Pursuing parity

Odette Harris was the only black woman in Stanford School of Medicine’s class of 1996. Upon graduation, she became Stanford’s sole first-year neurosurgery resident.

“I don’t think I’ve ever been in a professional situation where I wasn’t the first or the only,” says Harris, MD, now an associate professor of neurosurgery at Stanford, the associate chief of staff for rehabilitation at the Veterans Affairs Palo Alto Health Care System and the director of brain injury programs at both institutions.

As a medical student, Harris had conducted research with Stanford neurosurgeon John Adler, MD, who likes to warn incoming residents about the grueling program they’re embarking on. “He was incredibly candid with me about what people thought about me joining the residency, and he did that in a way not to freak me out or depress me, but he wanted me to have a very real perspective about what I was getting into and not be Pollyanna about it,” Harris says. “He was like, ‘Listen, I want you to have your guard up.’ It was good baggage to carry through residency, to know that I had to be better and to do more.”

She knew she was joining a department that had recently been roiled by controversy. In 1991, Frances Conley, MD, the only woman on the neurosurgery faculty — and, in fact, the first female full professor of neurosurgery in the United States — had submitted a letter of resignation after a colleague whose behavior she found demeaning was promoted to acting department chair. After a year of turmoil, the colleague’s appointment was reversed and Conley rescinded her resignation, but her revelations of the treatment she and others experienced at the hands of their male colleagues — from exclusion and stereotyping to lewd remarks and unwanted touching — opened up a national conversation about women and sexism in academic medicine.

Five years later, Harris didn’t have much bandwidth to worry about whether she was entering an inhospitable environment. “I was very much aware of what had happened, but I think these are luxury concerns when your biggest concern is, am I going to survive this residency? Are people going to think I’m capable? Are people going to think I’m smart enough?” she says. Even in retrospect, she sees Conley primarily as the inspirational pioneer whose legacy she inherited when she joined the Stanford faculty.

“Fran went through more bullshit than Odette,” says Adler, a professor emeritus of neurosurgery who considers Conley a mentor and has himself been a lifelong mentor to Harris. “There was more hostility toward Fran. I know that Odette encountered individual animosity, but it wasn’t broad, across-the-department hostility.”

Today, Stanford’s neurosurgery faculty includes 13 women and 43 men in a variety of research and clinical specialties, not all of whom perform surgery. “Nowadays we just expect women to be in the operating room,” Adler says. “But even right now, we only have a few women and we should have more. And eventually we’re going to.”

“ ‘Eventually’ is too long to wait,” says Hannah Valantine, MD, a cardiologist who served as the School of Medicine’s senior associate dean for diversity for many years and is now the chief officer for scientific workforce diversity at the National Institutes of Health. At the current rate of change, without targeted intervention, Valantine has calculated it’s going to take more than 50 years before women in the United States achieve parity in academic medicine.

The argument for equal opportunity in academic medicine has moved from “because it’s the right thing to do” to “because it’s the smart thing to do.” Valantine and others who are working to bolster gender equality are increasingly marshaling data in support of their cause: on the benefits of a diverse workforce, on how underrepresented women are in the professoriate and in academic leadership, on the effects of unconscious biases and how to mitigate them, on the best way to compensate for differences in how male and female faculty tend to spend their time. After all, they say, they’re scientists.

Beyond the pipeline

The gender disparity in academic medicine can no longer be attributed to the so-called pipeline problem: Women make up roughly half of U.S. medical students and more than half of those receiving PhDs in the biomedical sciences. But they make up 22 percent of the tenured faculty at U.S. medical schools, according to 2013 data from the Association of American Medical Colleges. Their proportion declines as they rise in academic rank: Women are 44 percent of assistant professors — the junior faculty position that represents the first step toward tenure — but only 34 percent of associate professors and 21 percent of full professors. The only rank at which women outnumber men is that of instructor, a separate, non-tenure-track faculty line. And while women are increasingly likely to serve in medical schools’ leadership, their numbers in key positions are still small. Nationwide, they make up just 15 percent of department chairs and 16 percent of medical school deans.

‘Well, should we hire this woman, or some guy who’s going to come in and do the work?’

“What I hear a lot is, well, we just haven’t had women in the pipeline long enough to essentially trickle up,” says Diana Lautenberger, the director of women in science at the AAMC. “But if you look at it, women were 40 percent of medical students in 1993. Those women would be in their 50s now, and we don’t see anything even close to that percentage in the faculty ranks. So instead of looking at how to get women in the pipeline, because they’re already there, we’re trying to look at the climate and culture factors that push them out.”

Stanford’s School of Medicine has made a concerted effort in recent years to increase the diversity of its faculty, including its gender diversity. In 2013, Stanford exceeded the AAMC’s benchmarking data for female faculty — women were 52 percent of assistant professors, 41 percent of associate professors and 22 percent of full professors — whereas the school was below the national benchmarks a decade prior. (These numbers have continued to increase; in 2016, they were 56, 44 and 26 percent, respectively.) Women are also rising in the leadership ranks: Today, 27 percent of the departments in the School of Medicine are chaired by women.

“We need to build a diverse scientific workforce so that we can serve the needs of our diverse society,” says Lloyd Minor, MD, dean of the School of Medicine. “At Stanford, we have the opportunity to be a beacon of excellence in diversity and inclusivity, just as we are a beacon of excellence in science and clinical care. ”

Having a diverse faculty benefits the research, education and clinical missions of an academic medical center, says professor of pediatrics Yvonne (Bonnie) Maldonado, MD, Valantine’s successor as the senior associate dean for faculty development and diversity. “From an academic standpoint, we want to attract the best people. We know that if there are obstacles to women, you can lose up to half of your talented workforce,” she says. With respect to clinical care, patient surveys support the value of having a physician workforce that reflects the population it serves, Maldonado says. “People feel comfortable around others with whom they share common experiences or backgrounds,” she says. “Gender is a very simple one. Not to say that every woman should have a female physician and likewise for men, but giving patients opportunities to pick from a number of diverse providers is great.”

Plugging the leaks

When Mary Hawn, MD, applied for her first faculty job at the University of Alabama-​Birmingham, in 2001, a senior faculty member asked, somewhat rhetorically, “Well, should we hire this woman, or some guy who’s going to come in and do the work?”

“Ultimately, he was my biggest advocate and promoter,” says Hawn, now the chair of Stanford’s Department of Surgery. His remark has become a longstanding joke between the two of them. “He just laughs, ‘Oh, no, did I say that?’ And he knows he did,” she says.

Hawn has heard it all: “Mostly we’re told we don’t work as hard, we don’t see as many patients, and we’re going to need to double the workforce if we keep letting all these women in.” In a field where physicians frequently perform procedures, like surgery (as opposed to a less “procedural” field like family practice), those assumptions can be even more entrenched. “I think, to this day, women are discouraged from pursuing highly procedural fields because of the feeling that the time commitment is more significant and the flexibility is less,” Hawn says. “Whenever a woman declares she’s interested in being a surgeon or some other intensive specialty, it gets a lot of pushback, and I think it’s not intentional. Some of it is just the biases we all have.”

Exactly, say researchers. Everyone agrees that women should be in the operating room, but sometimes biases — unconscious ones — get in the way of hiring and promoting qualified women.

“If a woman walks into the room, you automatically have a certain set of expectations — which, by the way, both women and men have,” says associate professor of surgery Sabine Girod, MD, PhD, DDS. “For men there is a positive expectation: He’s young but he’s a great guy and he will get it done. And for a woman, it’s, well, she’s young and doesn’t have enough experience. This is very soft unconscious bias — I don’t think anybody is doing anything on purpose.”

Valantine, Girod and colleagues conducted a study, published in January 2016 in Academic Medicine, showing that a 20-minute educational intervention could change faculty members’ awareness of unconscious bias and their perceptions of female leaders. While she was still at Stanford, Valantine encouraged department chairs to provide this type of information at faculty meetings. “During that period of time, the hiring of women increased,” she says.

Now, every faculty search committee at the School of Medicine receives unconscious bias training at the outset of the search. “People have preconceived notions of who fits a particular job description,” says Maldonado, “and when you are able to free yourself to think a little more broadly about whether somebody who would not be a traditional choice for you can fill that position, frequently you can hit pay dirt.”

Educating search committees, Valantine says, is only half the battle. The other is to ensure women are applying for tenure-track positions in the first place. “Where in the career path do we lose people?” she asks. “It’s that transition into independent careers in academia.” Valantine notes that in the biomedical sciences, women make up almost half of post­doctoral scholars but only 25 percent of applicants for assistant professor positions. Instead, they take jobs in other fields, such as industry or policy. “This is a very scary phenomenon for academic medicine,” she says.

The leadership gap

Seven years ago, when Laura Roberts, MD, was offered the position of chair of the Department of Psychiatry and Behavioral Sciences at Stanford, some counseled her not to take it. “People thought that Stanford would not be a supportive environment for a woman leader,” she says. “And that’s not been the case at all. I’ve felt incredibly well-supported at Stanford.”

Case in point: Shortly after her arrival, Roberts asked for, and received, the approval of university leaders to review the compensation and faculty-line classifications in her department and make adjustments for equity. Then, she expanded its leadership team. “The people who had been leaders in the department were outstanding in every way — they were collaborative and they were lovely to me. They also happened to be from, let’s say, a narrow demographic,” she says. “They were extraordinary colleagues and I did not want to signal disrespect or disregard for their great work over many years — instead I just elevated other people around them so that our leadership team would reflect the broader perspectives, backgrounds and strengths of our department.” The effect of her larger-than-ordinary leadership team has been salutary. “Our people can see that there are many ways to advance professionally and to become a recognized leader in the department,” she says. “We identify positions so that people can apply for them. My sense is that these efforts have lifted morale because the opportunities for promotion and leadership are merit-driven, fair and logical.”

That’s exactly the kind of transparency that’s necessary to get more women into leadership positions in academic medicine, says Girod, who, along with Roberts, represented the School of Medicine on Stanford’s Task Force on Women in Leadership. “A lot of women want to do it, but they don’t get picked,” she says. “When you hire someone for a leadership position, you tend to, because of unconscious bias, pick somebody who is like you. And there are not many women who are picking for these positions, right?”

Roberts is particularly concerned with boosting the number of female department chairs in academic medicine. Although assistant and associate deans are higher on the org chart, the financial power in medical schools is concentrated in departments. “I am happy to see women in visible leadership roles, but I admit that what I really look for is women in leadership roles with actual budgets — women who are enabled to direct resources, to set a vision and allow strategic steps to be taken,” says Roberts. “Because that’s rare.”

Moreover, chairs set the tone for their departments, “from pay equity to culture and climate,” says the AAMC’s Lautenberger. “We work a lot with the deans and the deans are very much on board, but departments are really like their own independent organizations. They have their own budgets and their own culture and their own structure. Sometimes these departments are largely untouched. It’s interesting when you get in there to find climates that are not supportive of gender equity or considering women for leadership positions.”

Ensuring a healthy climate was one reason women in Stanford’s Department of Surgery banded together and asked to participate in their department’s recent search for a new chair. “We said we are 16 female faculty; in the past 10 years we hired 12 women and 11 women left. It’s like a revolving door at the associate and assistant professor levels,” says Girod, who, with several colleagues, is completing a study on the reasons faculty leave the School of Medicine. “The dean and the chair of the search committee were open to that argument and we actually interviewed every single candidate as a group of women. Then we wrote our recommendations to the dean.”

The result of the search: Hawn, whom Girod calls “fantastically qualified — she was really the best of everybody.”

Being selected as chair of surgery “validated my contributions were important and impactful, that a traditionally male field would aspire to have a female leader,” says Hawn. “I think for the women it’s great that they see a woman in charge. I’m curious what it means for the guys. I suspect the relationships are probably a little more formal than they would be with a male chair. But gender isn’t the only thing that aligns you with somebody or makes them feel accessible or inspirational.”

Hawn looks forward to the day when no one remarks on her gender. “To me, the goal is that there isn’t a qualifier,” she says. “That you’re not a ‘woman chair.’ That you’re not a ‘woman surgeon.’ That we say, ‘Remember the day when we were worried about women being promoted to leadership positions?’ Nobody questions a woman’s equal right to vote, or admission to college.”

Carrying an extra load

Bonnie Maldonado has three children, two of whom were born after she became a faculty member. “How do you deal with going home at night?” she remembers wondering. “How do you balance that?”

The answer came from a more senior colleague, who said, simply, “I don’t go to events on evenings and weekends.”

In that moment, “I realized it’s OK for me to say, ‘I really can’t go to that event,’ ” Maldonado says. “I was afraid people would say, well, she just wants to go home and take care of her kids, not be a physician-scientist. And there’s no longer a reason to say you have to be one or the other. You should be able to be both.”

“If you look at the generation before me, the majority of women who went into surgery never had children,” says Hawn, who has two. “They felt like they did have to make a choice.”

That was true for Conley, who decided with her husband early on that they would not have children. “You can only have so many lives,” she says. “I was really into my neurosurgery program, and it would have taken away from that. I was just so enthralled, to open up the skull and see the brain, the whole soul of the person opened up in front of you.”

Roberts, who has six children, calls herself a “poster child for everything you’re not supposed to do” to be successful in academia. “The decision to have a large family was contrary to all of the advice I received when I was an assistant professor,” she says. “Now, everywhere I go, I am told that I am an ‘inspiration’ because of my dedication to both my children and my career — but at the time, it was hard not to feel like a negative outlier. I had to quickly learn to reject the idea that your personal life and professional life are a teeter-totter in which one must be sacrificed for the other. Doing both fully, and joyfully, has been my intent.”

‘The issues that are traditionally thought to be gender-based are actually issues that affect all of us.’

Today, Hawn, Maldonado and Roberts say, both male and female faculty acknowledge greater interest in pursuing work and family goals simultaneously. “The issues that are traditionally thought to be gender-based are actually issues that affect all of us,” says Maldonado. “I’m an epidemiologist, and one of the things we learn in training is that outliers can sometimes tell you the key to the problem you’re looking at. Since women tended to be the primary caregivers, it seemed to be amplified for women, but it’s a problem for everyone.”

Women also do more housework, says Girod, citing a 2010 study by Stanford professor of history Londa Schiebinger, PhD, that found that female scientists performed 54 percent of core household tasks, whereas male scientists performed 28 percent. There are also studies showing that women faculty members shoulder a disproportionate share of “academic housework” — work that benefits the institution but does not necessarily advance individual careers, such as committee service, extra teaching responsibilities or student advising.

To address work-life pressures, in 2013-14 Stanford piloted a time-banking program, which provided faculty with credits for such things as serving on committees or providing mentoring. They could exchange those credits for things that would buy them time back at work or at home, such as grant-writing support, housecleaning or meal delivery. Time banking is a better fit for academic culture, Valantine says, than giving people time off in exchange for extra work, or an extra year on the tenure clock after maternity leave. “These integrative policies have to be framed as career advancing, rather than career pausing,” she says. “We were able to demonstrate tremendous return on investment.” Although the pilot has ended, the Department of Emergency Medicine has chosen to provide time banking for its faculty, and other departments may follow suit.

The next generation

Odette Harris has a pair of photos of the Stanford neurosurgery faculty and residents on her office wall. One day, her two young daughters came in, saw them, and asked, “Mommy, where are the women?”

“I was like, ‘What are you talking about?’ ” Harris says. “And I came over to look at the pictures and I was like, holy crap, you’re absolutely right.” In the photo from 2003, when Harris finished her residency, there is one other woman, and she’s a neurologist rather than a neurosurgeon. In the 2009 photo, from Harris’ first year on the faculty, there are a smattering, but again, most of them are not surgeons. In certain surgical specialties, women remain rare.

“The sense of isolation is pretty overwhelming if you don’t have the sounding board and the mentorship,” Harris says, emphasizing that she herself has felt strongly supported by the senior members of her department. “Everyone needs a sense of community to be able to thrive in this environment.” In collaboration with the school’s Office of Faculty Development and Diversity, she is spearheading a new program that will create small, supportive groups of women. The office also offers a monthly networking luncheon for all female faculty.

Outside of her work in neuro­surgery, Harris has made it her mission to improve access to careers like hers, primarily through science outreach to children. “There are few jobs where you can take the time outside of work to serve on the board of a Boys’ and Girls’ Club,” she says. “Where you can bring in an entire all-girls school to volunteer for a year at the VA when you’re a neurosurgeon and some may think your time is better spent in the operating room. I have amazing bosses who authentically support that kind of vision. And to have opportunities like that and still be a neurosurgeon is a dream.”

There’s only one workplace Harris could combine these threads, she says: academic medicine. “If I have a legacy in the next 30 years, I hope it’s my grass-roots efforts to inspire kids,” Harris says. “Someday, my children will not be the first or the onlies.”