Keywords

Disparities for women in pediatrics have existed for decades [1,2,3,4,5,6,7,8]. The term “equal opportunity” has been used to describe ongoing commitment to equal treatment by organizations despite the inequity in pay, promotion, leadership, and rank that women in medicine have encountered for years. Recent publications highlight inequity in every aspect of medical careers for women [1,2,3,4,5,6,7,8,9,10].

In pediatrics, women comprise 72.3% of residents, 63.3% of practicing physicians, and 57.4% of academicians, yet women comprise of only 16.8% of deans and 18% of medical school department chairs and 26.2% of pediatric chairs [8,9,10,11]. Despite an increase in percentage of women as professors to 25%, the number of women as deans has remained steady since 2016 [10,11,12]. One would assume that pediatrics with its high proportion of women in the workforce would lead the way with higher number of executive and senior leaders compared to other medical and surgical fields. But women of all backgrounds and specialty types experience similar disparities in the workplace and in achieving executive leadership roles that involve handling and controlling resources [1]. Women in pediatrics face similar challenges related to work-life integration, workplace culture, climate, disparity in compensation, rank, promotions, harassment, microaggression, and implicit biases [1]. Challenges of intersectionality, that is, multiple underrepresented identities including gender, race, sexual orientation, ability, age, or socioeconomic status, further complicate the advancement of underrepresented women [1, 13]. These disparities are being acknowledged and called out by a few national pediatric organizations.

In 2018, the Women’s Wellness through Equity and Leadership (WEL) project, led by the American Academy of Pediatrics (AAP) and in collaboration with the American Academy of Family Physicians (AAFP), American College of Obstetricians and Gynecologists (ACOG), American College of Physicians (ACP), American Hospital Association (AHA), and American Psychiatric Association (APA), brought together a diverse group of women physicians to empower them to build cross-specialty relationships critical to address the myriad of issues facing physicians in the evolving US healthcare system [14]. The project identified many of the current challenges that women face and explored strategies for advancing women in medicine [14]. In 2019, Spector et al. [2] identified that fair treatment of women in pediatrics will require commitment from four key gatekeepers groups: academic medical centers, hospitals, healthcare organizations, and practices, medical societies, journals, and funding agencies. They further described a six-step equity, diversity, and inclusion cycle through a scientific and data-driven approach that would pave the path forward for women in medicine (Fig. 9.1) [2].

Fig. 9.1
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The equity, diversity, and inclusion cycle: a strategic approach to accountable documentation and the resolution of gender (and other) disparities in medicine [1]

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The current culture of inequity, gender bias, and discrimination for women in medicine is pervasive. Such a pervasive culture leads to burnout for women and favors men over women. It promotes inequity in pay, promotion, and leadership. A drastic change is needed. But where will the change come from and how will the change be implemented and measured? Literature shows that women physicians achieve better patient outcomes; a diverse workforce has also been shown to achieve better healthcare outcomes and reduce disparities in care [15, 16]. Whether change is top-down, bottom-up, or mandated through national organizations, it will require thoughtful and strategic implementation.

This chapter aims to identify the key steps that organizations must take to implement, measure, and manage change related to global issues faced by women in pediatrics, and to successfully advance, promote, recruit, and retain women in pediatrics. We adapted the time-tested change management framework by John Kotter [1] and Nancy Spector et al.’s equity, diversity, and inclusion cycle [2] to create this stepwise approach.

FormalPara Box: Stepwise Approach to Drive Equity in the Pediatric Workplace

Step 1: Acknowledge the problem and commit to change

Step 2: Create a powerful coalition

Step 3: Create and communicate a vision for change

Step 4: Develop strategic plan using improvement science and empower others to act

Step 5. Develop quick wins and build on change

Step 6. Ensure sustainability and institutionalize change

A Stepwise Approach to Drive Equity in Pediatric Workplace

Step 1: Acknowledge the Problem and Commit to Change

Implementing change in any organization first requires acknowledging the problem and committing to change. Leaders of institutions can recognize pressing problems as opportunities and start by transparently acknowledging the current organizational problem(s) and commit to change. Sharing the most recent organizational data elements (such as in Table 9.1) in open forums and committing to change is the first step in engaging faculty.

Table 9.1 Initial overview of organizational culture: metrics by gender and URiMa status
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Step 2: Create a Powerful Coalition

Form a multidisciplinary and equitable coalition of leaders within the institution who can persuade others to implement policies and procedures for change. Organizations can do so by establishing an “Office of Equity” or an equity taskforce for change management. Such a powerful coalition should represent a broad group of faculty that are diverse in age, gender, race and ethnicity, rank, and power structure. Such a coalition can be charged to review literature and internal data and develop a vision and strategic plan.

Step 3: Create and Communicate a Vision for Change

The third step is to create a vision and a strategic plan to initiate change. It is crucial that organizations review gender- and URiM-specific internal data and develop a clear vision for change including a strategic plan for stepwise approach to change. Examining (and re-examining) gender and URiM data can help identify early wins (e.g., equity in pay/promotion/committees). Once the vision is established, then it should be shared broadly in a transparent manner.

Step 4: Develop Strategic Plan Using Improvement Science and Empower Others to Act

While the first step is acknowledging the problem and committing to change, equally important are identifying key strategic initiatives required for change. Internal data can identify and drive these initiatives (Table 9.1). Once the priorities are identified, writing and communicating SMART aims, which are specific, measurable, attainable, realistic, and time-bound [17], is important. These goals clearly define a population (i.e., pediatric practice), a metric, and a timeline, and are ambitious enough to be worthy of effort but also clearly achievable. As each strategic priority is identified, organizations will benefit from writing SMART aims and developing key driver diagrams to identify drivers and interventions required for change. Sharing the strategic plan, with clear metrics and timeline for achievement, will ensure accountability and demonstrate commitment.

For example, a global aim may be to achieve equity in academic promotion for women and men. To work toward this vision, a SMART aim might be to “increase the percentage of women promoted to professor within 8 years of associate professor rank by 20% within 3 years.” Writing a data-driven SMART aim requires some investigation into the current state of the problem at the organization to target the issue and identify an achievable, but worthy, goal.

Once goals are defined, the next step is to generate a hypothesis as to key drivers [19]. What do organizational leaders believe are the factors which most influence the issue? Key drivers are important because they inform the HOW of change. They define the organization’s theory of successful change. How might an organization refine what may be a long list of potential drivers? Published literature, local data, stakeholder opinions, and knowledge of an organization’s climate and culture (including appetite for change) can drive these. For example, the key driver diagram for improving timely academic promotion for women in pediatrics may have many potential key drivers as per Fig. 9.2: clear, objective promotion criteria, equitable process for inviting speakers to institutional conferences, implementation of mentorship programs, term limits for key committee positions, and changes in process for institutional grant review scoring rubric to emphasize science rather than investigator background.

Fig. 9.2
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Key driver diagram for an initiative to improve the timely and equitable promotion of women

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How will the leaders of this work know where to focus? Review of internal quantitative data (such as internal grant awards to women vs men, time to promotion, mentorship and sponsorship opportunities, leadership opportunities, and involvement in committees) may be helpful. Qualitative data from faculty interviews, surveys, or focus groups may elucidate what faculty perceive as the biggest barrier. An example of survey data in helping focus an intervention is displayed in Fig. 9.3. The figure shows a possible Pareto diagram generated by a survey of women faculty who are 5 or more years into assistant professor rank, with the diagram showing the frequency of response to “select what you perceive to be the most significant barrier to promotion to associate professor.” Pareto diagrams are powerful because the Pareto principle holds that 20% of the causes are typically responsible for 80% of the effect. Therefore, targeting the 20% of causes (drivers) will help drive the largest change [18].

Fig. 9.3
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Pareto diagram of responses to a survey of female assistant professors regarding the primary barrier to achieving timely academic promotion

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What other data might be useful? Perhaps the decision-makers on nominating faculty for promotion (division directors, department chairs) and those reviewing packets (i.e., promotions committees) could be asked to provide feedback on why faculty were not deemed “ready.” This source of data may illuminate different key drivers (Fig. 9.4).

Fig. 9.4
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Key driver diagram for an initiative to achieve equitable pay

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Once key drivers are chosen, the next step is to brainstorm interventions involving a larger group that includes both men and women in pediatrics. Potential interventions should be tested on a small scale and data collected on feasibility, effectiveness, and any untoward effect (i.e., balancing measure). Interventions promising on a small scale can then be scaled up and spread to increase impact.

An example potential intervention to impact timely academic promotion might be the introduction of career development committees for faculty at regular intervals in a promotion cycle. Instead of mandating career development committees as policy, a small group of faculty could be chosen as a pilot group, and the logistics of selecting, scheduling, and running a career development committee could be worked out on a small scale, with data collected on usefulness/value. Data from the pilot group could then be used to “scale up” the availability of career development committees in a way that maximizes efficacy.

It bears noting that having faculty engagement in the early intervention planning will not only help improve the intervention but will also help with buy-in and acceptability to a larger number of faculty.

Fig. 9.5
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Key driver diagram for an initiative to improve representation of women in senior leadership roles

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Fig. 9.6
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Key driver diagram for a project to achieve an inclusive environment

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To help jump-start an organization’s approach to this important quality improvement, we provide three additional common disparities with suggested aims, key drivers, and potential interventions.

  1. 1.

    Improve pay equity. One key driver is gender-driven differences in negotiation styles. Women have been socialized to be less assertive than men when asking for compensation, and are in a double bind in that they are also perceived to be more aggressive when asking for resources, while men are perceived as more confident and competent in asking for the same [20]. How can organizations help women avoid this trap? A simple answer is to move away from individual negotiations and toward a more standard approach, especially for entry-level positions where standardization is more possible. Another potential intervention may be performing regular equity reviews, whereby the compensation for faculty in similar roles and rank is reviewed and adjustments are made to achieve equity (Fig. 9.4).

  2. 2.

    Improve representation of women in senior leadership roles. One key driver that may be common to many organizations is the tendency to ask women to serve on committees and in roles that do not control resources rather than those that do allocate resources. We label this tension “service vs power.” A common example is women serving in educational roles and social or wellness committees (service roles), rather than chairing finance or compensation committees (power roles) (Fig. 9.5).

  3. 3.

    Improve inclusive, supportive environment. This key driver diagram illustrates that organizations can harness tools used for other key mission-driven efforts, such as improving patient safety, to inform work to improve an inclusive, nonhierarchical culture. For example, many children’s hospitals administer a safety culture survey every 1–2 years to assess progress in safety culture. This instrument measures attitudes and behaviors that are also foundational to inclusion and thus can be used to inform diversity, equity, and inclusion efforts as well (Fig. 9.6).

Step 5: Develop Quick Wins and Build on Change

It is important to celebrate small wins and build momentum for change. Announcing a diverse taskforce or sharing data with proposed outcomes measures can be an example of developing quick wins. Sharing such early wins with all stakeholders including frontline physicians can further help build on the change by improving buy-in, building trust and accountability. To maintain trust, continuing to share progress and timeline is equally important.

Effective communication and transparency around reporting data for equity efforts is important for several reasons. Reporting data via published dashboards or other easily accessible and visible routes communicates the organization’s commitment to equity, promotes an accountable and equitable culture, and keeps all levels of the organization informed of progress and challenges. It moves equity from a bullet point in the mission statement into a visible effort toward meaningful change.

Step 6: Ensure Sustainability and Institutionalize Change

A challenge that is common to all quality improvement work is sustaining progress once a project moves from an active improvement phase to one of sustaining success. Once attention moves to another initiative, it can be easy for progress to backslide. One way to guard against this tendency is to maintain key indicator measures on a dashboard. With data reported on a regular basis, leaders can see if previous gains are faltering. After making significant progress toward pay equity, one institution (University of Alabama at Birmingham Department of Pediatrics) has implemented an annual “compensation equity review” process to guard against pay inequity for women and underrepresented groups. Mitigating emerging disparities on an annual basis can thus prevent large inequities from recurring.

Identify Policies and Programs for Achieving Gender Equity Milestones

While we provided key driver diagrams for key initiatives, organizations must review current policies and procedures and revise old policies or develop new policies. Some of the policies and programs that are crucial for equity include those in Table 9.2. Such policies should be reviewed on a regular agreed upon interval, be revised regularly, and be available to all faculty.

Table 9.2 Suggested areas for policies/procedures with sample resources
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