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Invited Commentaries

Leading by Design: Lessons for the Future From 25 Years of the Executive Leadership in Academic Medicine (ELAM) Program for Women

Jagsi, Reshma MD, DPhil; Spector, Nancy D. MD

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doi: 10.1097/ACM.0000000000003577
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Abstract

A quarter century ago, leaders at the academic medical center (AMC) that arose from the first women’s medical college in the United States fittingly initiated a program to foster the development of women for executive leadership in academic health care. At the time of its founding in 1995, just over 2 decades had passed since the enactment of Title IX, the key policy intervention responsible for the rapid increase in women’s enrollment in U.S. medical schools.1 Women’s enrollment exceeded 40% of the medical student body,2 and the time seemed ripe to implement a leadership development program focused on women, who would soon enter the senior-most positions in the field, but had few female role models before them. Yet even the visionary founders of the program say that they never imagined the influence that the program would have, nor anticipated that it would still be necessary a quarter of a century later. Now known as the Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) Program for Women,3 the fellowship welcomed for its 2019–2020 class 59 new participants (including R.J.), selected from a rich pool of nominees holding senior leadership positions in academic health care at institutions throughout the United States and in Canada.

The longevity of the ELAM program raises several important questions. First, why is such a program still needed? Second, what exactly does it do, and what has been its influence on its participants and beyond? And third, what lessons can ELAM’s example provide to help guide the medical profession as it strives to promote gender equity in the field? In this Invited Commentary, we seek to answer these questions from the perspective of a recent program participant (R.J., who, in the same year that ELAM was established, joined a Harvard Medical School entering class in which women outnumbered men, and who believed that gender inequity in academic medicine would soon be relegated to history and never imagined that she would one day enroll in a program like ELAM) and the current program director (N.S., who, 25 years ago, was told by ELAM’s founding director, Dr. Page Morahan, that, as a woman, it was imperative to obtain leadership development training at every stage of her career).

Why are women’s leadership programs still needed? Women currently constitute over half of all medical school matriculants4 but only 19% of deans5 and 19% of department chairs.6 It took 53 years to go from 0 women deans to the 29 who led U.S. medical schools in 2019; if the academic medicine community were to continue at this rate of change, current medical students will have retired before we achieve parity.7 Women also remain in the small minority in other influential positions: as specialty society leaders,8,9 authors,10,11 editors-in-chief,12 and editorial board members.12 Given the increasing evidence showing that organizational performance improves when women are integrated into leadership,13,14 concerns have grown that ongoing gender inequity impedes the ability of AMCs to optimally serve their worthy missions. Regrettably, convincing evidence suggests that the failure to achieve gender equity at the level of leadership in academic medicine is not simply the result of a slow pipeline, but, instead, reflects multiple complex causes.15

Considerable evidence now shows how women face accumulating disadvantage over the course of their academic careers,16 stemming from repeated encounters with powerful unconscious biases and stereotypes,17 societal expectations for a gendered division of domestic labor,18 and still-present overt discrimination and sexual harassment.19 Numerous studies document gender differences in compensation20,21 and access to critical resources such as personnel22 and start-up funding23 that are not explained by differences in qualifications or productivity. Women are—even today—less likely to be called by their professional form of address when delivering prominent presentations.24,25 Women frequently report derogatory and demeaning gender harassment,26 and sometimes they face coercion or even assault by patients or colleagues.27,28 Clearly, structural solutions and wholesale cultural transformation are necessary to change the systems that perpetuate gender inequity in medicine. Indeed, scholars argue that organizations and professions must strive for “a ‘well-integrated, structurally egalitarian workplace’, in which women and men equally share power and authority.”29,30

How does a program like ELAM help? ELAM builds the knowledge and skills of the senior-level women who participate in the program, while also intentionally raising their visibility within their home institutions.31 Exercises include in-depth, experiential, and problem-based trainings that emphasize how personality types influence team dynamics. These exercises help participants develop sophisticated yet practical approaches for navigating the complex financial considerations that affect AMCs in the modern era. Participants work in close-knit learning communities to foster reflection and inspiration and, together, they synthesize insights from sessions on conflict resolution and work–life integration. Perhaps one of the most effective aspects of the program is the intentional requirement for its participants to meet with leaders within their institutions, which allows them opportunities to share what they have learned in ways that not only promote their own careers but also support gender equity in the broader environment.

Indeed, ELAM recognizes that the path to true gender equity requires systems-level transformation—not the “fixing” of individual women. By both creating a network of leaders who explicitly recognize this need and fostering their relationships with existing leaders, ELAM seeks to sow the seeds of wider scale transformation, that is, to effect change in the very culture of academic medicine itself. Participants are encouraged to take the insights they learn back to their institutions, and many implement—sometimes as part of their required institutional action projects—programming similar to that employed in ELAM itself. For example, former participants have adapted for use in their home departments an intensive, case-based session (similar to the style used by many business schools) that involves strategic planning for a hypothetical AMC in financial crisis. Others have developed new curricula; faculty mentoring and career development programs; quality improvement and community engagement programs; and policies that enhance equity in faculty recruitment, retention, and compensation.

The evidence of ELAM’s effectiveness is abundant. Alumnae, who are called “ELUMs,” number 1,084 and include 15 of the 29 women who are deans at U.S. medical schools, 6 of the 12 women who are deans at U.S. dental schools, and 3 of the 21 women who are deans of U.S. public health schools. A total of 38 ELUMs have served as past, interim, or permanent U.S. and Canadian medical school deans. As of this writing, ELUMs serve as executive leaders at 263 academic health organizations; they include 91 chief executive or academic officers, 233 department chairs, 219 center directors, and 203 associate deans.

The number of ELUMs in leadership positions is but one measure of the program’s influence. Research has shown that deans perceive the ELAM program has had a positive effect on alumnae, increasing their eligibility for promotion.32 Studies comparing women’s self-perceived leadership capabilities before and after participating in the program demonstrate large gains in the knowledge of leadership and organizational theory, environmental scanning, financial management, and general leadership, as well as gains in career-building, communication, networking, and conflict management skills.33 Interviews with participants suggest enhanced self-efficacy.34 Moreover, compared with women faculty of similar seniority who did not participate in ELAM, ELUMs experienced improvements in multiple indicators of leadership attainment and competencies (e.g., environmental scanning, financial management, communication skills, tolerance for the demands of leadership, conflict management) over the same period of time.35

However, the greatest legacy of ELAM is perhaps the hardest to quantify, as it extends beyond the success of its participants in achieving leadership. ELAM contributes to gender equity through its approach to disseminating the findings of decades of research to inform the creation and enhancement of evidence-based interventions that are designed expressly to promote gender equity in academic medicine. It seeks to educate not only its participants but also the existing leaders of their institutions so as to facilitate interventions that target root causes of gender inequity and the structures that support it. For example, medical education’s widespread neglect of negotiation skills as a core competency of all professionals tends to disadvantage women more than men36–38; ELAM seeds the idea that training in negotiation is vital in a small number of individuals whom it positions to capture the ears of existing leaders and, ultimately, to become leaders themselves. The idea is that as these women speak with their institutional leaders and eventually become institutional leaders themselves, more institutions will recognize the need for and support widespread implementation of workshops and training in negotiation. Similarly, ELAM identifies for its participants those aspects of search and hiring procedures that can perpetuate gender inequity and provides evidence-based strategies to reduce the influence of unconscious bias in selection processes.17,39 The hope is that participants will, in turn, take these strategies back to and apply them in their own institutions. ELAM also provides information about a panoply of other interventions that, together, target unconscious bias,40 improve civility,41 and transform culture42 within academic medicine. Women learn of interventions that help them develop their mentor networks,43 identify sponsors,44 and manage extraprofessional caregiving demands.45–47 As those who participate in ELAM become experts in understanding and applying these existing evidence-based strategies, they not only learn how best to advance their own careers but also recognize the need for and the most effective approaches to advance the careers of other women.

So, where should academic medicine go from here? Clearly, individual programs like ELAM have value, but they cannot possibly address the tremendous need that persists. Other institutions are developing internal programs. For example, the University of Michigan’s Rudi Ansbacher Women in Academic Medicine Leadership Scholars Program48 offers programming similar to ELAM but reaches far more than the maximum of 2 nominees Michigan is allowed to send to ELAM each year. Such programs are essential for promoting greater participation of women in the leadership of academic health care and for deploying other evidence-based interventions that target the root causes of gender inequity. Leveraging the promise of technology and social media to disseminate effective programming like ELAM’s on a broader scale may also provide promising opportunities for the future.49–51 Of course, thoughtful design and evaluation of such efforts is necessary to ensure that interventions seeking to promote equity serve their intended ends and do not have unintended consequences.

The Association of American Medical Colleges (AAMC) recently issued a call to action on gender equity focusing on the need for leaders of academic health institutions to ensure that their structures and processes are equitable and to be accountable for progress on gender equity metrics.52 The initiative calls on institutions to address inequities in 4 primary areas: “the physician and scientific workforce, leadership and compensation, research, and recognition.”52 These are precisely the issues that ELAM has equipped its participants to address in the same evidence-based fashion that physicians use to address other complex challenges in health care. ELAM represents an example of a successful program, and together with other organizations, societies, and funding agencies such as the AAMC, WomenLift Health (a new initiative sponsored by the Gates Foundation), the Carol Emmott Foundation Equity Collaborative, the National Academies Action Collaborative, and TIME’S UP Healthcare, it is well positioned to join in an integrated approach to accelerate the rate of progress toward gender equity at all levels of academic medicine. In the wake of the #MeToo movement and as awareness of the need for gender equity grows in the field, now is a particularly opportune time to learn from the model of ELAM and to leverage the wisdom of the many ELUMs it has prepared for this very moment, a moment we hope will constitute an inflection point, accelerating the trajectory toward equity in the field.

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