Evolution of women physician leadership at the Ottawa Hospital, 2011–2022: a mixed method study by the Women Physician Leadership Committee
Eliana Wolfe, Kathleen Gartke, MD, FRCSC, Lara Khoury, MD, FRCPC, Jasmine Gandhi, MD, FRCPC, Jean M. Seely, MD, FRCPC, Camille Munro, MD, CCFP (PC)
Purpose: To assess the evolution of women physician leadership after implementation of initiatives introduced by the Women Physician Leadership Committee (WPLC) from 2011 to 2022 at The Ottawa Hospital (TOH). Methods: We conducted a mixed-methods study using a transformative sequential research design. During phase 1 (2011–2022), we held three rounds of semi-structured interviews with division and departments heads. The results were organized into eight themes, providing insight into TOH’s work environment and culture. In phase 2, we determined the number of women physicians holding privileges and leadership positions at TOH in 2011, 2016, and 2022. Results: Despite an increase in the number of women physicians over the last decade (from 30% (255/862) in 2011 to 42.5% (486/1144) in 2022), the number of women division and department heads did not change significantly. In fact, only one of 12 department head positions has been held by a woman. We compiled comments from division and department heads to capture various perspectives and provide concrete examples of efforts and barriers to women physician leadership. Interpretation: We attribute the progress we have achieved in the last 11 years to the WPLC’s initiatives. Among other positive changes, there has been an increase in the number of formal mentoring opportunities, as well as the number of leaders who consider bringing in a locum when needed to balance the workload. Although progress toward achieving gender parity at TOH is encouraging, it has not eliminated barriers that women in medicine face. Further intentional change is required to counteract deeply rooted societal constructs within TOH culture.
KEYWORDS: barriers, culture, equity, leadership, policy, women
Wolfe E, Gartke K, Khoury L, Gandhi J, Seely JM, Munro C. Evolution of women physician leadership at the Ottawa Hospital, 2011–2022: a mixed methods study by the Women Physician Leadership Committee. Can J Physician Leadersh 2023;9(3):92-102
https://doi.org/10.37964/cr24774
Despite the increase in the number of female medical students over the last 20 years1 — leading to gender parity among physicians in Canada under age 40, and projected for all ages by 20302 — the percentage of women physicians who hold medical leadership roles remains disproportionately low.3 In short, “women in academic medicine are not reaching the same levels of career advancement [or] leadership responsibility” as men.4
The disparities in leadership are not attributable to a lack of leadership aspirations: women and men faculty members share similar ambitions.8 However, women more commonly work in undervalued areas of medicine, are less likely to have their professional title acknowledged, and receive less supportive reference letters for positions of leadership in medical schools.5 As a result, academic medicine lags behind other STEM (science, technology, engineering, mathematics) professions in eliminating gender differences in job promotion.6 The barriers to the progression of women physicians in leadership — financial inequities, gender bias, microaggressions, familial responsibilities — remain unsolved despite being well documented.7 It is important for institutions to continually observe the barriers they have yet to eliminate to decrease the gap between women and men physicians in leadership because achieving gender equity in leadership improves the making of health policies and patient care.5
The Women Physician Leadership Committee
The Ottawa Hospital’s (TOH’s) Women Physician Leadership Committee (WPLC) was founded by Dr. Virginia Roth in 2011. The committee aims to overcome gender inequities by identifying and supporting women physician leaders.9 The central construct of the WPLC is to interview division and department heads to assess the leadership opportunities for women physicians at TOH. The results inform initiatives that foster an environment conducive to gender-balanced leadership (see Table 1 for an overview of the WPLC’s initiatives since 2011).
Table 1. Initiatives of the Women Physician Leadership Committee, 2011–2022
Subsequent surveys assess the impact of these initiatives. This cycle has been performed three times: in 2011, 2016, and 2022. The purpose of our current study was to assess the evolution of women physician leadership since the implementation of our initiatives, i.e., from 2011 to 2022. We sought to document the growth in the proportion of women physicians holding privileges and leadership positions at TOH, as well as the impact of the WPLC’s initiatives. Please note that, in our article, the term “women” encompasses all groups that identify as women and/or biologically female for inclusivity.
Methods
We conducted a mixed-methods study using the transformative sequential research design.10 Phase 1 extended from 2011 to 2022; during these years, we held three rounds of semi-structured interviews with the division and departments heads at TOH. The study prioritized qualitative research (phase 1); a subsequent quantitative component (phase 2) developed and supported the findings from our interviews. Phase 2 involved determining the number of women physicians holding privileges and leadership positions at TOH in 2011, 2016, and 2022.
Phase 1: Survey results and the impact of the WPLC’s initiatives
The theoretical framework of phase 1 was ethnography, using the participant observation research strategy.11 This framework was fitting given that it aims to capture a picture of people’s perceptions and behaviours12 to explain the dynamics within a culture.10 Although the committee members conducted these interviews to examine the culture in the divisions and departments (according to the leaders’ perspectives) and to determine whether opportunities for women leadership have evolved, their active roles and individual experiences as women physicians at TOH enabled them to conduct these interviews from an already rich perspective.
Participants were purposely selected based on their TOH division head or department head role. The WPLC members conducted the interviews. These committee members belong to a variety of divisions and departments at TOH; some are division heads. In 2011, each committee member was asked to interview their own department head. In 2016 and 2022, committee members did not interview their own division or department head. Often, WPLC members had not met their interviewee before the study. Participants were informed of the purpose of the interviews by email and were told that the interviewer would be a WPLC member. There are 12 departments and 39 divisions (in 2011, there were 42 divisions), and each physician lead of division and department was expected to complete one survey. In 2022, we had 49 participants, as two division heads (nephrology and midwifery) were unavailable.
Interviews were conducted in person, by telephone, or by virtual online meeting. The TOH leaders and WPLC members were the only people present during the interviews. WPLC members were provided an interview guide (Appendix A) detailing the questions to ask. Except for a few minor adjustments, the guide has remained the same since 2011. The first survey was designed following an article published by Dr. Gartke et al.13 on work-life balance at Canadian medical schools. No repeat interviews took place. Meetings were not recorded. WPLC members completed their field notes during and after the interviews. Transcripts were not returned to participants for revision. Each meeting lasted approximately one hour. Data saturation was not discussed. Data collection was complete once all available division and department heads were interviewed (within one year) for each round of interviews.14
Phase 2: Growth in the proportion of women physicians holding privileges and leadership positions at TOH
The quantitative component of our study was retrospective, given that we sought to examine the same group of people (women physicians holding privileges and leadership positions at TOH) over the past decade.10 We identified the number of women physicians holding privileges in 2011, 2016, and 2022 from TOH’s internal database, filtering the query to eliminate cross-appointments and non-active/associate privilege categories. We determined the number of women physicians holding leadership positions in 2011, 2016, and 2022 from Roth et al.,15 an unpublished WPLC report from 2016, and TOH’s June 2022 medical head of department/division list, respectively.
Analysis
A university student from TOH’s Department of Medical Affairs coded the data. Interview results were organized into eight themes (Table 2) derived from the interview questions examining TOH’s work environment and culture. Participant quotations were anonymized by assigning a number to each division and department; this ensured that responses remained confidential. We used a spreadsheet to manage the data and allow easy comparisons. We calculated growth in the number of women physicians holding privileges and leadership positions in percentages. At TOH’s October 2022 Medical Advisory Committee meeting, we presented our findings to senior leadership (including department heads). This enabled leaders to compare leadership opportunities for women physicians in their department with other departments of the hospital. Feedback focused on the next steps for TOH to promote change (e.g., targeting women for the leadership skills development courses sponsored by Medical Affairs).
Table 2. Overview of interview responses arranged under eight identified themes
Results
Phase 1: Survey results and the impact of the WPLC’s initiatives
The three sets of interviews of division and department heads provided insight into TOH’s work environment and culture (Table 2). Although the WPLC’s initiatives have contributed to fostering an environment that promotes women physician leadership, barriers remain. We recorded comments from interviewees to illustrate the various perspectives and provide concrete examples of barriers to women physician leadership at TOH (Table 3).
Table 3. Notable comments from the 2022 interviews regarding obstacles to women physician leadership and proactive initiatives to encourage women physician leadership at TOH
Even though most interviewees did not mention any specific initiatives to encourage women physicians to advance into leadership roles over the past decade (other than general encouragement and equal opportunities for both men and women), some of these leaders have made commendable efforts. Initiatives include leadership courses, increasing representation of women on committees, and encouraging women to participate in division recruitment activities, succession planning, and mentorship.
Phase 2: Growth in the proportion of women physicians holding privileges and leadership positions at TOH
Since 2011, there has been a steady increase in the number of women physicians holding privileges (active and associate staff): from 30% (255/862) in 2011 to 42.5% (486/1144) in 2022. Since 2016, the largest increases in the proportion of women leaders have been in the Departments of Pathology and Laboratory Medicine (9.4%), Mental Health (8.1%), and Ophthalmology (7.8%). There was no significant improvement in the number of leadership positions held by women physicians at TOH. In fact, although the number of women division heads has increased slightly, from 7 in 2011 and 2016 to 10 in 2022, the number of women department heads (1 in 12) has remained the same since 2011. (Table 4). Figure 1. Percentage of women physicians holding privileges at TOH by department in 2011, 2016, and 2022 (active and associate staff).
Interpretation
Overall, we attribute the progress we have achieved in the last 11 years to the WPLC’s initiatives or, simply put: intentionality. However, despite steady progress, our results illustrate that obstacles to women physician leadership at TOH remain, as the increase in the number of women physicians at TOH is disproportionate to the increase in the number of women division and department heads.
Our findings support the notion that “gender parity [among medical students] does not correspond to gender equality,”16 and thus gender parity in leadership.17 Overall, the percentage of leaders (35%) who recognize potential barriers to women physician leadership at TOH has not changed since 2016. The barriers identified in our study (e.g., women physicians’ familial responsibilities) are consistent with other studies.7,18 The lack of women division and department heads suggests that the culture for leadership at TOH is predominantly viewed from a man’s perspective. Because a man’s experience differs from a woman’s, some obstacles encountered by women may have been neglected. We suggest this might be one reason why barriers still exist.
This ties into the concept of unintentional gender bias, according to Gawad and colleagues.18 Tricco and colleagues, on the other hand, argue that gender inequities in leadership are largely a result of “socially constructed gender norms, roles and relations”5 (e.g., that doctors are men).16 These designated gender norms, roles, and relations support Khoury’s observation that “the biggest barrier women face when contemplating leadership positions is the fact that women do not perceive themselves as leaders,”3 otherwise known as “imposter syndrome.”19 Evidently, ongoing intentional initiatives are still required to counteract deeply rooted societal constructs in Canadian culture.
Further studies are needed to examine the gender inequities within institutions, as this helps increase awareness and promote public accountability.5,20 Within the context of TOH, it is important that the WPLC continues its surveys at regular intervals to prevent stagnation. Studies show that the most efficient way to oppose the barriers to women in medicine is to adopt a “top-down” approach, as opposed to a “bottom-up” approach. The former requires change to first be implemented by higher management,18,21 which includes division and department heads. TOH’s division and department heads wish to support their women physician leaders but seek direction. Suggestions on ways we can promote opportunities for women leadership and reduce barriers exist (e.g., see Harvard Business Review’s list22 or box 3 in Tricco and colleagues5), but they need to be advertised, implemented, and assessed. In the most recent 2022 interviews, multiple leaders requested a “best practice guide,” in response to the question: How could the TOH Women Physician Leadership Committee assist your division/department to further develop and support its women physician leaders? As a start for possible next steps, we have encouraged TOH leaders to consider the proactive initiatives within their neighbouring TOH departments as an unofficial guide for their division or department (see Table 3). Other institutions are also encouraged to consider these recommendations to promote women physician leadership in their centre.
What are the next steps for the WPLC? In addition to the request for a “best practice guide,” leaders identified four main targets for the WPLC: leadership skills, well-being, networking, and recognition. Recommendations to develop the leadership skills of their female physicians included offering courses on leadership, crucial conversations, and just culture training. To foster the well-being of female physicians, some leaders advised providing strategies for work-life balance as well as advocating increased administrative support for the positions of leadership. Some leaders also requested that the WPLC establish a formal mentorship program (outside of the departments) and organize talks with guest speakers (e.g., on how to get promoted), to promote networking. Finally, with the intention of recognizing their female physicians, some leaders suggested expanding award systems and emphasizing the fact that positions are given on merit, not gendered-based quotas.
Table 4: Proportion of women physicians holding privileges (active and associate staff) and leadership positions (division and department heads) at TOH in 2022, 2016, and 2011
Limitations
Our study had several limitations. As the third round of interviews was conducted during a series of COVID-19 waves, leaders were forced to turn their focus away from leadership promotion initiatives and toward COVID-related issues, such as staffing gaps, burnout, and the shift to a virtual environment. This may have overshadowed some of the areas of progress at TOH since 2016. In addition, the possibility for turnover in the division and department head roles over the past 10 years was limited by 5-year terms. It was not feasible to determine how many roles were vacant, because contract terms end and begin at different dates and roles evolve over time with structural and funding changes. Furthermore, because the interviews took a year to complete, some of the data collected in 2010, 2015, and 2021 may have changed by 2011, 2016, and 2022. Limited meeting times restricted the number of interview questions and also resulted in not getting answers to all the survey questions, creating data gaps. Moreover, our study results may have been affected by interviewer variability, considering the number of interviewers, as well as interviewer bias (inherent to semi-structured interviews). Because the interviews were performed without recordings and with informal note taking, without returning the transcripts to the interviewees for revision, interpretation of the results could have been impacted by interviewer bias. The study was performed without funding, and the time to perform the study was limited by availability of the WPLC members. Finally, since many of the interviewees were men, we were unable to specifically document what women leaders want and need from TOH.
Women Physician Leadership Committee (as of June 2022)
Conclusion
Although there has been an increase in the number of women physicians holding privileges at TOH since 2011, it is disproportionate to the increase in the number of women division and department heads. This illustrates that significant obstacles to women physician leadership remain. Women are reluctant to put their name forward, they lack role models in previous women leaders, and they must overcome stereotypical views. Studies like this one are important, as painting a picture of the work culture may be a step toward bringing about change.4 Continuing to eliminate barriers to promoting women physicians15 will make consistent progress achievable.
Recently, the WPLC was instrumental in the notable achievement of changing the TOH bylaws, so that one woman must always be nominated to be president or vice-president of the Medical Staff Association.23 Such intentional changes pave the way for future women leaders. However, work to improve gender parity at TOH appears to fall back to the WPLC versus the institution itself, which signals that the organization’s culture is underdeveloped in its ability to address diversity. We encourage open conversations on women physician leadership with co-workers and aspiring physicians to increase awareness of the barriers that exist and address them.
Acknowledgement
We thank Dr. Virginia Roth for pioneering this committee, as well as the committee members for their ongoing investment in developing women leaders.
References
1. Waugh E, Schipper S, Ross S. Female doctors in Canada. Toronto: University of Toronto Press; 2019.
2. Addressing gender equity and diversity in Canada’s medical profession: a review. Ottawa: Canadian Medical Association and Federation of Medical Women of Canada; n.d. Available: http://tinyurl.com/5t3fb3xm
3. Liu A, Rhee G. Promoting female leadership in healthcare: an interview with Dr. Lara Khoury, co-chair of the Female Physician Leadership Committee. Univ Ottawa J Med 2017;7(2):9-11. https://doi.org/10.18192/uojm.v7i2.2185
4. Westring AF, Speck RM, Sammel MD, Scott P, Tuton LW, Grisso JA, et al. A culture conducive to women’s academic success: development of a measure. Acad Med 2012;87(11):1622-31. https://doi.org/10.1097/ACM.0b013e31826dbfd1
5. Tricco AC, Bourgeault I, Moore A, Grunfeld E, Peer N, Straus SE. Advancing gender equity in medicine. CMAJ 2021;193(7):E244-50. https://doi.org/10.1503/cmaj.200951
6. Richter KP, Clark L, Wick JA, Cruvinel E, Durham D, Shaw P, et al. Women physicians and promotion in academic medicine. N Engl J Med 2020;383(22):2148-57. https://doi.org/10.1056/NEJMsa1916935
7. Ramas ME, Webber S, Braden AL, Goelz E, Linzer M, Farley H. Innovative wellness models to support advancement and retention among women physicians. Pediatrics 2021;148(Suppl 2):e2021051440H. https://doi.org/10.1542/peds.2021-051440H
8. Pololi LH, Civian JT, Brennan RT, Dottolo AL, Krupat E. Experiencing the culture of academic medicine: gender matters, a national study. J Gen Intern Med 2012;28(2):201-7. https://doi.org/10.1007/s11606-012-2207-1
9. Decade of success: committee fights inequality and supports female physicians. Ottawa: The Ottawa Hospital; n.d. Available: http://tinyurl.com/yc8p6apz
10. Fortin MF, Gagnon J. Fondements et étapes du processus de recherche : méthodes quantitatives et qualitatives. 4th ed. Montréal: Chenelière Éducation; 2016.
11. Silverman D. Qualitative research. 4th ed. Los Angeles: Sage; 2016.
12. Reeves S, Kuper A, Hodges BD. Qualitative research methodologies: ethnography. BMJ 2008;337:a1020. https://doi.org/10.1136/bmj.a1020
13. Gropper A, Gartke K, MacLaren M. Work–life policies for Canadian medical faculty. J Womens Health (Larchmt) 2010;19(9):1683-703. https://doi.org/10.1089/jwh.2009.1809
14. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care 2007;19(6):349-57. https://doi.org/10.1093/intqhc/mzm042
15. Roth VR, Gartke K, Parai J, Khoury L. Unlocking the leadership potential of women in medicine. Can J Physician Leadersh 2018;5(1):27-32.
16. Raj A, Kumra T, Darmstadt GL, Freund KM. Achieving gender and social equality: more than gender parity is needed. Acad Med 2019;94(11):1658-64. https://doi.org/10.1097/ACM.0000000000002877
17. Azam TU, Oxentenko AS. Gender parity in medical school does not equal gender parity in medical school leadership. J Womens Health (Larchmt) 2019;28(5):563-4. https://doi.org/10.1089/jwh.2019.7762
18. Gawad N, Tran A, Martel AB, Baxter NN, Allen M, Manhas N, et al. Gender and academic promotion of Canadian general surgeons: a cross-sectional study. CMAJ Open 2020;8(1):E34-40. https://doi.org/10.9778/cmajo.20190090
19. Health care leadership in action: overcoming impostor syndrome. Ottawa: Canadian Medical Association; 2020. Available: https://www.cma.ca/physician-wellness-hub/content/health-care-leadership-action-overcoming-impostor-syndrome
20. Casadevall A. Achieving speaker gender equity at the American Society for Microbiology general meeting. mBio 2015;6(4):e01146. https://doi.org/10.1128/mBio.01146-15
21. Laver KE, Prichard IJ, Cations M, Osenk I, Govin K, Coveney JD. A systematic review of interventions to support the careers of women in academic medicine and other disciplines. BMJ Open 2018;8(3):e020380. https://doi.org/10.1136/bmjopen-2017-020380
22. What’s holding women in medicine back from leadership. Harv Bus Rev 2018;19 June (updated 7 Nov.). Available: http://tinyurl.com/32e2fwy9
23. Medical staff by-law of The Ottawa Hospital. Ottawa: Ottawa Hospital; 2022. Available: http://tinyurl.com/3j59453b
Authors
Eliana Wolfe is a fourth-year BScN student at the University of Ottawa and student/clerk in the Department of Medical Affairs, The Ottawa Hospital.
Kathleen Gartke, MD, FRCSC, is senior medical officer, The Ottawa Hospital, and assistant professor, Division of Orthopaedic Surgery, University of Ottawa.
Lara Khoury, MD, FRCPC, is head of the Division of Geriatric Medicine, The Ottawa Hospital, and assistant professor in the Division of Geriatric Medicine, University of Ottawa.
Jasmine Gandhi, MD, FRCPC, is medical director, Perinatal Mental Health, Department of Mental Health, The Ottawa Hospital, and assistant professor, Department of Psychiatry, University of Ottawa.
Jean M. Seely, MD, FRCPC, is a professor in the Department of Radiology, University of Ottawa
Head Breast Imaging Section, The Ottawa Hospital.
Camille Munro, MD, CCFP (PC) is assistant professor, Division of Palliative Medicine, Department of Medicine, University of Ottawa, The Ottawa Hospital.
Funding: This study had no funding.
Competing interests: None of the authors has a financial relationship with any organization that may have interest in the submitted work or relations or activities that could appear to have influenced the submitted work. They declare no competing interests.
Correspondence to: [email protected]
This article has been peer reviewed.