Towards gender equity in intensive care medicine: ten practical strategies for improving diversity

Abstract

Gender balance in intensive care medicine (ICM) is a worthy goal for numerous reasons. However, despite reaching parity in medical school and a substantial rise in the proportion of female ICM trainees over the past decade, women remain under-represented in ICM in Australia and New Zealand. 1 Women comprise 21% of fellows and are underrepresented in academia 2 and positions of leadership. 3 Beyond the well described business case and ethical imperative of diversity, gender balance in ICM ensures the specialty recruits from the full talent pool of medical graduates, builds a workforce representative of the diverse community of patients we serve, enhances organisational functioning, and may lead to improved patient outcomes. 1 , 4 There are numerous barriers to female doctors training in ICM. A paucity of visible female role models, 5 lack of sponsorship and leadership training, 6 , 7 difficulty in attaining promotions and grants for research, 3 ,8, 9, 10 unconscious bias, imposter syndrome, 3 inflexible work hours, difficulty achieving acceptable work-life balance, and bullying and harassment 11 all impede female advancement. The ongoing coronavirus disease 2019 (COVID-19) pandemic may be amplifying these barriers, with emerging evidence that women have been disproportionately affected in a variety of domains, including medicine and academia. 12 , 13 Analysis of authorship of articles written in the early part of the COVID-19 pandemic showed a reduction in female authorship compared with authorship in the same medical journals in 2019. 14 Addressing these disparities thus becomes even more urgent. 15 Shifting the focus from "fixing" women to reforming systems is central to the gender equity discourse. That is, reforming discriminatory systems and levelling the playing field, rather than changing individual behaviour to fit the mould of established structures. 15 The Women in Intensive Care Medicine Network (WIN), a subcommittee of the Australian and New Zealand Intensive Care Society (ANZICS), has advocated for systems level change, including guidelines addressing gender balance which incorporate commitments for female representation across leadership positions and academic forums. 16 , 17 Through a review of known barriers and strategies described in the literature, we outline ten evidenced-based, practical strategies that can be readily employed to improve gender balance in ICM (Box). 1 Make female role models visible Lack of visible female role modelling was seen as the top barrier to training in ICM. 5 , 18 The paucity of female fellows and leaders in ICM can perpetuate stereotypes that women cannot have successful careers in this specialty. Potential trainees should be identified and connected early with a variety of role models, including women. If a unit does not have a female ICM fellow, aside from making active efforts to recruit a more diverse consultant pool, a trainee should be linked with female senior trainees, academics and leaders in ICM elsewhere. Connections with local networks such as WIN ANZICS (Australia and New Zealand) are also important. 19 Box. Ten practical strategies for improving gender equity in intensive care medicine • Make female role models visible • Implement targets for female representation • Embrace sponsorship of women • Employ transparent selection processes • Strive for a respectful workplace culture with inclusive leadership • Undertake unconscious bias training — with caution • Create a flexible working environment • Provide institutional support • Facilitate broad collaboration through local advocacy groups • Engage men Alt-text: Unlabelled Box 2 Implement targets for female representation The meritocracy myth remains entrenched in medicine. 20 It has been demonstrated that instructing managers to select candidates based on merit alone can amplify the impact of unconscious bias in professional selection processes. 21 Targets instead counteract the covert effect of gender bias by providing an explicit goal for female representation, 1 are a transparent and measurable way to drive change, and provide a mechanism for accountability to ensure change is sustained. 10 Aiming for 50% female representation in ICM, particularly in leadership positions, such as on boards and committees and as conference speakers, is recommended. The oft- suggested workforce proportionate targets risk perpetuating the status quo. 1 A target of equal gender representation has been adopted by the peak Australasian ICM bodies, ANZICS and the College of Intensive Care Medicine of Australia and New Zealand, along with the Royal Australasian College of Surgeons, corporate organisations, and the parliaments of over 40 countries. 16 , 22 , 23 It is important to note that there is no evidence that targets result in the recruitment of less competent people; rather, it has the potential to increase productivity and competence. Swedish modelling of their Social Democratic Party, which adopted gender quotas in 1994, showed that the introduction of quotas was associated with an increase in competence of both men and women as the playing field is levelled and the most qualified people are recruited into the party. 24 3 Embrace sponsorship of women Although mentorship can assist with professional development, it has limited scope in truly advancing the careers of women. 6 , 7 Sponsorship, which focuses on enhancing the visibility, credibility and networks of talented women by sponsors with significant organisational influence, may be more effective for career fast-tracking. 6 , 7 Talented women working in ICM require sponsorship by influential senior members of staff. They should be actively involved in competitive projects and collaborations; developing clinical services, research grant applications, and consensus guidelines; and considered for leadership opportunities and high level committee or board membership. 6 , 25 They should also be given specific advice on career advancement, be encouraged to apply for promotions, and be linked with people who can fast-track their career. 7 , 26 4 Employ transparent selection processes Traditional methods of providing opportunity and promotion are often subject to bias at the expense of women and other minority groups. 25 This can be reduced by: • transparent appointment and promotion pathways — avoid the "tap on the shoulder”; • blinding of curricula vitae, including removing names and photos; and • ensuring that diverse interview panels include senior medical women. This applies not only to specialist and training appointments but also to new projects, leadership opportunities, course faculties, consensus guidelines authorship, major research publications, conference convenor positions, speaking appointments, mentorship opportunities, and private practice appointments. Coupled with sponsorship, this will ensure that talented employees of any sex have the opportunity to excel. 5 Strive for a respectful workplace culture with inclusive leadership To eliminate both extreme and subtle examples of unacceptable behaviour, the creation of respectful and inclusive workplaces is imperative. 1 Open dialogue empowers workers to create such workplaces. Crucially, leaders, policymakers and male colleagues need to listen to women share their experiences, without comment, to effect sustained cultural change. 15 Accountability is an important driver for sustained change; it is essential that this, and the burden of diversity work, does not fall upon the under-represented groups who already face the "minority tax". 15 , 27 Inclusive leadership is essential to create organisational change 15 and is well recognised as a key to effective leadership in the corporate sector. 28 The following initiatives are recommended: • ensure leaders undertake professional development of core competencies relating to gender equity; • establish and enforce non-discriminatory recruitment processes; • dedicate committed resources (including financial and administrative) to gender equity strategies described; • visibly recognise contributions made towards positive cultural change (in evaluation processes for key performance indicators); and • implement mechanisms to monitor and be accountable for changes, such as publishing metrics on gender balance, documenting clear vision and aspirational goals including targets, regular audit and linking accreditation with pro-diversity measures such as availability of quality part-time jobs. 15 , 27 6 Undertake unconscious bias training — with caution Unconscious bias training provides an opportunity for individuals to identify internal biases and mitigate their effects on behaviour disadvantaging minority groups, while helping to establish equity and inclusion awareness as a cultural norm. 15 , 29 However, there are concerns unconscious bias training may distract organisations from sustained systemic change. 30 Furthermore, it may reinforce the belief that once training is completed, individuals are no longer biased and make decisions based on merit, when paradoxically the bias can be exacerbated. 21 Unconscious bias training should be undertaken by those involved in recruitment, training and leadership, such as board members, heads of units, and supervisors of training. However, it should not be undertaken in isolation as a "silver bullet”. Participants should be aware of the limitations of this type of training. 7 Create a flexible working environment Workplace and training inflexibility are significant barriers to a career in ICM. 5 Intensive care units should evaluate their policies and rosters, and incorporate dedicated parental leave policies (for all genders), compassionate rostering (eg, review night shifts in late pregnancy, breaks for breastfeeding doctors), proactive support for doctors returning from leave with return to work policies and refresher courses, and high quality part-time or flexible time roles. 25 Intensive care societies and colleges should examine their training curricula and leave policies and consider removing any requirements which may disadvantage women and other minority groups. Engaging with local advocacy networks may assist in achieving this. 8 Provide institutional support There are inherent challenges in shifting organisational culture. Intensive care societies and academic bodies wield collective power for change, and must demonstrate leadership by advocating for gender equity and ensuring accountability through accreditation processes. 15 , 27 They can achieve this by establishing gender advocacy subcommittees, 1 clear policies and meaningful commitments to improved gender balance. Effective measures include commitment to gender-equitable conferences (in terms of speakers, panels, chairs, committees and attendees 16 , 17 ), guidelines for transparent selection processes, and the previously described approaches to make part-time work and parental leave more accessible to trainees. 1 , 16 9 Facilitate broad collaboration through local advocacy groups Initiatives such as WIN ANZICS and the Women in ICM (WICM) group in the United Kingdom provide visible female role models, actively promote the interests of female ICM physicians, improve participation in leadership, and work closely with ICM colleges and societies. 1 , 16 , 18 , 19 Membership of such networks may enhance professional progression and retention within the specialty by facilitating leadership, enabling scholarly work to advance equity and inclusion and cultivating a sense of belonging. 19 , 31 10 Engage men Systemic change is impossible without engaging men, given they overwhelmingly hold influential roles in ICM (87% of intensive care unit medical directors in Australia and New Zealand are men) and can therefore access the resources necessary for change. 32 Furthermore, a man's professional reputation is often enhanced when he demonstrates prodiversity behaviour, whereas women incur an emotional and professional toll when they highlight the sexism they experience. 15 Numerous global organisations have adopted initiatives specifically aimed at engaging men in the quest for gender equity. 32 Male inclusion should not come at the expense of effective initiatives. Low expectations of the role of men in this space may result in token efforts that do not translate to meaningful change. 33 One such example is the criticism levelled at the White Ribbon campaign, whose aim was to involve men and boys in ending violence against women and girls. 34 While their goals and mission were important, the campaign ignored the importance of structural change in ending violence against women and girls 34 and often reinforced gender stereotypes, including the fact that their events where predominantly organised by women while shining a spotlight on "good men". 34 , 35 The charity collapsed in 2018. The bar must be set high for anyone engaging with gender equity initiatives, and a clear vision and set of goals will assist with this. 33 Even without direct involvement with gender equity initiatives, men can work towards improving gender equity in their everyday work by using their individual and collective power to collaborate with key stakeholders in the aforementioned strategies, and support and release funding for gender equity initiatives. The importance of intersectionality In relation to these issues, it is important to consider the complex relationships between gender, race, migration status, age, gender expression, religion, sexuality and ability when forming policy and initiatives relating to gender equity. 36 Thus, it is imperative that within any policy or initiative, there are inbuilt frameworks so that women, including transgender women, who belong to other minority groups are not excluded. Conclusion Improving gender equity in ICM requires commitment, effective leadership, allyship, education, intentionality, accountability and resources. Removal of barriers to marginalised groups, from individual to structural and from invisible to overt, necessitates a multilevel approach. These evidence-based practical strategies can be readily implemented in units and organisations worldwide. Competing interests No relevant disclosures.