Women constituted 50% of applicants and new entrants to U.S. medical schools in 2003.
As shown in t1, the proportion of total full-time, female medical school faculty was 29% in 2002. This proportion (37%) was considerably higher in psychiatry (1). Currently, the proportion of female medical school instructors has risen to 46%. Overall, however, only 24% of associate professors and 13% of full professors are women. In psychiatry, these proportions are 29% and 15%, respectively. Women constitute only 15% of tenured medical school faculty nationally (all ranks).
t2 displays faculty data from another angle—that is, looking at the proportion of males and females who are full professors. In 2002, 11% of all female faculty, compared with 31% of all male faculty, were full professors. It has taken more than 15 years for this proportion of women to grow from 10% to 11%. t2 also shows that these proportions were 8% and 26% in medical school departments of psychiatry, revealing a lower than average percentage of both female and male faculty at the rank of full professor.
The Association of American Medical College’s Faculty Roster System data also reveal that the average annual rate of female faculty attrition (9.1%) exceeds that of males (7%) (2). The gender gap in attrition is even greater for psychiatry faculty, with the attrition rate for women being 9.5% and the rate for men being 7.8%
With regard to academic administrative roles women chaired approximately 214 departments in 2002 (91 basic science departments and 123 clinical departments, including interim/acting Chairs), which is about 8% of all medical school Chairs (1), and eight women chaired a medical school psychiatry department (which equals 6% of Chairs if all 125 schools have a department). Currently, no female psychiatrist is dean of a U.S. medical school.
Many recent studies have elucidated continuing gender differences in professional opportunities and advancement. The two primary areas of findings discussed in this article are sexism and mental models of gender and mentoring. The intersection of gender and ethnicity is also considered. While no study of psychiatrists is cited, recent findings discussed are generalizable to psychiatry departments.
Sexism and Mental Models of Gender
Harassment and gender discrimination continue to detract from the education and opportunities of female professionals. Even medical school department Chairs admit to witnessing inappropriate sexual behavior, including pressuring women to participate in sexual relationships (3). Almost one-half of American female physicians believe they have been harassed during their careers, and most cite medical school as the location. Harassment is associated with depression, suicide attempts, and a desire to switch specialties (4). Abused students are more likely to lack confidence in their clinical skills and in their ability to provide compassionate care (5, 6).
As troublesome as overt sexual harassment continues to be, subtler forms of bias pose a much larger challenge to women’s development as professionals. American culture associates decisiveness, rationality, and ambition with men, and gentleness, empathy, and nurturance with women (7). For instance, students judge female faculty members who are not nurturing much more harshly than they do male professors who are not nurturing (8). Such stereotypes deny individuals the opportunity to be appraised positively on the basis of their unique traits. Indeed, men or women who act "against type" tend to be dismissed or marginalized. The "feminine" man who displays more sensitivity or emotion than is culturally normative risks derision; the assertive woman is perceived as "uncaring" and "unfeminine."
These widely shared "gender schemas" mean that women must work harder than men to be considered professionally competent. Women report feeling "invisible" and that their contributions are frequently ascribed to men at meetings (9). Medical school department Chairs confirm that lack of recognition of and respect for women in routine interactions has been prevalent (3). When rating works of art, articles, and curriculum vitae, both men and women tend to give lower ratings when they believe they are rating the work of a woman (8). An analysis of peer review scores for postdoctoral fellowship applications revealed that female applicants had to be 2.5 times more productive than the average man to receive the same competence score (10).
The concept of mental models of gender offers a less judgmental avenue to understanding these phenomena than simply labeling them "bias." Mental models are assumptions that act as filters through which we continuously select data from the stimuli surrounding us. Without being conscious of their mental models of gender, both men and women still tend to devalue women’s work and to allow women a narrower band of assertive behavior (8). Mental models persist in part because individuals, especially dominant personalities, tend to ignore information discrepant to their stereotypes (11). Moreover, features common to clinical medicine (i.e., time pressures, stress, and cognitive complexity) actually stimulate stereotyping and "application error" (i.e., inappropriate application of epidemiological data to all group members) (12). Nonetheless, most scientists and physicians appear to believe that they work in a meritocracy and that they are not influenced by stereotypes (13). Yet, power is so deeply woven into their lives that it is most invisible to those who are most empowered (14). However, women cannot realize their full potential until the men in positions of power are willing to examine their own mental models and to use their power to challenge gender stereotypes of their colleagues.
While female faculty members are just as likely as their male colleagues to have a mentor, they gain less benefit from the mentor relationship. One internal medicine department found that mentors would more actively encourage a male protege to participate in professional activities outside the institution and that women were three times more likely than men to report their mentor taking credit for their work—an unethical practice rarely discussed (15). One study (16) found that female cardiologists report their mentors to be less helpful with career planning than do men and more commonly that their mentor was a negative role model (19% of women versus 8% of men).
These challenges in obtaining mentoring are particularly unfortunate because, for a variety of reasons, women have a greater need for mentoring than do men (17). Not only does our culture tend to devalue women’s work, women tend to be more modest than men about their achievements, and they are less apt than men to see themselves as qualified for top-tier positions, even when their credentials are equivalent or superior (18). Moreover, women’s informal networks are less extensive and less likely to include superordinate associates or colleagues from previous institutions (19). Without the "social capital" and essential information that grow out of developmental relationships, women remain isolated. This isolation further reduces their capacity for risk-taking, often translating into a reluctance to pursue professional goals or a protective response such as niche work or perfectionism (the obverse strategy of identifying a hot topic). Paradoxically, however, a woman who seeks affiliation through a women’s group risks the label of "weak" or lesbian or "rabble-rouser" (20).
Clearly then, many women’s careers stall due to a lack of guidance and coaching. Many men are ineffective mentors for women simply because they lack experience with career-oriented women or because they find it easier to relate to women in social roles rather than professional roles. Such individuals can improve their mentoring skills, beginning with the recognition that styles and advice that worked for them may not work for their more heterogeneous protégés (21).
The Intersection of Gender and Ethnicity
In 2002, the 125 U.S. medical schools had a total of 1,199 African American female faculty (which equaled 4% of all female faculty). Smaller numbers of Native Americans as well as Mexican Americans, Puerto Ricans, and other Hispanics added up to an additional 4% of female faculty, for a total of 8% underrepresented minorities. While these numbers are small, the national proportion of male faculty from underrepresented minorities equaled only 6%. Psychiatry departments have a slightly lower proportion of minority female faculty, as compared with other specialties (7%), but the same proportion of men (6%).
Faculty from ethnic minorities are no more likely to attain senior rank than women (22, 23). Both women and minorities share the disadvantages of negative mental models and difficulties in obtaining career-advancing mentorship. Thus, female ethnic minorities experience "double jeopardy." A study of African American female physicians found that the majority cited racial discrimination as a major obstacle during medical school, residency, and in practice. In addition, they perceived gender discrimination to be a greater obstacle than did non-African American female physicians (24).
Women of color must frequently overcome assumptions that they owe their positions to affirmative action rather than professional qualifications. Thus, speaking and acting with authority present particularly complex challenges. At the same time, minority women encounter severe "surplus visibility," that is, their mistakes are more readily noticed, and they’re less likely to be given a "second chance."
Compounding all of the above extra challenges, minority female physicians are also at highest "risk" for institutional service obligations (also known as "affirmative abuse") (25), including committee work, student counseling, and patient care (26). Increasing the numbers of ethnic minorities who progress in academic medicine is difficult due to their low numbers. Both female and minority physicians face similar obstacles, for instance, overcoming mental models of "what a leader looks like" (27).
A common misperception is that initiatives to develop the careers of female physicians will either lower standards or disadvantage male physicians. No evidence supports either conjecture. In fact, interventions on behalf of women tend to improve the environment for men as well. For instance, when the Department of Medicine at Johns Hopkins evaluated its interventions to increase the number of women succeeding in the department, the proportion of women expecting to remain in academic medicine increased by 66% and the proportion of men increased by 57% (15).
To date, the most comprehensive analysis of initiatives to develop female medical school faculty (28) found that exemplary schools focus on improvements that are not specific to women, such as heightening department Chairs’ focus on faculty development needs, preparing educational materials on promotion and tenure procedures, improving parental leave policies, allowing temporary stops on the tenure probationary clock and a less than full-time interval without permanent penalty, and conducting exit interviews with departing faculty. These schools regularly evaluate their initiatives by comparing the recruitment, retention, and promotion of female and male faculty and by conducting faculty satisfaction and salary equity studies. Surveying faculty about their career development experiences and their perceptions of the environment, comparing the responses of men and women and presenting the results to faculty and administrators are particularly useful strategies.
Despite these examples, most approaches to improve the advancement of women continue to be too narrowly focused on "fixing" women (29). A broader focus raises questions such as: What’s wrong with our systems and organizational culture in which women have such a hard time succeeding? For instance, the tenure and promotion systems are a forced march in the early years, allowing a slower pace later on. Most women would prefer the opposite timing, allowing them more flexibility while their children are young. Tinkering around the edges is insufficient. Family leave policies rarely allow for more than 3 months and require women to deplete their annual and sick leave. Some schools have introduced less-than-full-time options. In many cases, however, users of these options sacrifice benefits and the flexibility to return to the tenure track (30). Even when these types of flexible policies exist, individuals who take advantage of such policies are treated as if they were "uncommitted" to their careers and profession.
Another example of women’s organizational disadvantage is medicine’s overvaluation of heroic individualism, with the largely invisible work of preventing crises and maintaining relationships going unrewarded. Since women tend to do less visible, collaborative, relational work, their contributions remain underrecognized (20).
Strategies to promote women must creatively examine the various features of the work culture. For instance, methods that recognize and reward the contributions of all team members, not just the head, are necessary. Additionally, these models must avoid expectations that women will perform the "relationship" work, and dialogue between men and women is required in order to achieve compassion and leadership on the part of both.
Many of the ways in which women are disadvantaged are created and reinforced at the department level (e.g., recruitment, mentoring, accessing resources). Thus, department heads are key to all strategies aimed to develop the careers of female physicians. One way to stimulate the cooperation of departments may be to emphasize diversity issues in departmental reviews and to offer Chairs support with regard to human resources development.
Another avenue of action is via professional societies. If the officers of all professional societies were to recognize and become more informed about the systemic nature of the disadvantages facing women, they could become effective spokespersons and change-agents regarding women’s professional development, as their leadership is desperately needed for improvements to occur.
Nearly all medical schools find themselves challenged by the increasing heterogeneity of new entrants, not only in terms of gender but also ethnicity, age, values, and previous life experience. In order to competently mentor younger persons unlike themselves, a relatively homogeneous senior faculty must be willing to examine their assumptions and acquire new skills. All psychiatrists would probably acknowledge that in order to develop sufficient motivation to challenge one’s beliefs and learn new ways of behaving, an individual must be able to experiment in a climate of "psychological safety" (32). Thus, senior faculty and administrators should have developmental, safe opportunities to examine how their mental models may be limiting their effectiveness (33). Schools are beginning to evaluate faculty on their effectiveness in meeting mentorship responsibilities. For instance, promotions committees have tended to primarily consider first authorships of articles published in major journals, but some schools are now considering last authorships in instances where an individual being mentored is a first author (34). An increasing number of schools and departments also facilitate mentor/protégé pairings and have created mentor-of-the-year awards (35).
In this article, two strategies designed to increase the likelihood of the success of female physicians (especially highly visible and heavily recruited women) are presented: 1) offer her the services of a professional career coach (36), 2) and facilitate her access to leadership development programs such as ELAM (37).
Psychiatric educators can offer strategies to dismantle gender stereotypes. During psychiatric clerkships and residencies, trainees can be assisted to become conscious of their mental models of gender and of the common tendency to devalue women’s work and feminine characteristics. Psychiatric educators can also lead the way in educating the community about the psychiatric and other consequences of gender discrimination and harassment. They can join forces with other medical educators in increasing emphasis on professionalism (38, 39) and on improving mentoring relationships (40). More attention to barriers created by mental models of gender and race would strengthen all professionalism initiatives. The extra challenges faced by female psychiatrists who are also members of ethnic minorities merit specific emphasis, however. Likewise, programs designed to improve patient communication skills should include assistance in overcoming gender stereotypes.
While the numbers of female faculty in psychiatry have increased, this growth has not substantially swelled the ranks of female full professors. The number of women entering the field of psychiatry and medicine in general obscures the work that remains—part of which is convincing many that academic medicine still greatly favors the development of men. However, many young women entering medicine, surrounded by female peers and unaware of their predecessors’ struggles, often assume that women may be freely choosing to reap fewer rewards than men for their work but that they themselves won’t have to settle for less (41). Thus, impetus for change is lacking in that women who do not realize their potential tend to leave the profession or to be invisible.
While no "glass ceiling" prevents women from advancing, the number of cumulative career disadvantages they face translates into a "personal glass ceiling"—that is, women internalize their difficulties. Among the most disadvantageous structures and practices are tenure and promotion policies that force unnecessary choices, either advancement or family, during the decade following residency training when most female and male physicians have young children. Since female physicians tend to be most productive between the ages of 50 and 60, they do not fit the career trajectory assumed by promotion policies, and they often do not strive for promotion to senior rank as a result.
Is the increasing number of women entering psychiatry mitigating the impact of gender? Improvements to complex systems do not occur naturally or develop out of the coping mechanisms of isolated individuals. Thus, it is not surprising that cohort studies comparing the careers of male and female physicians show that increases in the number of women are not reducing gender disparities in advancement (42, 43). Moreover, increases in the number of professional women do not appear be lessening the power of mental models of gender in the general culture.
Is the increasing number of women entering the field changing the practice of psychiatry? Too many diverse forces (e.g., scientific, economic, political) are shaping the field to link trends to the increasing numbers of female providers, especially given the extent to which men and women share characteristics. However, the primary difficulty in answering this question is that too few women have achieved leadership positions to allow comparison with the records of their male predecessors. Many of the few women who have gained prominence more closely resemble "honorary men" than they do their female peers, and many have made sacrifices for their careers that their male colleagues have not had to make.
The paucity of women achieving senior ranks and leadership positions is becoming more of a liability. Diverse teams outperform homogeneous ones, and in natural systems, as diversity increases, so does stability and resilience (44). Thus, psychiatry’s failure to realize the full value of its female professionals may be considered both poor stewardship and bad business.
The costs associated with the uncultivated potential of so many women remain largely hidden. Given the leadership challenges with which psychiatry is faced, however, this loss is one that the profession cannot afford. Leaders within psychiatry owe future generations of trainees a more equitable environment, where assumptions and judgments about competencies are not colored by gender, where women’s goals and traits are as valued as men’s, and where nonpunitive options facilitate the combining of professional and family responsibilities. The future of psychiatry is inextricably linked to the development of female professionals.