Central Line

Episode Number: 116

Episode Title: Women in Anesthesia Leadership

Recorded: November, 2023

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Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Welcome to Central Line. I'm your host and editor, Dr. Adam Striker. I'm excited today to welcome Dr. Jane Moon back to the show. Dr. Moon joined us on one of our very first episodes to talk about history of anesthesia, and she is back today to discuss women in anesthesia leadership. I'm excited to have her back today. Dr. Moon, you've contributed to the January Monitor on the topic, and welcome back to the show.

DR. JANE MOON:

Thank you very much for having me again, Dr. Striker. I'm excited to discuss this topic. Most of all, I hope many people will read the special section of the January issue of The Monitor. I’d also like to say that before we begin our discussion that I'm still fairly junior in my career, currently an assistant clinical professor at UCLA. I’ve been thinking a lot about the issues we’ll discuss as I face a long journey ahead, but I have by no means already made it to the upper levels of anesthesia leadership, but I'm very honored to be here today.

DR. STRIKER:

We are thrilled you're here with us. You know, you've made it to an elite group in the returning podcast guest category for Central Line. So we have that to work with. And so but we're thrilled you're here.

Let's start off with something I know you're interested in, which is history of anesthesiology. But let's focus in a little bit more on on women in anesthesia. There certainly are early, early women pioneers for the specialty of anesthesia. I was wondering if you could just talk a little bit about them, and also talk about how women leaders in anesthesia have progressed throughout the previous decades. Is it something that's consistently gotten better in, in the sense that women have been more front and center and contributing, or has it been more of a fits and starts kind of a situation?

DR. MOON:

Sure, that's a great question. And as you ask, the history of women in anesthesiology has certainly not been a linear one. It's been more turbulent than linear in my opinion.

There was actually quite a bit of success for women in anesthesia relative to other medical specialties in the early 20th century, then a period of setback in the mid 20th century, around the time that the science of the field was really taking off. And then there was renewed progress in the late 20th century due to broader societal gains made by the civil rights movement.

But as a start, I think it's important to understand that in 1846, the year of the public discovery of surgical anesthesia, which is arguably the greatest medical discovery of all time, there were zero women physicians in the world. Um, by the time the early 20th century came around, around 1910, the earliest woman anesthesiologist in the US, Isabella Herb at Rush in Chicago and Mary Botsford at UCSF, they were becoming more prominent, but at the time, only 6% of physicians in the US were women. And around that same time, 1910 was also the year of the now controversial Flexner Report, which exposed the poor state of medical education in the US, but also contributed to the dissolution of many commercial medical schools, including many women’s schools. So by 1930, the percentage of women physicians in the US declined from 6% to 4% and would only come back up to 6% in 1950. So during this period when women physicians in the US were, as a whole, they were decreasing in number. Dr. Herb and Dr. Botsford were growing as leaders in anesthesia, which was a very small group of physicians at the time. Isabella Herb actually became president of the first national anesthesia society, the American Association of Anesthetists, in 1922, and Botsford became president of the society in 1930. By contrast, there wouldn't actually be a woman president of the American College of Surgeons until 2005, and a woman president of the American Surgical Association, which is the oldest national surgery society until 2014. Physician men during Herb and Botsford's era shunned anesthesia because pay and professional status were low. And so even when Ralph Waters started the first anesthesiology residency at the University of Wisconsin-Madison in 1927, three out of his first six residents were women. So in the early 20th century, women physicians definitely had more opportunities in anesthesiology than in most other medical specialties. But during the 1930, Waters and his male colleagues throughout the nation, people like Emery Rovenstine at Bellevue in New York City, John Lundy at Mayo Clinic in Rochester, established the structural foundations of anesthesiology as a medical specialty. They helped establish the ASA, ABA, and secured formal recognition for the field from the AMA.

And then anyone who's familiar with the history of anesthesia will know that World War Two was truly a watershed moment for the specialty. There was this great and sudden demand for anesthesia in combat zones, which converted many general practitioners into anesthesiologists virtually overnight. And so many of the men who first delivered anesthesia during World War II chose anesthesiology as their full time career when they came back home. And only six American women anesthesiologists served during World War Two, compared to 16 in World War One. And none of these six women were actually deployed abroad. So soon after the war, scientific growth within the specialty accelerated, but women were left behind and men suddenly began to vastly outnumber women in the field.

I would say the tide slowly began to turn again in the 1970s, after the civil Rights movement and the passage of title nine, which prohibited sex based discrimination in any federally funded education program. And this is when women started to enter medical school in greater numbers. So it wasn't really until the 1980s that women anesthesiologists began to gather to address gender issues within our specialty. And at that time, only 4% of women medical school graduates were choosing to enter anesthesiology. And the 1990s were an important decade, as Betty Stevenson became the first woman ASA president in 1991. The ASA bylaws were finally de-gendered and an ASA committee on women's issues, which was the precursor to the ASA Committee on Professional Diversity, formed for the first time.

DR. STRIKER:

Well, it's certainly come a long way, obviously, but we know that women are still underrepresented in leadership roles, whether it's professional organizations or clinical practices or administrative positions. Why don't you take us to the current time and give us a lay of the landscape, how it stands now in 2023?

DR. MOON:

Sure. It's definitely true that the specialty has come a long way. One of my closest mentors, Dr. Salma Khamis, who I co-authored the article I wrote for The Monitor with. She attended medical school in the 1960s, and at that time, her class at Baylor in Houston had only three women out of 84. And that's only 3.6%. And then when she started her anesthesia residency at Penn, there were actually no other women anesthesia residents. And when she got pregnant during her second year, for many, many years afterwards, she would be introduced at ASA meetings as the first pregnant resident at Penn. So we've come a long way since the 1960s, but gender disparities still continue to exist today. According to an AMC physician specialty data report from 2021, women made up 37% of the active physician workforce, but only 26% of anesthesiologists. And over time, there have been increasing numbers of women anesthesiologists at the entry level. Now, half of the medical students in the US are women, and 34% of anesthesiology trainees are women, which is more than ever before in the modern era. But still, there is significant gender disparity in the senior ranks of full professors and department chairs and academic anesthesiology. And women leaders are still lacking in leadership of practice and organizational settings, professional societies, and also as senior editors of journals. In addition, I would say that in the hospital setting, women make up 75% of the American hospital workforce, but only 31% of US hospitals are led by women, with only 13% of health care CEOs being women. Women in academic anesthesiology are also advanced and promoted at a much slower rate and with less frequency than men. And then in recent years, the Committee on Women Anesthesiologists, led by Dr. Linda Hertzberg, surveyed the ASA membership and found that women anesthesiologists across the board earned 8.3% to 8.9% less than men when adjusted for other variables like age, hours, worked, geographic region, practice type, and position.

DR. STRIKER:

Well, I want to talk about a couple of these items and delve into the factors that contribute to to why some of these disparities exist. Before we get to that, though, let's talk a little bit about why diversity and gender is important in health care leadership. We've talked previously on the show a number of times about why diversity in general is important for patients and clinical care, but let's maybe focus in specifically on women. Why is gender diversity in leadership important?

DR. MOON:

I think it's definitely related to the diversity data as a whole. Gender diverse teams have been shown to have better performance, employee engagement and organizational outcomes than less diverse teams. And along with gender diversity, you do get diversity and background experience mindset. And so in the industry sector, there's evidence that gender diverse boards and managers are associated with greater creativity, innovation, as well as financial returns. There's also evidence in medicine that teams led by women may have better health outcomes, for example, in code situations. I recall my mentor, Dr. Khalmis, had mentioned how when she was a practicing anesthesiologist at UCLA back in the day, she actually distinctly remembered the time that she had her first case with an all female team, and it was the first time that she had the attending surgeon, the surgical resident, intern, be all women. And Dr. Khamis was the anesthesiologist with a female medical student. And she recalls the tenor of the OR that day just being unusually calm, confident and caring without the stress and fuss of male surgeons trying to assert their dominance, which was, I guess, very typical in her time. But to continue answering your question about the importance of gender diversity, I think that it's also really crucial for fostering a sense of belonging in the workplace for women, which increases employee engagement. When all of us feel that we can be truly authentic at work, we tend to be happier and more committed. And when junior women anesthesiologists see senior women anesthesiologists who model effective leadership, it's really inspiring and it might even motivate them to have higher career aspirations themselves. On the flip side, when there are very few women in leadership roles, it can create a sense that women can't truly thrive in that group.

DR. STRIKER:

Well let's talk a little bit about communication styles. It's probably fair to say that society expects women and men to communicate differently in any particular situation, but I'm wondering how how that might be perceived and actually take place when it comes to patient communication and specifically in anesthesiology. Do you have any insight on the differences and how that might play out and and how that could be either beneficial or problematic in certain practices? What do you think about communication styles?

DR. MOON:

That's a great question. And I think we can all agree that great leaders should requires good communication skills. And like you mentioned, I do think communication is context specific. As anesthesiologists we do work in teams. So I think a team based model of patient care really benefits from having a communication style that is both authoritative and directive, with a clear leader in place, but also as collaborative and inclusive of everybody involved with the team. Traditionally, people have believed that good leaders are predominantly authoritative in the way that they communicate. And this is a style that's typically been associated with men. And society as a whole has, of course, expected men to communicate also in a direct, confident manner. And women to communicate in a warm, caring way. And when women communicate with authority, they're often labeled as bossy and aggressive. And there's evidence that this phenomenon contributes to prejudice against women leaders. So there's actually a really interesting article in this issue written by Dr. Cynthia Wong, where she makes a compelling argument that adopting gender diverse communication styles can not only enhance organizational success, but really enhance patient care in a team based leadership model, which I think clinical anesthesiology definitely falls under. So there really could be a huge benefit to having anesthesiologists communicate in a style that combines a traditionally male authoritative and directive style, along with a traditionally female inclusive and collaborative one.

DR. STRIKER:

I do want to circle back and talk about the factors that contribute to women not being promoted at the same rate as men to leadership positions. Let's delve a little bit into the specifics. What are those barriers? What is causing women to be promoted at a slower rate than than men to leadership positions?

DR. MOON:

It's true. Another great question and many, many reasons. I really loved reading Mary Dale Peterson's article on this issue, because she actually does a great job of conceptualizing these barriers as either internal, arising from within the individual woman, or external a product of the system. And so some of the internal barriers include personal issues that women face, like family responsibilities and foster syndrome, and a lower willingness than men to self promote. And so first, women today still tend to have far greater caregiving and domestic responsibilities than men outside of work. This can decrease the amount of time and energy they have to seek positions of greater responsibility in the workplace. A recent JAMA network article from July 2023 showed that 40% of women physicians with children actually reported passing up on career advancement to accommodate parenthood. And second, while both men and women can struggle with imposter syndrome, I think it shows up in different ways with women tending to overachieve to prove their worth, but still having a lot of stress and anxiety even when they're meeting performance standards. In her article, Dr. Peterson discusses her own personal journey, how she overcompensated for her own imposter syndrome as she considered leadership by getting an extra degree, a master's in health care administration, getting extra board certification in critical care medicine, and over preparing in general for meetings. She later realized that while additional training can certainly be helpful, leadership wasn't so much about knowing every single detail as it was about inspiring and directing teams composed of subject matter experts. So along these lines, I think women more than men tend to go for promotions only when they feel 100% qualified. And this is for a variety of reasons, perhaps a combination of fear of failure or humiliation, and maybe also because women tend to be more focused on following the rules and may view the hiring process as more by the book than it really is. And finally, women, more than men, tend to struggle with self promotion. We tend to be reluctant to share our own accomplishments, but eager to celebrate someone else's. I am in no way advocating for exaggerated self promotion, but it is true that when women assert their own achievements, people tend to respond more negatively because they're seen as failing to show more traditional feminine traits, like being humble and nurturing. But there is evidence that, in general, visibility is a huge factor in professional advancement. So women may miss out on leadership opportunities if their achievements remain invisible.

So these are some of the internal barriers, but there are also several external barriers. Probably the biggest one is that there is a pervasive gender bias within both men and women against women leaders. I think this bias comes from both above and below. There's a lot of research that shows that women faculty, for example, tend to be evaluated more harshly and held to higher standards than men. There's that famous Sheryl Sandberg quote from the book Lean In, “men are promoted based on potential, while women are promoted based on past accomplishments.” There is also a false perception that women are less ambitious and less interested in career advancement and promotion than men. Multiple studies have shown that this simply isn't true, but this bias may actually cause some senior leaders to discount qualified female candidates.

And people often talk about gender bias from above, which is what I've done. But the issue that may actually be even tougher to tackle is gender bias from below. There's evidence that people in general, men and women alike, don't really like women bosses. We don't like women to tell us what to do, tend to be more critical of leaders who are women. And so while overt gender hostility is very uncommon today, women in medicine also often experience microaggressions, which are the more subtle forms of disrespect or invalidation in the workplace. And this may not just be from colleagues, but also from nurses, other hospital support staff and patients themselves. And this can take many different forms, like being interrupted while sharing ideas during meetings. Seeing someone else get the credit for an idea that was yours. Being frequently delegated non promotable more service oriented tasks. Having our abilities be underestimated or being repeatedly mistaken for a non physician. There was a recent report published by the AAMC that was fairly surprising. Women faculty anesthesiologists reported the highest incidence of gender harassment, 52.6% in academic medicine, with harassment being defined as behaviors that convey hostility, objectification, exclusion, or second class status about members of a particular gender.

DR. STRIKER:

Well, a lot to to unpack there. I would like to talk about the future and what we can do to improve this situation, and how we can all contribute to a more ideal environment. And so before we do that, let's go ahead and take a short patient safety break, and then we'll we'll come right back and talk about that. Please stay with me.

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DR. ALEX ARRIAGA:

Hi, this is Dr. Alex Arriaga with the patient Safety editorial board.

Perioperative insulin administration in the pediatric population requires attention to detail. There are considerations pertaining to preoperative fasting, insulin formulations and dosing and management of hypoglycemia, hypoglycemia, and other potential metabolic abnormalities. In addition, insulin pumps and continuous glucose monitors are becoming increasingly common. Attention to principles of patient safety can help avoid preventable patient harm regarding perioperative insulin administration. Avoid excessive reliance on verbal communications over those that are written. Have an ongoing mechanism to review insulin order sets and policies with attention to any insulin ordering practices that may be unclear. Provide clinicians with a means for updated and accessible education on the latest in perioperative diabetic management. By promoting patient safety and best practices in perioperative insulin administration, health care professionals can work together towards providing even safer anesthetic care to the pediatric population.

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For more information on patient safety, visit asahq.org/patientsafety22.

DR. STRIKER:

We are back with dr. Jane Moon talking about women in anesthesiology and leadership. Dr. Moon, we just got done discussing really a litany of of factors and impediments that are responsible or at least could be responsible for a lot of the disparity we see when it comes to women in leadership, particularly in anesthesiology. Let's discuss where we go from here. Talk a little bit about the path forward. What can we do as a specialty and then maybe even individually?

DR. MOON:

Sure. I think that before we start discussing potential solutions, I also want to emphasize the idea that striving for gender equity in anesthesia leadership really isn't about meeting a specific quota or checking off a box, but really about upholding the basic human right of equality of opportunity. I really recommend the recent Central Line episode E is for Equity that featured Dr. Kia Locke, where she defined equality as ensuring that everyone has a pair of gloves on a cold winter day, and defined equity as ensuring that everyone has a pair of gloves that fits their hands. So I think in terms of solutions, we need to think of ways to better equip women to become effective leaders. And this involves a wide gamut of things, including more flexible family leave policies, providing women with time and access to training and leadership development opportunities, as well as professional networks. Doing our best to provide women and really all people of different backgrounds at all different levels of their career with a sense of community and belonging. Practically speaking, outsourcing household work can be very helpful. And then in terms of starting to address the unconscious bias that all of us have, the very first step is raising awareness of these issues, continuing to do so so that we can all become more intentional and effective in our efforts. In terms of compensation, hiring, and promotion practices, transparency and standardization can be helpful because, you know, it's been said that bias thrives in ambiguity. So the more open and protocolized we can be in evaluating candidates for a job or promotion, the more likely we are to be truly fair and not affected by our personal biases. I think also just greater awareness in general can help us all to extend more grace to our women leaders and do our part to minimize the microaggressions that we were talking about.

And I know we discussed the different communication styles that women and men bring to the table, but I think also actively celebrating the qualities that women traditionally bring, like the emotional intelligence, the collaborative aspects, seeing these as true assets to team oriented anesthesia leadership as well as to patient care. I think these can help appreciate our women leaders more.

Of course, mentorship and sponsorship of women in medicine is also very important. Mentors can help provide knowledge and advice. Sponsors provide access to professional opportunities and networks that women would not ordinarily have access to. And so I think it's important for mentors to help women figure out not only which opportunities to pursue, but sometimes also which activities to drop because I think women are at higher risk of being given these activities that may not directly help advance their career. And there's also evidence that women actually need sponsorship more than mentorship to have successful career advancement.

Another thing that I think is is important is to help make women's achievements more visible in the workplace. As we discussed earlier, many women aren't as comfortable with self promotion, so I think it helps to have a way that they can share their achievements without feeling like they're being obnoxious, or fearing that they might be penalized in some way. So, for example, in our department at UCLA, we have a bimonthly newsletter that includes human profiles, articles about people in our department, as well as lists of recent publications, presentations and awards. And we have a staff communications coordinator who makes a call for submissions before each issue. And anybody in our department can simply respond to that email with any recent notable professional activities. And it's a nice, neutral platform for everybody to kind of celebrate each other's achievements.

And finally, there's evidence that cluster hiring or appointments can be effective in diversity efforts. And so, for example, it might be beneficial to hire or appoint at least two women instead of one to a committee, division, board or panel. If there aren't any other women to begin with to try and really structure in a sense of community, because it can definitely be very isolating being the only woman or only person of color in any group and environment.

DR. STRIKER:

Well, let's talk about some of the specific pathways to leadership roles and how women can access and take advantage of those pathways. What are some of those opportunities? How are they accessed? Go ahead and just talk about a few of those pathways.

DR. MOON:

Sure. I think one of the best pieces of advice I've heard is simply to show up. And that applies to leadership pathways across the board for men and women alike. When you show up and show interest, drive and commitment, people notice and generally really welcome the help of a new, enthusiastic person. I think first, it's important to define which leadership pathway is actually important to each woman individually. Is it scientific academic leadership? Is it clinical leadership within a specific subspecialty? Is it hospital administration? Political advocacy? There are several anesthesia related organizations that women can get involved with. And most of the time the entry level involvement begins at the committee level. And so most committees are very open to newcomers. And committees are great ways to first begin participation in relevant activities and to start networking with anesthesiologists who are interested in similar topics. And so, for example, I started out at the committee level within both the California Society of Anesthesiologists and the Wood Library Museum of Anesthesiology, and soon found myself being asked to chair the CSA history committee, as well as to serve on the Board of Trustees of the Wood Library Museum. I also unintentionally met a lot of my personal mentors simply by showing up to things I was interested in and forging genuine connections with people with similar interests. There's also a great article in this issue written by Dr. Paloma Toledo and her co-authors, where they discuss the value of doing a good job as peer reviewers for academic journals to be considered for editorial board positions. They also discuss the importance of applying for entry level mentored research training grants, such as the ones offered by FAER and the IARS to set junior women in academic anesthesiology on the right path to a productive career.

Dr. Linda Hertzberg also established the ASA Committee on Women Anesthesiologists, which started first as an ad hoc committee in 2016, around the time that she was the ASA director from California. And this committee was instrumental in in investigating the gender pay disparity that we had discussed earlier. They helped develop the ASA statement on compensation equity. They also developed an ASA statement on personal leave. Her article in this issue of The Monitor also discusses the work of the ASA Committee on Women Anesthesiologists and supporting leadership development, mentoring, and providing networking opportunities for women both in person and online. I understand that the committee also collaborates with other ASA committees and task forces on issues like flexible scheduling, workplace harassment, and they've helped state component societies form their own women's groups and committees. So if the ASA national scale is not where people are wanting to begin, a lot of state component societies may have women's groups as well for people to join. There's also the nonprofit corporation Women in Anesthesiology, which was founded in 2015 that similarly supports the professional and personal development of women anesthesiologists. And so I know the Women in Anesthesiology group has been a very useful forum for women anesthesiologists across the nation to network and connect with each other. They have chapters at various institutions. And the groups that I mentioned, in addition to different women's affinity groups and various subspecialty societies, continue to be valuable spaces in which women anesthesiologists can meet and network.

DR. STRIKER:

Wonderful. Let's talk briefly about what male anesthesiologists like myself can do to contribute to helping with this disparity. How can we be good allies day to day? I imagine that most male anesthesiologists out there, if you were to ask, would probably say, I don't, I have no issues, I don't, you know, I never have that problem. You're talking about other people. And I don't necessarily think that most people would probably even be purposefully hindering advancement of women or contributing to disparity. I imagine, and correct me if I'm wrong, that most of it is probably, as you pointed out, maybe unconscious bias, or you had referred to microaggressions or, you know, day to day activity that people don't even realize they're contributing to. And so whether it's along those lines or more specific lines, what can male anesthesiologists do to help? Or what would you like to see more from your male colleagues?

DR. MOON:

I think that's a great question. I really appreciate you asking that. And you're absolutely right. I would say pretty much, I really can't imagine any male anesthesiologist actively wanting to to hinder the success of their women colleagues or to have any sort of negative intent that's overt. I think just having a heightened awareness of, of this issue of gender inequity is really the first and most important step. And then I think actually being willing to participate and engage in these discussions like you're doing today is also really important, because it can signal to other men and to everybody in the specialty that this is not just a woman's issue.

I think because men still make up the majority of leaders in our specialty, men really do have the ability and power to help, mentor, sponsor, advance women with leadership potential in our specialty. And so men are in the unique position of having the power to be able to to provide meaningful opportunities for for women who may make great leaders. There are ways to take conscious actions to recognize and call out bias if you're ever in a situation where you play a role in hiring and promotion decisions. Sometimes just being willing to mentor women and being willing to give them honest, sometimes tough feedback with the aim of developing them into leaders in the specialty, just as you would do for junior men in the specialty. I think that's also very useful. And along those lines, some of my closest mentors in the history of anesthesia have also been men who've been willing to give me very direct, honest feedback and willing to help nurture my potential.

DR. STRIKER:

Well, this is an incredibly important topic in a very broad one. And before I let you go, I wanted to ask one last question. Um, there might be some listeners out there or readers of the current Monitor that might be wondering why the January issue is, is returning to the subject of women in anesthesia. Let's have you get the last word in as to why it's important to keep discussing this topic, and then also maybe throw in personally what you took from this particular issue of the monitor.

DR. MOON:

Yeah. I'd really like to express my appreciation for Dr. Barbara Jericho, who was the guest editor for this special issue of The Monitor. She did a really phenomenal job of inviting an excellent group of authors and highlighting themes that are particularly relevant to women in anesthesia leadership today.

Although we've come a really long way from zero women physicians at the time of the discovery of anesthesia to half of all medical school graduates being women today, the issues we've discussed today show that we still have quite a bit of work to do. And I think one lesson from history, which we discussed earlier, too, is that growth and success aren't always linear, so we can't really let down our guard. For example, in the business sector in the last decade, according to the most recent women in the workplace annual report of corporate America, there are more women in the C-suite than a decade ago, but there's still a pipeline issue with far less women than men being promoted from the entry level to the manager level. And in anesthesiology, we definitely have evidence that women are still not being promoted to the senior executive levels.

And so I think what is unique, though, about this issue of the Monitor is that is that it provides a sweeping overview of the past, present and future of women in anesthesia leadership in a very succinct and relatable manner. So for people who don't have a lot of time to read several full length manuscripts or books on the topic, it provides a very interesting and helpful synopsis of the key events and themes, and what I personally appreciated was that many of the authors for this issue wrote from the heart. They shared tidbits from their own journeys as women in anesthesia leadership, and I think that people will really enjoy reading all the data and evidence that's presented, but also the personal stories that are shared.

DR. STRIKER:

Well, I'm looking forward to sitting down with this issue, and it's chock full with a lot of great pieces, and I encourage everyone to check out this this issue of the ASA Monitor. Dr. Moon, we really appreciate you coming back to the show and talking with us about this important topic. Certainly can't wait to have you back on to discuss this and some other history topics, and a whole host of other issues that that we can delve into. So thank you so much for joining us.

DR. MOON:

Thank you so much, Dr. Striker.

DR. STRIKER:

And to our listeners, if you want to check out the current monitor issue, please visit asamonitor.org for more information and please tune in again next time on Central Line. Take care.

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