Power Reimagined: Advancing Women Into Emerging Leadership Positions

Abstract

Academic medicine is evolving from the traditional model of a medical school and teaching hospital owned by the same entity to one with complex academic medical centers and health systems. This increased complexity is evident not only in the funding streams and organizational priorities of these growing health systems but also in the evolution of leadership roles toward more matrixed positions and more individuals who hold both medical school and health system roles. Given this changing landscape, the authors of this commentary raise the following questions: Will the levers of power remain in the hands of those in traditional academic roles? Or are they moving toward those in roles that are more aligned with the clinical enterprise and health system? Then, if this shift is occurring, what is needed to prepare women to be competitive candidates for these new roles?

Because of the long history of and current gender imbalance in academic leadership roles, professional development programs have traditionally focused on preparing women to advance through the faculty ranks and for department chair and decanal roles. With the shift to more complicated health systems, the definitions, responsibilities, and types of leadership roles in academic medicine are also evolving to include nontraditional academic positions in the health system, such as c-suite and other senior executive roles. In parallel to the gender inequities in traditional roles, women are also underrepresented in health system leadership roles. Therefore, it is critical to explicitly identify emerging roles in health care leadership, address systemic barriers, and actively train and prepare women with the knowledge, skills, and experience required for these positions. Only with consistent attention to outcomes and the implementation of intentional systems to engage, prepare, and advance women will the gender gap be closed.

Academic medicine is rapidly changing, including the organizational structures of medical schools and teaching hospitals and the roles within them.¹ The last decade has seen a shift away from the traditional model of a medical school and teaching hospital owned by the same entity to that of a medical school with clinical sites at affiliated or contracted teaching hospitals and/or large academic health systems. In addition, the shifts in funding streams and organizational priorities that are associated with these evolving models have led to more matrixed leadership roles. For example, at some academic medical centers (AMCs), the medical school dean and department chairs are responsible for the academic enterprise, while other leaders, such as the health system or hospital chief executive officer (CEO), faculty practice plan leaders, and service line directors, are responsible for the health system and ultimately the clinical placements and clinical education of medical students and residents. At other AMCs, these roles are held by the same individual; for example, there are those who are both dean and CEO/senior vice president or dean and president of the practice plan. There are also department chairs who lead both the academic and clinical enterprises. In fact, 47% of the 123 medical school deans who responded to a questionnaire from the Association of American Medical Colleges (AAMC) reported that they carry dual responsibilities for the medical school and health system or the medical school and practice plan, and many carry additional responsibilities for other health professions schools.²

Understanding these new models and their associated leadership needs is critical to developing faculty with the knowledge, skills, and expertise to lead the AMCs of the future. According to a 2021 report from the American College of Healthcare Executives, the most pressing challenges facing these executives were personnel shortages, financial challenges, patient safety and quality, behavioral health/addiction issues, government mandates, access to care, patient satisfaction, physician–hospital relations, technology, population health management, and reorganization (e.g., mergers, acquisitions, restructuring).³ These priorities differ from those of traditional medical and professional school leaders, who often focus on accreditation, research, and education, and they require additional leadership competencies in strategic planning, financial and business matters, health insurance/third-party payers, government mandates, patient safety and quality, technology, and legal and regulatory matters. Skills in fostering teamwork, transparency, accountability, and communication associated with change have also been emphasized as keys to success in these matrixed roles.¹

With this lens of change, we raise the following questions: Will the levers of power and influence in academic medicine remain in the hands of those in traditional academic roles? Or are they moving toward those in roles that are more aligned with the health system and clinical enterprise? Then, if this shift is occurring, what is needed to prepare women to be competitive candidates for these new roles?

Rationale for Focusing on Women in Evolving AMC Models

The lay press and, increasingly, peer-reviewed journals have documented the continuing inequities between women and men in leadership roles in many professions, including academic medicine.^4,5 According to the AAMC’s State of the Women in Academic Medicine 2018–2019 report, the percentage of women amongst medical school applicants, residents, and faculty has increased.⁶ While these data are encouraging for the future inclusion of women in leadership roles, the rate of change is less favorable. For example, although there have been slow but steady gains in the percentage of women at the associate and full professor ranks (40.4% and 27.6%, respectively, in 2021),⁷ there was only a 5% increase in women in these roles from 2009 to 2018.⁶ If this rate of change remains the same, women will not achieve parity with men at the full professor rank until 2055.

In leadership positions, such as center directors, division chiefs, department chairs, and deans, the percentage of women is even lower than that at the full professor rank. For example, only 22% of interim and permanent department chairs are women, reflecting a paltry 4% increase from 2016 to 2021.^6,8 In fact, the majority of academic leadership roles, such as center directors, division chiefs, and senior associate deans, are held primarily by men, with only approximately one-third held by women.⁶ Some organizations point to the number of women in decanal positions as a sign of advancement for women. However, when the titles and specific roles women hold are further explored, we learn that women are more likely to be assistant or associate deans (52% and 47%, respectively) than senior associate/vice deans (34%) and to hold roles that are in student education, faculty affairs, and diversity, equity, and inclusion, which traditionally have fewer financial and other organizational resources and less influence within the AMC.⁶ In addition, in the senior associate dean role, there was less than a 1% increase in the percentage of women from 2013 to 2018. And, while women make up 25% of all medical school deans, 31% of women deans are at community-based medical schools compared with 24% of men.²

With the shift to more complex health systems, the definitions and types of leadership roles in academic medicine are also evolving to include nontraditional academic positions in the health system, such as health system CEO, chief academic officer, and chief diversity officer. In parallel to the gender inequities in traditional roles, few AMC CEO positions are held by women. For example, a 2021 study of more than 4,000 hospitals found that 27% of hospital CEOs and 13% of health system CEOs were women.⁹ The gender of those in chief positions was associated with the size of the health system and/or hospital (defined by bed capacity), with women being less likely to be in a chief role in a larger hospital or health system. Similarly, a 2019 Korn Ferry report on women in health care leadership roles found that only 4% of health care company CEOs were women.¹⁰

We must move toward gender equity in leadership roles in academic medicine, not just in titles but also in influence, authority, and power. Diverse teams lead to improved team communication, innovation, productivity, and financial performance.¹¹ In addition, women leaders are perceived as more proficient than men leaders across multiple skills required for leadership.⁵ However, few robust training and leadership pathways exist for women to advance into health system leadership positions. Therefore, we must ensure that women not only have the appropriate knowledge, skills, and experience for these new roles but also that current senior leaders are mentoring and sponsoring women into these opportunities.

Perceptions of Evolving Roles and Power in Academic Medicine

To further explore this topic, we led a power mapping exercise at an AAMC conference in 2019 and invited attendees to think beyond traditional academic titles to identify future leadership opportunities in academic medicine. Organizational power mapping is an established framework for identifying individuals with different types of power in organizations.¹² This exercise was designed to identify other sources of power beyond those with formal leadership titles. To guide the power mapping exercise, 4 types of power were identified: positional, influential, decision making, and financial. (There are many power models that extend beyond these categories, but we used a simplified list for ease of the activity.)

A facilitated discussion followed, and several titles were identified for emerging and “powerful” leadership roles based on their position in the organization, influence, decision-making capabilities, and access to finances and/or budget. These titles included: president, provost, chancellor/vice chancellor, dean, department chair, vice dean for research, chief operating officer, CEO, chief financial officer, chief medical officer, chief information/technology officer, and CEO/practice plan president.

We then compared emerging leadership roles with more traditional roles and discussed the competencies and skills needed to attain them. Many competencies are needed for any leadership role: social intelligence, interpersonal skills, emotional intelligence, prudence, courage, conflict management, decision-making skills, political skills, influence skills, and area expertise/competence.¹³ Traditional academic leadership roles often rely on academic expertise and competencies. In addition, those taking on these roles, such as dean or department chair, historically have followed traditional education leadership pathways (i.e., program director, division chief, vice chair, chair, and associate dean), which will not necessarily be the pathways to emerging matrixed health system leadership roles.

To address these changing leadership needs, some organizations are beginning to offer leadership in health care programs along with traditional academic leadership programs. For example, Drexel University College of Medicine has offered the highly competitive Hedwig van Ameringen Executive Leadership in Academic Medicine program for more than 25 years and recently added the Executive Leadership in Healthcare program. More of these opportunities, especially those geared toward women early in their careers, are needed to prepare diverse individuals for matrixed health system leadership roles.

Strategies to Promote Gender Equity in Emerging Leadership Roles

Despite some progress, women today remain underrepresented in senior leadership positions (e.g., division chief, chair, dean). Now, women must prepare for the emerging leadership roles of the future. Thus, we must consider the skills women need to succeed in these matrixed positions and ensure that they receive the necessary training, mentorship, and sponsorship. We have a unique opportunity to provide specific programs for early-career women to ensure they are ready to take on clinical administrative leadership roles now and in the future. As well as ensuring individuals develop the knowledge, skills, and experience they need, AMCs must address the organizational and systems issues preventing women from reaching the highest levels of leadership. For example, increased dialogue is needed around the definitions of leadership roles and the importance of women holding these roles.

In addition, tracking the gender distribution of all leaders with an intersectional lens will be vital, so we call on national organizations, such as the AAMC, the American Medical Association, and the American Hospital Association, to collect national data not only on those in traditional academic roles but also on those in emerging AMC leadership roles, including those in dually held and matrixed roles. While national data are crucial, we also must act locally. We challenge each CEO and AMC leader to review the representation on their senior leadership team and the opportunities for advancement in their organizations. And we challenge them to ensure they are fostering a diverse, equitable, inclusive, and productive working and learning environment.

Without intentionally making these critical changes and closely tracking outcomes, we stand to recreate the gender inequities present in today’s academic medicine leadership roles in tomorrow’s health care system. Given the new challenges facing academic medicine and the already slow progress of building a diverse leadership, we cannot afford to repeat this mistake.

Acknowledgments:

The authors would like to thank the members of the Group on Women in Medicine and Science Steering Committee for their feedback and contributions to this commentary.