Raft of Otters: Women in Cardiology: Let Us Stick Together.

Narrative A∗

“It was all great while I was a timid trainee. As soon as I started making a little headway and was successful, I was seen as a competition. My success was deliberately not amplified. They (other women) would try to leverage their years of expertise to make my ideas sound dumb and undermine me in every possible way. I was told by my male friends “competition between women is fierce!”

Narrative B∗

“A powerful woman in leadership decided to sideline me after my promotion. I was not given any invites or talks despite my talent, expertise, and service to the organization for many years.”

∗Narratives taken from women in cardiology. Their identities have been kept confidential.

“There’s a special place in hell for women who don’t help each other.”

It was Secretary of State Madeleine Albright who voiced this remark during a 2004 panel at Wellesley College while reflecting on women’s leadership (1). Albright intended for the quote to serve as a counterpoint to stereotypical workplace dynamics, where women have been forced to function as opponents to survive in a male-dominated world. Only 14% of general cardiologists were women in 2017 (2) and 24% of cardiology trainees in 2018 to 2019 were women (3). The notion of “women not supporting women” generally remains unvoiced in cardiology, yet is brought up often behind the closed doors. In a male-dominated field like cardiology, how can women in cardiology (WIC) expect to effectively fight against gendered inequalities if they are too busy fighting one another? Is the perception true or is it the conditioning due to differences in expected gender roles?

In this paper, we will take a deep dive into the perception of women not supporting one another and discuss its relevance to female cardiologists.

Queen Bee Phenomenon: Perception or Reality?

The “queen bee phenomenon” is a phrase first coined over 50 years ago to describe female leaders who assimilate into male-dominated organizations (i.e., organizations in which most executive positions are held by men) by distancing themselves from junior women and legitimizing gender inequality in their organizations (4). The phrase is still quoted today probably due to gendered differences in the expectations and can be weaponized against women in the workplace (5). Contemporary literature and psychological studies in nonmedical fields have shed some light into the complex issue of workplace behavior among women.

A study in 2015 by the Columbia School of Business contends that the queen bee phenomenon is a myth. Looking at the behaviors in 1,500 companies over a 20-year period, this study found that when women were in senior roles, they promoted other women, but when men were in senior roles, only one-half as many women were promoted to senior roles (6). In a study performed in university settings in the Netherlands and Italy (7), the authors investigated gender differences in 2 factors that may contribute to the under-representation of women among university faculty—work commitment of student scientists and perceptions of these levels of work commitment by faculty members. In both countries, male and female students generally reported being equally committed to different work aspects. However, only older female, but not younger female or male faculty members perceived their female students as less committed to their work than male students. Older female faculty also had a more masculine self-description than younger female faculty. These results were thought to be due to overall smaller number of older female faculty and reflection of their own difficult career journey into their gender-stereotypical perceptions of the female students.

Other studies looking at incivility in the workplace have found that women report significantly more female-instigated incivility compared with men, but there was no difference between men and women experiencing male-instigated incivility. They also found that women who exhibit dominant behaviors at work (agentic) were likely to report receiving uncivil treatment by other women. For agentic women especially, such incivility had damaging consequences, resulting in reduced job satisfaction, lower psychological vitality, and higher turnover intentions (8).

Women perhaps start their career with low gender identification and as they progress, experience a high degree of gender discrimination. As there are fewer women in leadership positions in general, women who reach the top position are often subjected to intense scrutiny (5). Do women in leadership adapt to perceive themselves as nonprototypical women due to such discrimination? One can wonder if in these studies, as women in leadership positions contradicted the warm and nurturing female gender norm, did their assertive behavior get misinterpreted as ruthlessness by other women (and men) (7)? Is it years of societal conditioning on expected gender roles that leads to the belief that assertive behavior is expected from men but not from fewer female leaders?

It is critical to acknowledge that the queen bee phenomenon may be the result of a gender-biased milieu in the workplace rather than the cause of gender discrimination (9).

Why Is it Important To Stick Together?

While WIC have been expressing their concerns regarding gender equality for years, WIC continue to face multiple obstacles. In many countries, due to cultural expectations, women are not able to progress professionally, and it is impossible for them to hold a leadership position. Even in developed countries, women are less likely to be hired and/or promoted because of their sex (10). Compensation inequities persist for WIC, despite several studies in the past decade demonstrating that large differences in physician salaries are found when stratified by sex (11).

Sexual harassment is a huge obstacle in women’s efforts for progress and has been demonstrated to worsen burnout and affect productivity (12). However, it is severely under-reported due to fear of stigmatization or retaliation.

Motherhood can be a very important part of a woman’s life, whether she is partnered or unpartnered. To this day, many women are still forced to choose between career or family, as there continue to be significant discrepancies in parental leave policies across the world. Furthermore, pathways should be created to allow women to continue to advance professionally while taking into account prioritization of family and family responsibilities. Women are also often unfairly and negatively labeled as emotional, hysterical, or aggressive for the same actions or behaviors that in a man may be called passionate, assertive, or ambitious, due to both conscious and unconscious biases (13). When the challenges of WIC at personal, organizational, or institutional levels are the same, the time has come for WIC to band together to the battle these common issues.

Framework of Support: Proposed Solutions for the Narratives

“Raft of otters” is a model discussed by Piazza et al. (14); using the analogy of a group of otters that hold hands so as to not drift apart from each other, Piazza’s model focuses on creating a tight-knit circle of women who help, support, mentor, and sponsor each other by conducting honest and effective communication and successful team building exercises among women.

We strongly believe that the following framework may help women work effectively with one another, hopefully preventing the perception of women being unsupportive of other women (Figure 1).

Figure 1

WIC Raft of Otters and Framework of Support

WIC = women in cardiology.

More women in leadership

Women in medicine are not always truly empowered and supported to lead freely, making it difficult for them to support other women (5). The published data show that women leaders hire more women to work for them compared to when men lead (15). This effect is the strongest when a woman leader is re-elected; when a woman does not have to worry about the security of her own role or position, she is able to advance and promote other women, who in turn, continue to promote more women, learning by example (15). Leadership training for both sexes but particularly WIC should explicitly include not only why to mentor, but how to mentor and advocate for other WICs. As more WIC leaders rise to leadership positions and promote other WICs, the hope is that like the example above, continued sponsorship and further promotion of WIC will self-sustain.

Competition and communication

Studies find little evidence that women are more competitive toward other women compared with men (16). Healthy competition can provide motivation, foster growth, and lead to progress, and should be normalized. WIC should be encouraged to communicate frequently, openly, and honestly with one another to help foster supportive interpersonal relationships in the workplace. The published data suggest that the situation of conflict between women is seen much more problematic than between men (17). In case of conflict, all parties regardless of sex should have a period of introspection to understand if their own situational interpretation has been tainted by personal biases.

It is equally important to control the narrative of the workplace dynamics, particularly when speaking to others as this may provide a skewed impression of interaction between women (17).

Organizational/institutional support

We recognize that the critical conversations about gender equality and equity within an organization or an institute are not always easy to carry out. Suggestions that may help ensure that the organizations and opportunities are free of gender bias include: organizational focus on gender-related equality; making the solution part of leadership success; and having a gender equality officer.

Organizational resource groups or affinity groups for women, preferably sponsored by senior female leaders or mentoring programs that pair aspiring women with female leaders, may also help reduce the gender biases and change the stereotypical views about gender role in cardiology. An example of a support channel is the WIC Council at the American College of Cardiology. The goal of the council is to help women who may be a minority at their place of practice by connecting them with peers and WIC leaders who can act as mentors and sponsors, especially if mentorship and sponsorship are not otherwise readily available at their own locality or institution. In addition, WIC councils of various cardiovascular organizations could focus on collaborative efforts to continue to mentor and sponsor early career, midcareer, and more senior WICs both nationally and internationally.

Amplifying the WIC voices

Amplifying the success stories of the WIC, particularly the ones whose accomplishments may not be acknowledged, may help empower the WIC and navigate the workplace dynamics better.

Social media

With the growth of the cardiovascular community on social media, it has become easier for WIC to connect with one another, network, find sponsors and mentors, and even provide support virtually without the limitations of time or distance. Social media has become an important avenue for discussing WIC issues (18).

Conclusions

Women in cardiology can survive, thrive, and succeed the decades-long quest for professional equity by supporting one another. Forming the raft of otters will keep us united and create a critical mass that will help us reach our goal of equality and equity within our field of cardiology. As more female cardiologists rise in leadership, we should get past the concept of queen bees and believe in the power of amplification of other women that can bring upon the change.

Author Relationship With Industry

Dr. Parwani serves as a Social Media Editor for JACC: Case Reports. Dr. Grapsa serves as Editor-in-Chief of JACC: Case Reports. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.