude is associated with higher learning. Loneliness and less workplace support are more common in individuals who have advanced degrees than those who have only attained undergraduate or high school degrees. Respondents with professional degrees in law and medicine are the loneliest; according to the survey, they are 25% lonelier than respondents with bachelor’s degrees and 20% lonelier than those with Doctor of Philosophy degrees [17].

Isolation has not been extensively addressed in the medical literature; most of the literature that does exist is primarily centered around rural medicine [18]. However, isolation occurs beyond the context of geography. Professional isolation refers to a lack of networks or a sense of isolation from professional peers, which may result in a sense of estrangement from work identity and practice currency. Individuals with professional isolation feel that they lack colleagues with whom to discuss work-related issues [19]. Components of professional isolation include making decisions alone, deficient collaboration, not being a part of the work community, and lack of mentorship [20]. Professional isolation can occur at any stage of career. It is not limited to specialty type, length of time in the profession, or gender.

Gender-based professional isolation is a generational construct of academic culture stemming from a historic paucity of women in academic medicine. Lack of a critical mass of women in general and women in leadership create this imbalance. Gender-based professional isolation may include a psychological, qualifiable component that affects self-confidence and motivation. Lack of women role models at the highest levels of leadership can limit the outlook of what is achievable for women at junior levels. Gender-based professional isolation is also a condition of physical quantifiable work-environment barriers that impede success. Studies show that resources for women including space, salary, and ability to participate in outside professional activities are inequitable [21,22,23]. Though these inequities have been identified for decades, they continue to exist. In a 17-year follow-up study of a survey initially conducted in 1995, Freund et al. found that a 10% lower salary persists for women compared to men [24]. Women in academic medicine may face inequities in assignment location and effort allocation that may contribute to professional isolation in the academic system. Women may be more likely to choose flexible schedules for work-life integration or may seek community-based practices with academic affiliation and instead may spend more time performing educational and clinical duties over research efforts [25]. Temporary leave from the workforce for childbearing, child care, and elder care may delay promotion, may interrupt research endeavors, and can derail tenure time- specific goals. Women with children also spend a disproportionate amount of time performing parental duties as compared to their male counterparts. In a study comparing obstacles in career success, both male and female surgeons reported social and family issues as major concerns. Men noted a higher tendency to miss family activities due to job demands. Women were significantly more likely to miss work activities due to family responsibilities [26]. Female physicians with children spend an average of 11 hours less time at work than male colleagues due to domestic duties, including child care and elder care [27]. Extrapolated over 1 year, this leads to a time difference of 572 hours that can contribute to lagging career success and isolation from colleagues. The differences in priorities of work and home are changing with more enlightened dual-career couples. Over time, the home responsibilities of women and men in medicine may reach better parity. However, even though there are fiscal and/or professional costs for time that women take off in their careers for home and child care responsibilities, the limits on academic progress may be persistent and out of proportion to the time lost [5].

Even women who remain full time in the academic setting with robust research careers may experience professional isolation due to lack of clear pathways to success. Gender may influence career goals of academicians. In a survey of motivations, goals, and aspirations of male and female faculty, both groups equally perceived the importance of career goals related to publication quality and quantity, clinical care, and teaching. Male faculty were more likely to consider earning a high salary, having national and international reputation as an expert, and achieving a leadership role as important career goals than female faculty [28, 29]. The paucity of female role models at the highest levels may not only influence top male leaders but may have a rate-limiting effect on career aspirations in other women. Without clear and abundant examples of female faculty succeeding in all aspects of academic medicine, there may be limited perspective of possibilities in career growth leaving women with lower sets of expectations.

Leadership may have gender bias in the recognition of accomplishments. Women may be overlooked for selection for new opportunities and promotion. When women have achieved success in research and have reached the full professor status, they are still overlooked for top leadership roles. They remain penalized by cultural stereotypes and are relegated to the “out group” when top positions are available [30]. For example, while men are stereotypically recognized as possessing the agentic traits of logic, independence, and leadership, women are thought to possess the more communal traits of kindness, dependency, and being group oriented, which may diminish consideration from traditionally male-dominated leadership roles. These character trait assumptions and associations may make women’s accomplishments less recognized in departmental and institutional cultures. These disadvantages become more prominent with career stage advances [30,31,32].

In business literature, the majority of leaders advocate for protégés who remind them of themselves. Unconscious and affinity biases motivate leaders to seek the company of individuals who make them feel comfortable: those who share their race, gender, upbringing, culture, and religion. This advocacy for majority of men is a roadblock to widespread sponsorship for underrepresented groups. The majority of corporate America is led by white males, which may be self-perpetuating, keeping diverse talent outside of the C-suite (“chief” officer suite) [33].

The business literature further supports this concept of professional isolation experienced by women and minority leaders who do achieve senior-level positions. Women business leaders often find loneliness at the top and can experience peril if they advocate for other women, resulting in negative performance reviews. In a survey of 350 executives, Hekman and colleagues concluded that individuals engaging in diversity-valuing behavior were evaluated less favorably than those who did not actively promote balance [34]. In response to inequality of opportunities by gender and race, there is a tokenism that is also perpetuated that further marginalizes women who have ambition. Anne McNulty notes “some senior-level women distance themselves from junior woman, perhaps to be more accepted by their male peers…it’s easy to believe that there’s limited space for people who look like you at the top when you can see it with your own eyes.” [35]

The professional isolation documented in the general education and business environments similarly affects both women and underrepresented minorities in medicine. Recognition of isolation may be subtle at first, but there may be social clues. The isolated physician may be more withdrawn and less likely to speak up in group professional settings. This is paralleled in UIM data on social isolation of medical students. Students, who are not welcomed in a social network, can be mistakenly perceived as less interested, unprofessional, or lacking knowledge [36]. Similarly, faculty who are isolated may not be perceived as professionally engaged in the culture of the organization. Women and UIM faculty who experience ongoing frustrations with the institutional framework may move from passive behavior eventually asserting themselves or issuing complaints. Unlike men in the academic majority who speak up and are favorably perceived as self-advocates, women and UIM faculty are perceived as unwelcomingly aggressive [36].

The long-term sequelae of professional isolation may be disengagement, career dissatisfaction, and attrition. The three most common reasons that women and minority faculty cite for leaving academic medicine include lack of career/professional advancement, salary inequity, and chairman/departmental leadership issues, including harassment and discrimination [37]. In a survey on workplace discrimination, women were more likely than men to file a complaint of discrimination (14.6% vs 8.1%) but were more likely to report a worsening situation following the complaint as compared to men (26.7% vs 5.3%) [38]. The discriminatory actions and the lack of response and resolution of the situations are equally damaging. If professional isolation is not addressed, it may lead to the three dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment [39]. Effects of burnout are numerous and can affect patient care, health system outcomes, and physician health. These results of burnout can lead to lower quality of patient care, medical errors, lower patient satisfaction, reduced physician productivity, increased physician turnover, and increased health-care costs. Finally, isolation, loneliness, and burnout can lead to the adverse physician health effects of substance abuse, depression, suicidal ideation, poor self-care, and motor vehicle accidents [40,41,42].

As professional isolation is linked to deficiencies in promotion and career success, these determinants are multifactorial and include lack of mentorship, coaching, and sponsorship, unclear or circuitous pathways to success, limited feedback, and lack of a conducive organizational structure. In order to move forward to solutions, these factors must be addressed. Sustained transformation of the gender climate to reduce professional isolation and inequity requires change at individual, organizational, and national levels. The academic culture must shift to allow for this progress in four key areas (Fig. 8.1).

  1. 1.

    Mentorship, Coaching, and Sponsorship

Fig. 8.1
figure 1

Ending professional isolation by changing the culture of academic medicine

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Mentorship , coaching, and sponsorship are all on the continuum of professional development and facilitate professional engagement on an individual level. Definitions and characteristics of these roles vary in career development literature. Some aspects of mentoring, coaching, and sponsorship are intertwined. All help move the protégé to a higher goal. Mentorship typically occurs in the same field of expertise. The mentorship relationship can either be a one-on-one relationship, a group relationship with one mentor and several mentees, or a peer-based relationship [43]. Mentors are role models at the same institution or at other academic organizations. Mentors provide feedback, encourage professional growth, foster networking, and can give insight into the culture of an organization.

Coaches may not have expertise in the same area but can still provide the protégé the ability to self-reflect on his/her actions and help develop a career advancement strategy. In the business setting, Cummings and Worley define coaching as working with organizational members, managers, or executives on a regular basis to help them clarify their goals, deal with potential stumbling blocks, and improve their performance. It is typically a personal one-on-one interaction and helps the targeted individual gain perspective about career goals. Unlike coaching, mentoring is often more directive with the mentor intentionally transferring specific knowledge and skill and guiding the client’s activities [44].

Sponsors differ from mentors in that they are always in positions of leadership. Sponsors go beyond giving feedback and advice for an individual; a sponsor actively advocates to help an individual gain visibility. In the business literature, sponsorship is defined as active support by someone appropriately placed in the organization who has significant influence on decision-making processes and who is advocating, protecting, and fighting for the career advancement of an individual [6, 45, 46]. A sponsor has the capacity to appoint or elevate his/her protégé into a role that will lead to career advancement. In medicine, sponsors open doors to opportunities for scholarship, funding, or the establishment of a regional/national reputation for his/her protégé that are otherwise unattainable [6]. The roles of mentor and sponsor are not necessarily mutually exclusive and can have overlapping traits. One person may serve in both of these capacities for a protégé. Distinguishing these roles as separate but related activities may help female faculty develop appropriate relationships. Women are half as likely to have sponsorship than men, yet the significance of mentorship and sponsorship has been demonstrated in all professional fields including business, law, and health care [47].

Mentorship, both alone and in the context of sponsorship, improves professional productivity, career development, job satisfaction, perceived institutional support, and faculty retention [48,49,50]. Women tend to have difficulty finding mentors, and when they are mentored, they have less successful outcomes [45]. Mentorship is gender neutral; male and female faculty are equally capable of providing mentorship. Familiarity drives aspects of mentorship for both the mentor and protégé. Leaders prefer to mentor individuals who have shared qualities and traits. The protégé may feel uncomfortable approaching someone with a different background in anticipation of a greater likelihood of rejection. The benefits of gender-matched mentorship include shared experiences and roadblocks. However, limited female role models in the highest positions of leadership in academic medicine may give women the perception that they have limited opportunities to find mentors or sponsors. If there are not enough female leaders in the highest ranks, there can be less opportunities to appoint future leaders to these positions.

  1. 2.

    Focused Pathways for Scholarship and Promotion

In order to advance individual success, clear pathways for promotion should be outlined for women faculty. Instead of being encouraged to focus on research and writing when not involved in clinical duties, women and UIM are often asked to participate on committees, community service, and student mentoring. They tend to have more divergent responsibilities but less support. They often spend excessive time and energy in activities that are not traditional pathways to promotion [51, 52].

Woman also must be supported with protected time for research and given access to equal funding opportunities. Gender affects funding and publication [53]. To level access, women need aggressive mentorship and sponsorship to help establish a strong foundation of scholarship.

Creating focused pathways includes realistic goal setting, planning, and feasible time allotment to accomplish goals. This should be done early in the academic career, with the guidance of senior faculty. In addition, personal life responsibilities, such as child care, should be taken into consideration to allow flexibility in promotions and advancement criteria to reflect the range of work that women accomplish [54].

Equally important to the establishment of a focused pathway to career success is keeping perspective and balance. Medicine is a profession and a calling. The passion for the work and the volume of the work can easily make it possible to let other aspects of life be minimized. It can consume all space without proper boundaries. Maintaining overall life balance defined as achieving the proper balance of work and self and others should also be taken into consideration [55].

  1. 3.

    Constructive Comprehensive Feedback

Constructive comprehensive feedback may be challenging in academic medicine, for a number of reasons, including lack of proper training by department leadership in providing appropriate feedback [56]. Traditionally, feedback does not encompass the full scope of what physicians do in the academic setting. However, feedback is an important element in promoting the success of women faculty; prior research has shown that women are actually more likely to seek feedback than men [57]. If done incorrectly, feedback may perpetuate the professional isolation that may already exist among women faculty members. While assessment is an important step toward improvement, it is often based on limited clinical narratives and not fully representative of the full spectrum of academic work. For example, feedback has tended to focus on the areas of patient experience and clinical productivity.

Patient experience information collected through various survey measurements usually have poor compliance so are often an unreliable measure to use for faculty feedback. Often the responses that are obtained give voice disproportionately to negative patient experience perspectives based on patient expectations [57]. Too often are the system shortcomings packaged into the overall impression of the visit disconnected from the merit of the physician work. Since women provide a large proportion of the clinical workforce, the negative patient experience feedback can have a large effect on career perception. Clinical productivity is another primary driver of feedback but is not a driver of promotion. Productivity is not a direct measure of quality but often physicians feel substandard in their ability to be good doctors based on the message that they are not working hard enough or that quantity is the marker of quality.

Constructive feedback involves taking into account the full spectrum of contribution of a faculty member, including those activities in which women faculty have traditionally been more involved. Mentoring peers and learners, institutional, regional and national committee work, community engagement, and institutional emergency response in times of coverage shortages or urgent cases should all count toward stewardship of the institution. Each institution however has their own metric of how these contributions are valued and some factors may rarely count toward promotion strategy.

At least, annual review of academic progress should be conducted with the senior leader plus more frequent checkpoints with mentors or sponsors. Balanced feedback should be provided that includes the full scope of practice, including clinical productivity as well as institutional stewardship with committee, mentoring, and community activities. Promotion trajectory with clear expectations should be reviewed regularly. Faculty should not only discuss more clinical measurements of achievement (such as RVUs) but other contributions. Feedback is linked to the career pathway and both require accountability from all parties involved. If the junior faculty incorporates feedback and stays on the proposed pathway, then the leader should be compelled to deliver on the promise of progression.

  1. 4.

    An Inclusive Transparent and Equitable Organizational Structure

To end professional isolation the work environment must change. The focus areas listed in 1–3 can be achieved on a micro level with individuals or on a macro level across an organization. Real sustained change requires these steps to be imbedded in the organizational and society construct. This is to ensure not only individual gains but widespread shifts toward transformative change for all faculty.

In a study of faculty representatives from 24 medical schools, 40% reported no special programs for recruiting, promoting, or retaining women in medicine, primarily because these initiatives were deemed unnecessary [58]. This may be an important barrier to overcome in order to advance women in medicine substantially. It is important to note that changes in an institution’s organizational framework can lead to culture change. This includes building a pipeline to promote women in academia, ending social and professional isolation, encouraging mentorship relationships, and encouraging a culture of leadership (Fig. 8.2).

  1. A.

    Building a Pipeline for Women in Academia

    It is important for academic medical centers to focus on building a pipeline that focuses on recruiting and retaining women faculty. This will allow medical centers to create better gender equity at the institutional level that can further expand to equity in the national selection processes for funding, publishing, and speaking engagements. Carr et al. recommend the development of comprehensive programs for recruitment, promotion, and retention that focus on individual, interpersonal, institutional, academic community, and policy levels of intervention. This includes the provision of leadership development programs for women, either institutionally or nationally [8]. Grant writing and faculty development support should not be limited to a single seminar but instead focus on longitudinal sustained efforts to promote faculty success. In addition, women should be offered an environment supportive of work-life integration. Solutions may include changes in policies on parental leave, minimizing before and after work hour meetings, on-site child care, equitable pay, flexible work schedules, and job sharing [59, 60]. There should be customization for women’s career pathways that takes into account work-life integration.

    Women must also learn to aim higher than the status quo. This includes learning to be better negotiators and self-promoters. Women often take a passive approach to salary and promotion-level setting. When negotiating salaries, women frequently take offers that are below proposals that men would accept. Women seldom make competitive counteroffers [61]. Business literature demonstrates that the best effort to achieve salary equity is in the initial offer [62]. Pay inequities between men and women persist even at more advanced positions because women tend to negotiate less aggressively for better salaries [63]. In regard to promotion, both quantitative and qualitative measures should be considered. Traditional quantitative measures include clinical productivity (e.g., RVUs) and publications. Additional quantifiable factors should include educational effort including the number of lectures given as well as seminars and courses taught by faculty. Qualitative measures include team participation, committee leadership, and community outreach.

  2. B.

    Ending Social and Professional Isolation

    Affinity groups that bring together women in similar fields can reduce professional isolation. Such groups promote comradery and allow women to collectively work toward advancing scholarship and leadership in a supportive environment. Social networks are important for discussing challenges and sharing approaches across interprofessional and interdisciplinary groups. Common challenges may include gender-conscious experiences, workplace bias, discrimination, and gender-specific strategies. While these groups allow women to discuss common barriers, they are not always granular enough to help with the distinct challenges of promotion and publication.

    Women striving for professional progress often seek more similar professional networks. Women have been shown to be more productive academically in settings in which they have a higher number of women peers. For example, those departments with a higher number of female faculty also have more publications generated by women [64]. Organizations allow women to learn from other women experiencing similar work situations but also help them develop negotiating skills to promote career advancement [65]. Encouraging such networks is a key part of creating a successful work culture for women. Networks are not just important in early career; in fact, studies show that the type of internal vs external collaborations differs by stage of career. Early-career physicians get most value from internal departmental or organization networking. Mid- and late-career faculty are less local or organizationally dependent and seek more professional networks on a regional or national level [66, 67].

  3. C.

    Formalizing Enduring Structures for Role Models, Mentors, and Sponsors

    Mentoring, sponsorship, and coaching are all needed for healthy academic progress. In academic medicine, most mentorship programs have focused on mentorship for junior faculty. However, it is important to recognize that women academics at the mid-career level also need mentorship. Support at all levels to encourage faculty to obtain senior leadership positions can discourage stagnation at mid-level positions [43]. Mentorship programs have been far more common than sponsorship programs at US medical schools. However, sponsorship is necessary for women to achieve high-level positions, and typically, women are less likely than men to actively seek sponsors [68]. While most mentoring relationships are organic, there is some randomness in their creation which can overlook better and more thoughtful matching. Adding a framework for more intentional matching should be done on an organizational and national level. In recommendations for expanding sponsorship programming in academic medicine, Gottlieb et al. propose that academic medical centers, medical schools, and specialty societies should launch these initiatives. They encourage system-wide inclusive formal programs that use data to facilitate matching. Clear expectations with feedback should be set. Senior leaders should become “sponsor evangelists” promoting the organizational value of formal programs including the potential for succession planning [69]. Organized programs with the explicit goal of sponsorship can help facilitate this relationship. One notable national example of a successful sponsorship program is the Society of General Internal Medicine Career Advising Program (CAP). CAP supports relationships of women with senior leaders by placing them on influential national committees as well as promotes relationships that will further advance promotion. It has supported 300 women since its inception in 2013 [7, 70]. AAMC also advocates for professional career development and sponsors a group on women in medicine and science with comprehensive resource for women [71].

  4. D.

    Creating a Culture of Leadership with Equal Opportunities for Success

    This requires a culture change in the organization and society. Researchers Alyssa Fried Westring and colleagues have defined a culture conducive to women’s academic success (CCWAS) that includes having equal access to opportunities, support of a work-life balance, lack of gender bias in the workplace, and having a leader (such as division chief or department chair) that is supportive of success [72]. In order to encourage access to opportunities, institutions have to actively devote resources to the promotion of success of women in academic medicine. In a NIH-sponsored randomized trial to evaluate factors that would encourage productivity of women at the assistant professor level, University of Pennsylvania researchers explored a number of initiatives. These included goal-related task forces that recruited and promoted women, professional development programs that encouraged manuscript coauthorship and leadership among women faculty, and the engagement of institutional leadership in the promotion of women faculty. While there were no differences between the intervention and control groups, likely due to institution-wide changes impacted by the study, the authors recognized that these steps were still important in encouraging academic progress [73].

    In addition to promoting initiatives to encourage success, it is also important that faculty leaders are aware of any implicit gender bias they may have in approaching female faculty candidates for consideration for leadership positions or promotion. These behaviors can present in varying patterns, including intermittent, pervasive, subtle, or overt, and take a toll on job satisfaction and patient care [38, 53]. All forms of discrimination and harassment should be investigated. Leaders should complete and proactively institute implicit bias training for all team members [54].

    Addressing this bias also includes addressing the traditional inequities in salaries that women medical faculty have faced. Women faculty at public medical schools earn 8% less than their male counterparts, and the gender gap for physicians in clinical practice is even wider [74]. Academic leaders should encourage transparency, communication, negotiation, and compromise. Adopting transparency in compensation with a formula that is consistent and understandable to explain salary variations is important as well as sharing summary statistics of salaries by rank and gender internally [75, 76]. In addition, encouraging negotiating skills for women early in their clinical career is an important element of faculty development.

Fig. 8.2
figure 2

How to foster an inclusive, transparent, equitable, and sustained structure

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Finally, as role models, women show a pathway that is possible and provide unique insights into barriers that male leaders may not consider. Women in leadership have the power to positively affect workplace policy and lead change in national societies and regulatory agencies. With generational shifts and more women entering academic medicine, the gender gap may be closed in academic leadership as greater numbers of women enter tenure track positions. The work of developing senior women leaders in academic medicine must be intentional and strategic. Creating organizational change is difficult and requires the teamwork of all leaders regardless of gender. Women should avoid the temptation to retreat or leave academic institutions since most effective change starts within organizations. Women leaders, though few in number, must lead the change in partnership with their male associates. As more women become senior leaders, there is greater opportunity to encourage future faculty development. More women will be capable of inspiring and mentoring other women who are early in their career development, further perpetuating progress. Expanding the scope of qualifications for tenure, including taking into consideration all aspects of academic merit such as clinical excellence, teaching acumen, and administrative excellence, may expand leadership opportunities for all faculty, including women. These advances can lead national change with enforcement of policies that combat the bias and inequity that contribute to isolation and burnout. Only a systematic approach will have sustaining to break the glass ceiling for women in academic medicine.

Returning to the physician in the vignette, she would have benefitted from better department transparency. Implementation of an organized program to promote mentorship and sponsorship would help her identify a clear set of strategies for promotion, as well as open opportunities for her to be involved with activities conducive to career advancement. Transparency in the department would have made it clear about what objective components of her work contribute to her productivity. Targeted activities designed to promote faculty development skills among women in her department, which included negotiation skills, would also be helpful as guide for salary renegotiation to be on par with that of faculty of similar rank and productivity. These strategies could have reduced professional isolation and have led to a greater chance of retention in her department.