Women chairs in academic medicine: engendering strategic intuition.

PURPOSE: Because stereotypically masculine behaviors are required for effective leadership, examining female chairs' leadership in academic medicine can provide insight into the complex ways in which gender impacts on their leadership practices. The paper aims to discuss this issue. DESIGN/METHODOLOGY/APPROACH: The author interviewed three female clinical chairs and compared the findings to interviews with 28 of their faculty. Grounded theory analysis of the subsequent text gathered comprehensive, systematic, and in-depth information about this case of interest at a US top-tier academic medical center. FINDINGS: Four of five themes from the faculty were consistent with the chair's narrative with modifications: Prior Environment (Motivated by Excellence), Tough, Direct, Transparent (Developing Trust), Communal Actions (Creating Diversity of Opinion), and Building Power through Consensus (an "Artful Exercise") with an additional theme, the Significance (and Insignificance) of a Female Chair. While faculty members were acutely aware of the chair's gender, the chairs paradoxically vacillated between gender being a "non-issue" and noting that male chairs "don't do laundry." All three female chairs in this study independently and explicitly stated that gender was not a barrier, yet intuitively used successful strategies derived from the research literature. ORIGINALITY/VALUE: This study suggests that while their gender was highlighted by faculty, these women dismissed gender as a "non-issue." The duality of gender for these three female leaders was both minimized and subtly affirmed.

A qualitative study of work-life choices in academic internal medicine.

The high attrition rate of female physicians pursuing an academic medicine research career has not been examined in the context of career development theory. We explored how internal medicine residents and faculty experience their work within the context of their broader life domain in order to identify strategies for facilitating career advancement. Semi-structured interviews were conducted with a purposeful sample of 18 residents and 34 faculty members representing male and female physicians at different career stages. Using thematic analysis, three themes emerged: (1) the love of being a physician ("Raison d'être"), (2) family obligations ("2nd Shift"), and (3) balancing work demands with non-work life ("Negotiating Academic Medicine"). Female researchers and educators reported more strategies for multiple role planning and management than female practitioners. Interventions aimed at enhancing academic internists' planning and self-efficacy for multiple role management should be investigated as a potential means for increasing participation and facilitate advancement.

Barriers and facilitators of universal HIV screening among internal medicine residents.

BACKGROUND: Adoption of universal HIV screening has been low despite national recommendations. OBJECTIVE: To describe the barriers and facilitators to adoption of universal HIV screening in a low-prevalence setting. DESIGN: Qualitative, thematic analysis of focus group discussions among internal medicine residents who introduced universal HIV screening into their primary care practice in Madison, Wisconsin. APPROACH: Deductive and inductive codes constructed a hybridized thematic analysis model. Deductive codes stemmed from a knowledge-attitude-behavior framework for physician nonadherence to guidelines. Inductive codes emerged from the focus group discussions and were embedded into broader deductive codes to provide an HIV-specific model. KEY RESULTS: Residents were knowledgeable and had positive attitudes toward recommendations for universal HIV screening. Residents felt the majority of their patients were receptive to HIV screening, especially when introduced with normalizing techniques and reference to an expert authority such as the Centers for Disease Control and Prevention (CDC). They still perceived patient discussions as challenging due to stigma surrounding HIV and patients' perceptions of being at low risk. Residents employed individualized electronic medical record cues as a memory aid to discuss the issue. CONCLUSION: This qualitative study of internal medicine residents training in an area with low HIV prevalence suggests that stigma and patient perception of being at low risk are barriers that should be addressed to effectively integrate universal HIV screening into primary care.

Women leaders: the social world of health care.

PURPOSE: The purpose of this paper is to illustrate a microcosm of the complexities that women face in a masculine environment. DESIGN/METHODOLOGY/APPROACH: Ten women administrators were selected from one Southeastern University in the USA, using criterion sampling. The interviews of five women from male-dominated colleges (greater than 50 percent male faculty-MD) and five from female-dominated fields (FD) were analyzed. For further study, the texts of the four women from healthcare colleges were compared with the six from non-healthcare fields. Interviewees were asked questions about their background, leadership and power. Confidentiality was adhered to according to the university's IRB guidelines and policies. FINDINGS: The social world of the healthcare Deans was evident and was shaped around a "rigid hierarchy of authority and power" that goes beyond gender and is stratified among health-related professions. ORIGINALITY/VALUE: This examination of the hierarchical discourse of power within the social world of healthcare gives valuable instruction for women's negotiation through adaptation.

Presence of intraplaque hemorrhage stimulates progression of carotid atherosclerotic plaques: a high-resolution magnetic resonance imaging study.

BACKGROUND: Previous studies suggest that erythrocyte membranes from intraplaque hemorrhage into the necrotic core are a source of free cholesterol and may become a driving force in the progression of atherosclerosis. We have shown that MRI can accurately identify carotid intraplaque hemorrhage and precisely measure plaque volume. We tested the hypothesis that hemorrhage into carotid atheroma stimulates plaque progression. METHODS AND RESULTS: Twenty-nine subjects (14 cases with intraplaque hemorrhage and 15 controls with comparably sized plaques without intraplaque hemorrhage at baseline) underwent serial carotid MRI examination with a multicontrast weighted protocol (T1, T2, proton density, and 3D time of flight) over a period of 18 months. The volumes of wall, lumen, lipid-rich necrotic core, calcification, and intraplaque hemorrhage were measured with a custom-designed image analysis tool. The percent change in wall volume (6.8% versus -0.15%; P=0.009) and lipid-rich necrotic core volume (28.4% versus -5.2%; P=0.001) was significantly higher in the hemorrhage group than in controls over the course of the study. Furthermore, those with intraplaque hemorrhage at baseline were much more likely to have new plaque hemorrhages at 18 months compared with controls (43% versus 0%; P=0.006). CONCLUSIONS: Hemorrhage into the carotid atherosclerotic plaque accelerated plaque progression in an 18-month period. Repeated bleeding into the plaque may produce a stimulus for the progression of atherosclerosis by increasing lipid core and plaque volume and creating new destabilizing factors.

Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MRI--initial results.

BACKGROUND AND PURPOSE: MRI is able to quantify carotid plaque size and composition with good accuracy and reproducibility and provides an opportunity to prospectively examine the relationship between plaque features and subsequent cerebrovascular events. We tested the hypothesis that the characteristics of carotid plaque, as assessed by MRI, are possible predictors of future ipsilateral cerebrovascular events. METHODS: A total of 154 consecutive subjects who initially had an asymptomatic 50% to 79% carotid stenosis by ultrasound with > or =12 months of follow-up were included in this study. Multicontrast-weighted carotid MRIs were performed at baseline, and participants were followed clinically every 3 months to identify symptoms of cerebrovascular events. RESULTS: Over a mean follow-up period of 38.2 months, 12 carotid cerebrovascular events occurred ipsilateral to the index carotid artery. Cox regression analysis demonstrated a significant association between baseline MRI identification of the following plaque characteristics and subsequent symptoms during follow-up: presence of a thin or ruptured fibrous cap (hazard ratio, 17.0; P< or =0.001), intraplaque hemorrhage (hazard ratio, 5.2; P=0.005), larger mean intraplaque hemorrhage area (hazard ratio for 10 mm2 increase, 2.6; P=0.006), larger maximum %lipid-rich/necrotic core (hazard ratio for 10% increase, 1.6; P=0.004), and larger maximum wall thickness (hazard ratio for a 1-mm increase, 1.6; P=0.008). CONCLUSIONS: Among patients who initially had an asymptomatic 50% to 79% carotid stenosis, arteries with thinned or ruptured fibrous caps, intraplaque hemorrhage, larger maximum %lipid-rich/necrotic cores, and larger maximum wall thickness by MRI were associated with the occurrence of subsequent cerebrovascular events. Findings from this prospective study provide a basis for larger multicenter studies to assess the risk of plaque features for subsequent ischemic events.

Difficult Dialogues: Negotiating Faculty Responses to a Gender Bias Literacy Training Program.

Diversity training is challenging and can evoke strong emotional responses from participants including resistance, shame, confusion, powerlessness, defensiveness, and anger. These responses create complex situations for both presenters and other learners. We observed 3 experienced presenters as they implemented 41 gender bias literacy workshops for 376 faculty from 42 STEMM (science, technology, engineering, mathematics, medicine) departments at one Midwestern university. We recorded questions and answers as well as participants' non-verbal activity during each 2.5-hour workshop. Employing content analysis and critical incident technique, we identified content that elicited heightened activity and challenging dialogues among presenters and faculty. Results from analysis of this observational data found three important findings: (1) presenters continually reinforced the idea that implicit bias is ordinary and pervasive, thus avoiding participant alienation by allowing participants to protect their self-worth and integrity; (2) difficult dialogues were managed calmly without verbal sparring or relinquishing control; (3) the presenters created an environment where individuals were more likely to accept threatening information.

Impact of reflective writing assignments on dental students' views of cultural competence and diversity.

To respond to widespread disparities in access to oral health care, the Institute of Medicine, the Commission on Dental Accreditation (CODA), and the U.S. surgeon general have stressed that prospective dentists should become culturally competent, socially responsible practitioners. The aim of this study was to examine linguistic differences in dental students' reflective writing assignments before and after interviewing an individual who was culturally different from themselves. The authors analyzed 160 documents from 80 first-year dental students at the University of Florida in 2012. This cohort consisted of 36 male (45%) and 44 female (55%) students; 26 (32%) were from underrepresented minority (URM) groups and 54 (68%) were identified as white non-minority. Text analysis software identified word counts, categories, frequencies, and contexts. Significantly positive differences occurred for interviews between assignments 1 and 2 (p=0.005 to p<0.001) in five areas of cultural diversity. Differences were observed for Factor 1 ("important others' influence") between assignments (p<0.001), assignments by interview categories (p=0.033), and URM/majority participants by assignments by interview category (p=0.018). Factor 4 ("my social world in relation to others") was statistically different between assignments for URM/majority participants (p=0.019). Factor 5 ("wrong because") was statistically different for gender (p=0.041), suggesting that males may have experienced a rebound effect from stereotype suppression. The findings suggest that the use of reflective writing and interviews affected the students' awareness of how important others had influenced their lives and attitudes and facilitated their questioning preconceived assumptions. Reactions to coursework focusing on social and personal domains warrant further investigation.

The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.

PURPOSE: Despite sincere commitment to egalitarian, meritocratic principles, subtle gender bias persists, constraining women's opportunities for academic advancement. The authors implemented a pair-matched, single-blind, cluster randomized, controlled study of a gender-bias-habit-changing intervention at a large public university. METHOD: Participants were faculty in 92 departments or divisions at the University of Wisconsin-Madison. Between September 2010 and March 2012, experimental departments were offered a gender-bias-habit-changing intervention as a 2.5-hour workshop. Surveys measured gender bias awareness; motivation, self-efficacy, and outcome expectations to reduce bias; and gender equity action. A timed word categorization task measured implicit gender/leadership bias. Faculty completed a work-life survey before and after all experimental departments received the intervention. Control departments were offered workshops after data were collected. RESULTS: Linear mixed-effects models showed significantly greater changes post intervention for faculty in experimental versus control departments on several outcome measures, including self-efficacy to engage in gender-equity-promoting behaviors (P = .013). When ≥ 25% of a department's faculty attended the workshop (26 of 46 departments), significant increases in self-reported action to promote gender equity occurred at three months (P = .007). Post intervention, faculty in experimental departments expressed greater perceptions of fit (P = .024), valuing of their research (P = .019), and comfort in raising personal and professional conflicts (P = .025). CONCLUSIONS: An intervention that facilitates intentional behavioral change can help faculty break the gender bias habit and change department climate in ways that should support the career advancement of women in academic medicine, science, and engineering.

Afraid of being "witchy with a 'b'": a qualitative study of how gender influences residents' experiences leading cardiopulmonary resuscitation.

PURPOSE: Ineffective leadership during cardiopulmonary resuscitation ("code") can negatively affect a patient's likelihood of survival. In most teaching hospitals, internal medicine residents lead codes. In this study, the authors explored internal medicine residents' experiences leading codes, with a particular focus on how gender influences the code leadership experience. METHOD: The authors conducted individual, semistructured telephone or in-person interviews with 25 residents (May 2012 to February 2013) from 9 U.S. internal medicine residency programs. They audio recorded and transcribed the interviews and then thematically analyzed the transcribed text. RESULTS: Participants viewed a successful code as one with effective leadership. They agreed that the ideal code leader was an authoritative presence; spoke with a deep, loud voice; used clear, direct communication; and appeared calm. Although equally able to lead codes as their male colleagues, female participants described feeling stress from having to violate gender behavioral norms in the role of code leader. In response, some female participants adopted rituals to signal the suspension of gender norms while leading a code. Others apologized afterwards for their counternormative behavior. CONCLUSIONS: Ideal code leadership embodies highly agentic, stereotypical male behaviors. Female residents employed strategies to better integrate the competing identities of code leader and female gender. In the future, residency training should acknowledge how female gender stereotypes may conflict with the behaviors required to enact code leadership and offer some strategies, such as those used by the female residents in this study, to help women integrate these dual identities.

Male Spouses of Women Physicians: Communication, Compromise, and Carving Out Time.

As the numbers of female physicians continue to grow, fewer medical marriages are comprised of the traditional dyad of male physician and stay-at-home wife. The "two-career family" is an increasingly frequent state for both male and female physicians' families, and dual-doctor marriages are on the rise. This qualitative study explored the contemporary medical marriage from the perspective of male spouses of female physicians. In 2010, we conducted semi-structured, in-depth interviews with nine spouses of internal medicine resident and faculty physicians. Interviewers queried work-home balance, career choices, and support networks. We used an interpretive, inductive, iterative approach to thematically analyze interview transcripts and develop broad, consensus-derived themes. A conceptual framework based on three major themes emerged: "A time for us? Really?", "Supporting and protecting her, sometimes at my expense,'" and "Hers is a career, mine is a job." This framework described the inflexibility of physicians' time and its impact on spousal time, career development, and choices. Having a set time for synchronizing schedules, frequent verbal support, and shared decision-making were seen as important by the husbands of female, full-time physicians. This exploratory study examined the contemporary medical marriage from the male spouse's perspective and highlights specific strategies for success.

An educational intervention designed to increase women's leadership self-efficacy.

Women are sparsely represented in leadership in academic science, technology, engineering, mathematics, and medicine (STEMM). Cultural stereotypes about men, women, and leaders influence the attitudes, judgments, and decisions that others make about women and the choices women make for themselves. Multilevel interventions are needed to counteract the impact of these pervasive and easily activated stereotypes, which conspire in multiple ways to constrain women's entry, persistence, and advancement in academic STEMM. We describe an individual-level educational intervention. Using the transtheoretical model of behavioral change as a framework, we assessed the success of a semester course on increasing women's leadership self-efficacy for the first three cohorts of course participants (n = 30). Pre/post questionnaires showed gains in leadership self-efficacy, personal mastery, and self-esteem, and decreases in perceived constraints. Qualitative text analysis of weekly journals indicated increasing leadership self-efficacy as course participants applied course information and integrated strategies to mitigate the impact of societal stereotypes into their own leadership practices. Follow-up queries of the first two cohorts supported the enduring value of course participation. We conclude that providing strategies to recognize and mitigate the impact of gender stereotypes is effective in increasing leadership self-efficacy in women at early stages of academic STEMM careers.

Promoting Institutional Change Through Bias Literacy.

The National Science Foundation and others conclude that institutional transformation is required to ensure equal opportunities for the participation and advancement of men and women in academic science, technology, engineering, mathematics, and medicine (STEMM). Such transformation requires changing the habitual attitudes and behaviors of faculty. Approaching implicit bias as a remediable habit, we present the theoretical basis and conceptual model underpinning an educational intervention to promote bias literacy among university faculty as a step toward institutional transformation regarding gender equity. We describe the development and implementation of a Bias Literacy Workshop in detail so others can replicate or adapt it to their setting. Of the 220 (167 faculty and 53 nonfaculty) attendees from the initial 17 departments/divisions offered this workshop, all 180 who completed a written evaluation found the workshop at least "somewhat useful" and 74% found it "very useful." Over 68% indicated increased knowledge of the workshop material. Of the 186 participants who wrote a commitment to engage in new activities to promote gender equity, 87% incorporated specific workshop content. Twenty-four participants were interviewed 4-6 months after attending the workshop; 75% of these not only demonstrated increased bias awareness, but described plans to change-or had actually changed-behaviors because of the workshop. Based on our sample of faculty from a Midwestern university, we conclude that at least one third of STEMM faculty who are invited will attend a 2.5-hr Bias Literacy Workshop, that nearly all will find it useful, and that most will complete a written commitment to promoting gender equity. These findings suggest that this educational intervention may effectively promote institutional change regarding gender equity.

Do students' and authors' genders affect evaluations? A linguistic analysis of Medical Student Performance Evaluations.

PURPOSE: Recent guidelines for the Medical Student Performance Evaluation (MSPE) have standardized the "dean's letter." The authors examined MSPEs for linguistic differences according to student or author gender. METHOD: This 2009 study analyzed 297 MSPEs for 227 male and 70 female medical students applying to a diagnostic radiology residency program. Text analysis software identified word counts, categories, frequencies, and contexts; factor analysis detected patterns of word categories in student-author gender pairings. RESULTS: Analyses showed a main effect for student gender (P=.046) and a group difference for the author-student gender combinations (P=.048). Female authors of male student MSPEs used the fewest "positive emotion" words (P=.006). MSPEs by male authors were shorter than those by females (P=.014). MSPEs for students ranked in the National Resident Matching Program contained more "standout" (P=.002) and "positive emotion" (P=.001) words. There were no differences in the author-gender pairs in the proportion of students ranked, although predominant word categories differed by author and student gender. Factor analysis revealed differences among the author-student groups in patterns of correlations among word categories. CONCLUSIONS: MSPEs differed slightly but significantly by student and author gender. These differences may derive from societal norms for male and female behaviors and the subsequent linguistic interpretation of these behaviors, which itself may be colored by the observer's gender. Although the differences in MSPEs did not seem to influence students' rankings, this work underscores the need for awareness of the complex effects of gender in evaluating students and guiding their specialty choices.

A qualitative study of faculty members' views of women chairs.

BACKGROUND: Concurrent with the evolving role of the department chair in academic medicine is the entry of women physicians into chair positions. Because implicit biases that stereotypically masculine behaviors are required for effective leadership remain strong, examining faculty members' perceptions of their chair's leadership in medical school departments with women chairs can provide insight into the views of women leaders in academic medicine and the complex ways in which gender may impact these chairs' leadership style and actions. METHODS: We conducted semistructured interviews with 13 male and 15 female faculty members representing all faculty tracks in three clinical departments chaired by women. Inductive, qualitative analysis of the subsequent text allowed themes to emerge across interviews. RESULTS: Four themes emerged regarding departmental leadership. One dealt with the leadership of the previous chair. The other three described the current chair's characteristics (tough, direct, and transparent), her use of communal actions to help support and mentor her faculty, and her ability to build power through consensus. Because all three chairs were early in their tenure, a wait and see attitude was frequently expressed. Faculty generally viewed having a woman chair as an indication of positive change, with potential individual and institutional advantages. CONCLUSIONS: This exploratory study suggests that the culture of academic medicine has moved beyond questioning women physicians' competence to lead once they are in top organizational leadership positions. The findings are also consonant with experimental research indicating that women leaders are most successful when they pair stereotypic male (agentic) behaviors with stereotypic female (communal) behaviors. All three chairs exhibited features of a transformational leadership style and characteristics deemed essential for effective leadership in academic medicine.

Interventions that affect gender bias in hiring: a systematic review.

PURPOSE: To systematically review experimental evidence for interventions mitigating gender bias in employment. Unconscious endorsement of gender stereotypes can undermine academic medicine's commitment to gender equity. METHOD: The authors performed electronic and hand searches for randomized controlled studies since 1973 of interventions that affect gender differences in evaluation of job applicants. Twenty-seven studies met all inclusion criteria. Interventions fell into three categories: application information, applicant features, and rating conditions. RESULTS: The studies identified gender bias as the difference in ratings or perceptions of men and women with identical qualifications. Studies reaffirmed negative bias against women being evaluated for positions traditionally or predominantly held by men (male sex-typed jobs). The assessments of male and female raters rarely differed. Interventions that provided raters with clear evidence of job-relevant competencies were effective. However, clearly competent women were rated lower than equivalent men for male sex-typed jobs unless evidence of communal qualities was also provided. A commitment to the value of credentials before review of applicants and women's presence at above 25% of the applicant pool eliminated bias against women. Two studies found unconscious resistance to "antibias" training, which could be overcome with distraction or an intervening task. Explicit employment equity policies and an attractive appearance benefited men more than women, whereas repeated employment gaps were more detrimental to men. Masculine-scented perfume favored the hiring of both sexes. Negative bias occurred against women who expressed anger or who were perceived as self-promoting. CONCLUSIONS: High-level evidence exists for strategies to mitigate gender bias in hiring.

EBM: evidence to practice and practice to evidence.

RATIONALE: The purpose of this paper is to explore new perspectives about difficulties academicians may have communicating with clinicians, obtaining subjects, and gaining compliance for their research. AIMS AND OBJECTIVES: Evidence-based medicine (EBM) has been defined as an integration of best research evidence, clinical expertise, and patient values; however, clinical observation and experience are placed last in the evidence hierarchy with the randomized controlled trial held as the standard for clinical intervention. This paper describes how the hierarchical model of power in the research community obstructs new areas of knowledge, and how clinicians create resistance. Methods Foucault gave new perspectives describing how power circulates through individuals within organizational discourse. Drawing on literature and experience, and using a framework based on postmodern theoretical concepts, this paper examines patterns of discourse, subjectivity, resistance, and power/knowledge within the physical therapy profession. RESULTS: The hierarchical discourse of medical knowledge produces opposition rather than collaboration between researcher, clinician, and patient. Alleviating perceptions of dominance and creating connections produces cohesion within medical communities. CONCLUSIONS: Evidence to practice and practice to evidence redefines EBM as a circular integration of best research evidence, clinical expertise, and patient values.

Predictors of carotid atherosclerotic plaque progression as measured by noninvasive magnetic resonance imaging.

The purpose of this in vivo MRI study was to quantify changes in atherosclerotic plaque morphology prospectively and to identify factors that may alter the rate of progression in plaque burden. Sixty-eight asymptomatic subjects with >or=50% stenosis, underwent serial carotid MRI examinations over an 18-month period. Clinical risk factors for atherosclerosis, and medications were documented prospectively. The wall and total vessel areas, matched across time-points, were measured from cross-sectional images. The normalized wall index (NWI=wall area/total vessel area), as a marker of disease severity, was documented at baseline and at 18 months. Multiple regression analysis was used to correlate risk factors and morphological features of the plaque with the rate of progression/regression. On average, the wall area increased by 2.2% per year (P=0.001). Multiple regression analysis demonstrated that statin therapy (P=0.01) and a normalized wall index >0.64 (P=0.001) were associated with a significantly reduced rate of progression in mean wall area. All other documented risk factors were not significantly associated with changes in wall area. Findings from this study suggest that increased normalized wall index and the use of statin therapy are associated with reduced rates of plaque progression amongst individuals with advanced, asymptomatic carotid atherosclerosis.