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A seat at the table is no longer enough: practical implementable changes to address gender imbalance in the anaesthesia workplace

2020; Elsevier BV; Volume: 124; Issue: 3 Linguagem: Inglês

10.1016/j.bja.2019.12.029

1471-6771

Reshma Patel, Ramani Moonesinghe,

Healthcare Systems and Challenges

There are a growing number of warnings about the challenges faced by anaesthesia and the National Health Service (NHS) in the UK. The most valuable resource anaesthesia has, its people, must continue to thrive within a pressured and evolving healthcare system. As the largest specialty in many hospitals, anaesthesia has a responsibility to remain at the forefront of inclusion and fairness. We aim to highlight some career progression and leadership challenges women in anaesthesia may face working in the UK, and then to provide six practical, implementable changes to facilitate optimal working relationships for all UK anaesthetists. Despite making up 77% of the NHS workforce, women are under-represented in senior roles; serving as 30% of NHS chief executives and 37% of Clinical Commissioning Group leaders.1The Royal College of Anaesthetists Bulletin. January 2015; 89 (Available from:)https://www.rcoa.ac.uk/document-store/bulletin-89-january-2015Date accessed: October 4, 2019Google Scholar Clinical leadership within anaesthesia demonstrates imbalance, despite 68% consultant workforce being male, only 27% of clinical directors are female. Twenty-seven percent of college examiners and 36% of regional advisers are women.1The Royal College of Anaesthetists Bulletin. January 2015; 89 (Available from:)https://www.rcoa.ac.uk/document-store/bulletin-89-january-2015Date accessed: October 4, 2019Google Scholar Intensive care medicine (ICM) also remains a male-dominated specialty in the UK, as 37% of ICM trainees and 22% of faculty registered consultants in the UK are female. The elected Board of the Faculty is 15% female.2The Faculty of Intensive Care Medicine Critical eye.https://www.ficm.ac.uk/news/critical-eyeDate accessed: October 4, 2019Google Scholar Lack of female keynote speakers has been noted at major meetings of anaesthesia. The Winter Scientific Meeting 2019, held by the Association of Anaesthetists, presented a total of 91 speaking opportunities, including lectures, panel chairs, and workshop leaders. Of these 91 leadership and speaking opportunities, 32 were afforded to women. The Royal College of Anaesthetists (RCoA) states very clearly their intention to ‘proactively establish a culture that allows us to gain access to, and represent, a more diverse pool of talent for event speakers’. The RCoA Anaesthesia 2019 meeting had a gender split of 41% female and 59% male speaking opportunities, meeting their goal of ‘a minimum 40 percent of speakers from either gender’. The authors welcome this commitment to equality and hope to explain in the following why visibility is key. A 2016 Nature article describes ‘the vicious circle of invisibility’.3Science for all.Nature. 2013; 495: 5Crossref PubMed Scopus (20) Google Scholar As Marian Edelman (American activist) says, ‘you can't be what you can't see’. Women are barely visible at these levels, fixing the subconscious idea that anaesthetic academia and leadership belongs to men. It is key for all anaesthetists in training to look to people who are already thriving and successful in the field for inspiration and guidance.4Moore J.N. McDiarmid A.J. Johnston P.W. Cleland J.A. Identifying and exploring factors influencing career choice, recruitment and retention of anaesthesia trainees in the UK.Postgrad Med J. 2017; 93: 61-66Crossref PubMed Scopus (10) Google Scholar Those who feel daunted, unsupported, or disillusioned about their potential, may be less able to flourish. Thus, it also possible that anaesthesia itself misses out on innovation. As Catherine DeAngelis, the first female editor-in-chief of the Journal of the American Medical Association, said: ‘We will waste half of our genetic pool of intelligence, creativity and critical insights and experience. Medicine simply cannot afford that loss.’ Anaesthesia, like the rest of medicine, is inevitably missing some of the best and the brightest. Supporting and encouraging anaesthetists at work is key as it is also known that staff perform better in organisations that value diversity and are committed to employee well-being.5Powell M. Dawson J. Topakas A. Durose J. Fewtrell C. Staff satisfaction and organisational performance: evidence from a longitudinal secondary analysis of the NHS staff survey and outcome data. NIHR Journals Library, Southampton (UK)2014http://www.ncbi.nlm.nih.gov/books/NBK263759/Date accessed: December 12, 2019Google Scholar Patient satisfaction is highest where there are fewer reported incidents of workplace discrimination, and where staff within the workplace believe that their trust provides equal opportunity for progression.5Powell M. Dawson J. Topakas A. Durose J. Fewtrell C. Staff satisfaction and organisational performance: evidence from a longitudinal secondary analysis of the NHS staff survey and outcome data. NIHR Journals Library, Southampton (UK)2014http://www.ncbi.nlm.nih.gov/books/NBK263759/Date accessed: December 12, 2019Google Scholar Reviews of the evidence indicate that greater gender and race diversity at board level is positively associated with greater innovation,6King’s Fund (London E, Commission on Leadership and Management in the NHS The future of leadership and management in the NHS: No more heroes: report from the King’s fund commission on leadership and management in the NHS. King’s Fund, London2011Google Scholar and that ‘high performing’ healthcare organisations were more likely than ‘low performing’ organisations to have a board with at least 50% female members.7NHS Improvement NHS women on boards: 50:50 by 2020.https://improvement.nhs.uk/resources/nhs-women-boards-5050-2020/Date accessed: October 4, 2019Google Scholar Diversity is clearly key for high productivity, creativity, innovation, and competitive advantage. Few amongst us dismiss the importance of diversity and inclusion. However, given the increased attention on diversity issues, one of the negative outcomes may be that people have grown weary and tired of talking about diversity. This scepticism is valid, given the number of diversity and inclusion drives that fail or are ineffective at changing long-term behaviours. The key to real change is about more than just having a seat at the table; women must also have a voice. As Gregory Lewis succinctly stated, ‘diversity is like being invited to a party, inclusion is being asked to dance, and belonging is dancing like no one's watching’. A mere presence in leadership roles is not the goal here. When minority groups are invited to the table, what are also invited are fresh perspective, increased accessibility for others, and an enabling and encouragement of wider sections of the workforce. This fosters creative participation and co-operation in order to encourage staff to stretch for excellence and innovation. Thus, women must be heard and be present. All professionals hope that publications, speaking opportunities, and all forms of career progression are based on merit; ‘it's about the best people for the job being encouraged regardless of gender, just as it should be for ethnicity and sexual preference’.1The Royal College of Anaesthetists Bulletin. January 2015; 89 (Available from:)https://www.rcoa.ac.uk/document-store/bulletin-89-january-2015Date accessed: October 4, 2019Google Scholar Positive discrimination is the practice or policy of favouring individuals belonging to groups known to have been discriminated against previously. Women may fear positive discrimination. Nobody wants to feel like a token. Imposter syndrome and anxieties therein are amplified when it is implied that accomplishments are down to identity rather than achievement. The lived experiences of many women mean that they are less likely to reach for opportunities than their male counterparts. As discussed in the Lancet, ‘if anything, underlying biases appear to be causing the current meritocratic systems to bypass many highly capable women and members of other minority groups’.8Kang S.K. Kaplan S. Working toward gender diversity and inclusion in medicine: myths and solutions.Lancet. 2019; 393: 579-586Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar The authors suggest that what we must undertake instead is positive action. This encompasses enabling or encouraging people to overcome or minimise their disadvantages. Legislation (although needed) will not fix our gender problem alone. The following changes, although small, are what we feel we can do today, right now, to help. The following are six suggestions for amplifying the opportunity, voices, inclusion, participation, recognition, and leadership of women in anaesthesia. It is hoped that these are practical and implementable changes that all anaesthetists, regardless of gender, might find helpful. When any of us are given a career opportunity—this might be a speaking role, a quality improvement project, acting as chair to a panel—take a moment for the following consideration. Is there someone else in your project team or department of anaesthesia who could deliver the role on offer? Someone whose visibility might be more impactful than your own? There may not be, but it is worth a moment of thought. This also applies when any of us are also giving career opportunities. Is there an idea for a departmental poster? Perhaps the perfect individual for the job is the very trainee who might never push herself forward to ask. The people we surround ourselves with have voices that we can amplify. ‘Amplification’ is a tool made famous by female staffers working for Obama: when a woman made a key point, other women would repeat it, giving credit to its author’.9Eilperin J. White House women want to be in the room where it happens. Washington Post.https://www.washingtonpost.com/news/powerpost/wp/2016/09/13/white-house-women-are-now-in-the-room-where-it-happens/Date accessed: October 4, 2019Google Scholar In practice, this is saying something in the departmental meeting such as: ‘I'd like to go back to the point that … made’. This is effective as two or three voices are much more powerful than one, and if the position is elevated, the authority added is invaluable. It may be helpful to amplify and diversify the voices we hear each day; this may be something as minor as who you follow on Twitter. By simply retweeting someone you have given them a platform. Consider ‘following’ or surrounding yourself with people whose discourse you may not have already heard. We have discussed the importance of balanced gender visibility at public events, and the following are some suggestions for increasing inclusion at conferences or public events, such as group teaching. First, the presence of those at these events should ideally be inclusive. If asked by an organiser to speak or to chair, consider asking if the panel/range of speakers is diverse and inclusive. If not, perhaps your attendance requires it. Perhaps conferences might consider offering travel support for partners or nannies to attendees who would otherwise not be able to accept conference speaking invitations.10Martin J.L. Ten simple rules to achieve conference speaker gender balance.PLoS Comput Biol. 2014; 10e1003903Crossref PubMed Scopus (91) Google Scholar Is there space to allow for a family room? As Jonathan Eisen (University of California, Davis) stated: ‘If you're going to spend money on an open bar instead of childcare … you should rethink what you're doing’.10Martin J.L. Ten simple rules to achieve conference speaker gender balance.PLoS Comput Biol. 2014; 10e1003903Crossref PubMed Scopus (91) Google Scholar Part of amplifying inclusion at public events also includes increasing participation from those who attend. When acting as a speaker or chair, please consider software tools for asking anonymous questions. Evidence shows that minorities are less likely to volunteer questions in Question & Answer sessions,11Hinsley A. Sutherland W.J. Johnston A. Men ask more questions than women at a scientific conference.PloS One. 2017; 12e0185534Crossref PubMed Scopus (60) Google Scholar but anonymous participation is preferable to no participation. As a visible leader in such a session, consider calling on a woman for the first question; it is known that if a woman is called on first, increased numbers of women will volunteer their questions.12Carter A.J. Croft A. Lukas D. Sandstrom G.M. Women’s visibility in academic seminars: women ask fewer questions than men.PloS One. 2018; 13e0202743Crossref PubMed Scopus (42) Google Scholar When in a teaching or other large group environment consider using Random Picker webtools. These are websites or software that can choose an attendant or student at random. This reduces the chance of your questions being consistently answered by only a select few members of your audience. Please consider no longer using the phrase ‘I don't see gender/race/colour’ in the workplace and beyond. It is in the lack of recognition that discrimination is found. It is not enough to treat everyone completely the same, because needs are different dependent on the individual's identity and a lack of recognition of this is akin to erasure. It is crucial to consider the complex needs of all our colleagues and to examine the set of intersecting privileges that may have prevented a full understanding of their experiences previously. There are scenarios in anaesthesia where examples of female leadership exist, but it is not always obvious to the passing observer. For example, an on-call team may comprise a male junior trainee with a female senior. It may be correct, or even clinically appropriate, to amplify the existence of this leadership by simply correcting those that mistake it. It is this intention through action-orientated behaviours that demonstrate a commitment to learning and advocating for gender equity. The best cross-ally relationships are reciprocal and often mutually growth enhancing. Part of the reason diversity programmes can fail is the understandable negative reaction to perceived coercion. None of the above suggestions are anything other than an attempt to try to deliver an autonomous and inclusive method to increase personal engagement. The most promising solutions are likely to be behavioural and systemic changes that focus on creating a climate for change.8Kang S.K. Kaplan S. Working toward gender diversity and inclusion in medicine: myths and solutions.Lancet. 2019; 393: 579-586Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar Increased accessibility and sense of personal responsibility increases the likelihood of people coming forward from minority communities not previously represented in leadership. Leadership needs to be more accessible, a partnership we must work together to achieve. An emphasis on valuing diversity ensures that anaesthesia retains its core mindset for renewal, reinvention, and growth. Conceptualisation, evidence collection, drafting of the manuscript: RP Critical review, commentary, and editing: SRM Both authors agreed on the final version The authors declare that they have no conflicts of interest.