Women in senior post-graduate medicine career roles in the UK: a qualitative study.

OBJECTIVES: This qualitative study sought to elicit the views, experiences, career journeys and aspirations of women in senior post-graduate medical education roles to identify steps needed to help support career progression.
DESIGN: In-depth semi-structured telephone interviews.
SETTING: UK. PARTICIPANTS: Purposive sample of 12 women in a variety of senior leadership roles in post-graduate medical education in the UK. MAIN OUTCOME MEASURES: Self reported motivating influences, factors that helped and hindered progress, key branch points, and key educational factors and social support impacting on participants' career in postgraduate medicine.
RESULTS: Respondents often reported that career journeys were serendipitous, rather than planned, formal or well structured. Senior women leaders reported having a high internal locus of control, with very high levels of commitment to the NHS. All reported significant levels of drive, although the majority indicated that they were not ambitious in the sense of a strong drive for money, prestige, recognition or power. They perceived that there was an under-representation of women in senior leadership positions and that high-quality female mentorship was particularly important in redressing this imbalance. Social support, such a spouse or other significant family member, was particularly valued as reaffirming and supporting women's chosen career ambition. Factors that were considered to have hindered career progression included low self-confidence and self-efficacy, the so-called glass ceiling and perceived self-limiting cultural influences. Factors indirectly linked to gender such as part-time versus working full time were reportedly influential in being overlooked for senior leadership roles. Implications of these findings are discussed in the paper.
CONCLUSION: Social support, mentorship and role modelling are all perceived as highly important in redressing perceived gender imbalances in careers in post-graduate medical education.

Introduction

A number of studies have explored the representation of women doctors within the health care system and universities in the UK and elsewhere, but little has been reported in the field of post-graduate medicine. This study sought to address this imbalance by exploring possible factors affecting women’s decisions concerning careers in senior post-graduate medical leadership roles in the UK, to examine key branch points in progression and to explore women’s perceptions and pathways into leadership positions.

The 2009 report – ‘Women Doctors: Making a Difference’[1] identified an under-representation of women working in medicine in senior leadership positions in comparison with their male counterparts. Demographic trends have been comprehensively described by Jefferson et al.[2] and have identified that there are clear gender differences in both working patterns and specialities. Examination of a cohort of doctors graduating in 1993 in the UK demonstrated equivalent progression amongst those who had always worked full time, with 94% of men and 87% of women of those working in general practice being principals, and of those working hospital practice 96% of men and 93% of women had reached consultant level.[3] However, approximately one-third of doctors worked less than full time, with women almost eight times more likely to be working part time than men, with those who worked part time less likely to have reached senior positions.[3] Women remained under-represented in surgery and general medicine.[1-3] There is also evidence of under-representation of women doctors in clinical academic careers.[4] Although just over half of those entering medical school are now women, there is a low proportion of women working within clinical academic medicine, and less than 15% of professors in UK medical schools are female.[4] The authors state that discriminatory practices and unconscious bias continue to occur in academic medicine, although they highlight progress in the number of female clinical academics, in the number of first author papers by female academics, and in the implementation of schemes such as Athena Swan[5] (which promote the embedding of gender neutral policies within institutions). Whilst there is some evidence that women have reported less interest in academic careers and leadership than men,[6-8] this may be less about intrinsic interest and perhaps because long hours impose considerable strain on relationships, as the careers of partners also have to be taken into account, even in dual career families where women are traditionally in charge of caring work.[9] Career decisions by women doctors tend to reflect complex decisions made to balance competing demands of family life.[10]

Female physicians may also be affected by a lack of opportunities compared with their male colleagues,[11,12] and deficiencies in career advice and mentoring may contribute to the ‘glass ceiling’ effect on women’s upward mobility.[13,14] Mentoring has been reported to beneficial in academic psychiatry.[15]

We were interested in exploring whether similar issues about career progression occurred in women doctors working in post-graduate medical education in the UK, where career structures are generally less structured than those leading to consultant, general practice or clinical academic posts. Many of those working in post-graduate medical education move into it at a later stage in their careers, once they are already established in their specialty. Individuals can take on a variety of roles, working in their own organisations to lead the medical training function, or within NHS structures responsible for overseeing education and training programmes. Some combine clinical work with this work, and others will move into full time educational leadership roles.

Method

This research used a qualitative approach to investigate the views and attitudes of women in senior leadership roles in post-graduate medical education in the UK. A semi-structured interview schedule was used to identify individuals’ views on their own career trajectories, using reflective, self-report techniques. All interviews were conducted by telephone by AC and were recorded and then transcribed. All notes were stored without identifiers in a secure filing cabinet.

Sampling

A purposive sample of 12 senior female leaders was selected to take part in this study. These women were identified by the research team as successful leaders in their own field or clinical and/or non-medical specialities. Purposive sampling was used to ensure a range of individuals of different ages and backgrounds, working in a range of different parts of the UK and in different types of organisations.

Participants were contacted by e-mail and invited to take part in a telephone semi-structured interviews lasting between 30 and 40 min. Questions were given out in advance to the participants in order to establish informed consent and also to help participants reflect on their own leadership careers prior to the telephone interview. A sample of the invitation letter is provided below:We confined the sample to respondents working in the UK NHS (including those with an honorary NHS contract, who were predominantly in senior leadership and/or clinical academic posts). All those invited to participate were willing to do so. Interviews were undertaken between March and November 2015.

As a senior leader in post-graduate medical education, we would like to hear about your experiences, and we have designed a set of short questions, to explore your views, these are summarised below:

Experiences of promotion and/or progression

Factors that helped or hindered you in your role/previous role

Key branch points, e.g., clinical leadership

Brief review of wider factors, e.g., mentoring, role models, family factors

How do notions of success differ for women?

How can we better prepare women for future senior leadership roles?

Data analysis

Analysis was through qualitative data analysis, which included coding and categorising to identify recurrent themes and key issues important to the participants. Such thematic analysis is specifically designed to obtain rich data and to gain the perspectives of the participants. Transcripts were scrutinised and analysed through the constant comparative method: each section of data was compared with every other. The data were examined for patterns and variations in ideas. An inductive approach was therefore adopted, consistent with a grounded theory approach as described by Strauss and Corbin.[16]

Results

A summary of the key themes emerging from the analysis was as follows: career progression; locus of control; factors that helped; factors that hindered; views on women in senior roles; comparison with male counterparts; work–life balance; role modelling; career aspirations and developing careers. A short summary of issues raised and illustrative quotes are given under each theme.

Career progression

A variety of personal career journeys were shared – each one unique, different and continuing – although common themes emerged from the data. Career progress was often perceived as ‘serendipitous’, ‘accidental’ and ‘haphazard’ rather than ‘formal’ and ‘structured/planned in advance’.Several reported that promotion or opportunities had arisen when they were not expecting it, with for example an unexpected promotion of a colleague. A recommendation from a ‘trusted’ other even when they did not feel ready to take on a bigger role was reported as important:Opportunities were often described as being unintended, unexpected and ascribed to serendipity or good fortune:

“I did not set out to be in the post I am presently occupy[ing]” AA

“My career direction has not been planned in advance” BB

“It’s a combination of luck and fortunate timing that I arrived in this post” CC

“If x had not told me to go for this post, I never would have done so!” AA

“we job shared the role, against my own personal expectations, and then the opportunity suddenly arose for me to do the role myself” DD

“It was sheer luck how this promotion opportunity arose” EE

Locus of control

All respondents reported having a high internal locus of control,[17] although opportunities were recognised to be external. All reported very high levels of commitment to the NHS and significant levels of drive, although the majority indicated that they were not ambitious in the traditional sense of a strong drive for money, prestige, recognition or power. All were working in their chosen field or speciality in order to ‘make a difference’ and ultimately improve patient care/patient journey, albeit indirectly through their leadership decision making.

“I guess what drives me most is making a difference to the NHS, ultimately to improving patient care” DD

“every day I come into the workplace with drive to improve the NHS and ultimately patient care” DD

Factors that helped

Having a supportive family (usually a significant other such a spouse, partner or son) was reported as significant. However, in contrast, in one case having a family was seen to have created the possibility and opportunities for a dedicated focus on a career without the ‘perceived distraction’ of family life.Several reported that specific leadership courses had been impactful:

“I could never have obtained this role had I had a family to look after at the same time. That would have been a huge distraction” FF

“My husband is retired and so it made sense for me to go for this role” FF

“Leadership courses were an invaluable networking opportunity to help grow my confidence for future opportunities” GG

Factors that hindered

The main hindering factor was perceived to be a lack of self-confidence or self-efficacy with reference to a self-imposed ‘glass ceiling’, derived from childhood and cultural influences.Some also reported that ‘other women in similar roles’ (notably if working relationships were not positive and/or the ‘hinderer’ colleagues had perceived different family arrangements) were a barrier. In contrast, the majority reported that they had needed other women, as well as significant men in their lives (e.g. at home and work), to help break through this perceived (and sometimes culturally self-imposed) glass ceiling.

“it’s a cultural thing. Women are still I think not expected to occupy the majority of senior leadership roles … that’s going to take some time to change I think” FF

“when growing up as a young woman, I never expected to climb this high on the career ladder … you just weren’t expected to” FF

Views on women in senior roles

There was a clear perception of under-representation of women in senior leadership roles in post-graduate medical education roles. Women in these roles reported that they were more likely to be ‘questioned’ about their role, albeit informally. An example would be the impression of the importance of dress code in women with implied criticism if a senior female leader is not dressed ‘appropriately’ for her senior role.This was acknowledged to be a wider societal issue than just medicine and was felt to be slowly changing but overall not changing as fast as it should. More positive leadership role models were felt to be needed, such as in sport. The role of the media and wider society in embracing and accepting women in senior roles also needs changing.

“As a woman, if I turned up to a board meeting in less than perfect attire, it would be noticed, by both men and women. I wonder how many men feel the same way?” HH

“I think that there is still an underrepresentation of women in roles equivalent to mine. I think that this country still has a long way to go” HH

“for sure we need more positive female role models in leadership positions. For that matter, we also need them in wider society. We need to challenge the ‘glass ceiling’ stereotype and accept women in senior roles as the norm, just as we do with men” DD

Comparisons with male counterparts

Respondents often reported themselves as operating strategically different from their male counterparts in similar or equivalent leadership positions, and saw themselves possessing somewhat different drivers and skills with respect to socio-emotional, relationship building and managing performance. Women perceived that they had high intrinsic drivers to undertake their present role that was less about the formal status and salary that the position entailed, and more about the opportunity to bring about real change in service delivery and relationships within and between the teams they were leading. A number felt that their own motivational factors and drivers were more intrinsic and subtle than those for their male leaders in similar positions. The majority reported that their senior leadership position was not directly about ‘gender’ per se but more about the skills, talents and dedication that they brought to the role. They perceived that other factors such as working part-time as opposed to full time mattered more than gender in terms of being overlooked for senior leadership roles. Exemplar statements included:

“I consider myself to be more socio-emotional in my dealings with colleagues in comparison to men. I have always achieved more this way than adopting purely results driven business” BB

“I don’t think this interview is necessarily about gender. In my experience, working only part-time is a much bigger barrier to leadership opportunities than whether one is male or female” CC

Work–life balance

The ability to manage this was seen as essential in rapidly changing working lives, with constant challenges of managing roles effectively and raising children, and increasingly caring for elderly parents. The conflicts inherent in juggling balls, fulfilling roles and expectations of others were highlighted. The importance of key practical issues was raised.

“I can honestly say that the biggest driver to my leadership success is having a private car parking space in the centre of XX! That reduces my stress levels even more than having a competent secretary!” CC

“I have been juggling balls in the air ever since going for leadership roles. Some have dropped but that has not stopped my drive and enthusiasm in these roles” CC

“I have surprised myself in terms of how I have managed elderly parents and child care whilst also leading teams in times of uncertainty and change” DD

Role modelling

Role modelling was considered highly important, but most respondents perceived that there was a lack of women role models, and that there could be more visibility and promotion of those that there were. Women in senior roles were seen to often inspire other senior women, if only indirectly. The importance of an inspiring mentor, a guiding hand, and a quiet word of encouragement was seen to be very influential and important. There was a sense that there was a need for more women leaders who are ordinary people doing extraordinary things, and that whilst the majority of women may have this potential concern that they may look around at the sacrifices and challenges and complexities and decide NOT to try to progress further in their careers.

“I think we women are all just ordinary people who every day happen to do extraordinary things” AA

“Having an inspiring female mentor was essential in terms of where I am today” BB

“The majority of women may have this (leadership) potential but they look around at the sacrifices and challenges of other women, and the complexities of the role, and decide NOT to progress further” BB

Career aspirations

There was a sense that that there is a perceived gap between women’s roles and their career aspirations, and the opportunities available on the ground to progress these. Latent aspirations were seen to often get buried, for example, following negative experiences of leadership, or internalised into other priorities such as family life. In contrast, realised aspirations arose through meeting challenges and opportunities at key points in own personal lives, and sometimes by a freeing or reduction in domestic responsibilities such as children leaving home, divorce or loss of a partner.

“I think that, looking back, opportunities to pursue promotion and leadership roles have arisen, at least in part, by changes in my home and personal life” DD

“when I see and hear the effects of leadership responsibilities on my female colleagues, it does rather make one focus on other priorities outside of this!” DD

Developing careers

There was felt to be a need for more advice for women in future career development opportunities, and having a supporting and inspiring mentor at key branch points was considered essential by all respondents. (Notably mentors were not always aware of the full range of their own influence here.)Despite the difficulty of breaking down macro factors such as cultural expectations, and addressing the dual and multiple roles of women, it was felt that workforce factors are driving the changes needed with an increased representation of women in middle and senior management and leadership roles.

“we should promote potential leadership opportunities for women more at our careers fairs. This is where they tend to be most receptive. We also need to highlight the crucial role of mentors there also” EE

Other comments

All participants were very pleased to have ‘shared their voice’ and reported that their own personal reflection arising from these interviews were very powerful for themselves as senior women in leadership roles – in the majority of cases, this was the first opportunity they had had to share their own personal views, and this was reported by the majority of respondents as a useful and by two respondents as a transformational experience.

“Thank you for interviewing me so carefully and respectfully. This is the first time that I have had the opportunity to share my story!” FF

“Sharing my career life story has now really enthused me again!” FF

Discussion

Statement of principal findings

This qualitative study sought to elicit the views and experiences of women in senior post-graduate medical education roles in a variety of roles and organisations across the UK in terms of their career journeys and aspirations. A key finding was that individual career journeys were often reported as serendipitous. The importance of mentors, recommendations and advice from a trusted influential individual, unexpected colleague promotion or opportunity was highlighted. All women leaders reported significant levels of drive.

Social support was particularly valued as reaffirming women’s chosen career ambition. Factors that hindered included perceived self-confidence/self-efficacy and perceived self-limiting cultural influences.

Strengths and weaknesses of the study

This is the first study that we are aware of that has explicitly looked at women working in the field of post-graduate medical education. Limitations of the present study must inevitably focus on the small sample size that limits generalisability to a wider underlying target population of female leaders. Post-graduate medicine at the senior level in the UK is a small community, and it would have been difficult to identify individuals who were not known at all to the research team. However, purposive sampling was used to ensure a range of individuals of different ages and backgrounds, working in a range of different parts of the UK and in different types of organisations, and all interviews were conducted by AM, who has no personal contacts in the field, so steps were taken to minimise bias.

In addition, the flexible nature of the questions used made results difficult to compare between participants, although there were significant levels of agreement between participants in terms of their underlying values and motivations for aspirational leadership.

Strengths and weaknesses and findings in relation to other studies

This was a relatively small in-depth study. Although post-graduate medicine has a less structured career path than some other medical careers, similar themes emerged from this study to those looking at women doctors’ careers in clinical academic medicine and other medical fields, particularly the importance of mentoring, role models and the importance of active encouragement to women doctors to consider senior positions.

Meaning of the study: possible mechanisms and implications for clinicians or policymakers.

This study highlights the important role that mentors (male and female) and role models in senior leadership positions play, and the importance of providing leadership opportunities at all levels in a transparent and open way.

Unanswered questions and future research

Further work might explore if male doctors have similar experiences and how much difference there is between those working full time and part time.