Gender Differences in the Path to Medical School Deanship

Key Points Question Are the paths toward deanships of US medical schools different between women and men? Findings This qualitative study of 34 US medical school deans (representing 25.8% of the total population of US medical school deans) found that compared with men, women needed to work harder to overcome a lack of organizational support and other biases they faced during their leadership ascent. Women were similar to men in the number of attempts and years taken to attain deanships. Meaning This study suggests that institutions should provide midcareer women equivalent levels of organizational support, sponsorship, and cultivation of their leadership potential that their male counterparts appear to receive more routinely on their paths to deanships.


Introduction
Over the past 30 years, the percentage of women medical school deans in the US has steadily increased, but at 28% as of 2023, it still remains far below the percentage of men in these positions. 1,2Historically, medical school deans have been White men in their 50s, former department chairs, whose primary specialty was internal medicine. 3,4Conversely, prior to pursuing a medical school deanship, women physicians have been particularly underrepresented in positions that involve complete leadership oversight of departments, centers and units responsible for research, clinical delivery, corporate strategy, or policymaking.6][7] The current proportion of women in medical college staff leadership roles remains consistent with historic trends: 18% of department chairs, 47% of associate deans, and 52% of assistant deans, 6 raising the question whether there is a difference in the path to deanship.
Among medical school deans, gender differences in leadership oversight are apparent.Women deans serve at schools with lower National Institutes of Health (NIH) research award rankings and have narrower responsibilities in their role as dean. 8Women deans also more commonly oversee just the medical school, compared with men deans who more commonly additionally oversee faculty practice plans, other health professional schools, or hospital and health systems. 8,9Women also earn less than their peers in the same decanal administrative roles. 10Despite these systemic barriers, there are no differences between women and men deans with regard to the mean number of NIH grants or mean total NIH funding. 113][14][15][16] Data from the corporate world suggests that "for each woman who achieves a leadership position in the first decade of her career, there are 1.8 men doing the same…for members who first reach a leadership position during their career's second decade, the ratio is 2.3 men for every woman." 17A Hewlett Packard internal report showed that women working at the company applied for promotion only when they believed they met 100% of the job requirements, whereas men applied when they thought they had met 60%. 18 we are to recognize that medical school deans not only represent and embody the mission of their institutions but also influence the future direction of medicine as a profession, diversification of the deanships is needed.Given the current underrepresentation of women in medical school dean positions, we sought to understand whether there were differences in the path to deanship between women and men with regard to number of years and attempts to attain the deanship and career and leadership development.

Methods
The institutional review boards of Nationwide Children's Hospital and Drexel University College of Medicine approved this study.We obtained verbal consent from participants.We followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.

Study Design
We conducted a qualitative descriptive study comparing women and men medical school deans.0][21] We selected this method given that the study aim was to provide a description of women and men deans' professional and personal journeys to deanship and identify gender differences in their experiences.

Sampling and Recruitment
We obtained permission from the Association of American Medical Colleges (AAMC) Council of Deans to access their roster of 170 US medical school deans as of 2023.This roster included name, title, organization, and postal address.We obtained email addresses and year of deanship appointments from website searches.We excluded deans of non-US medical schools, interim deans, nondecanal positions (eg, vice, senior associate, associate, or assistant deans), and those retiring prior to our data collection period (Figure).We contacted 100% (N = 36) of US medical school women deans through emails, describing the study and inviting participation.We randomly selected men deans whose appointments started around the same time as the women who agreed to participate and then contacted them via email.We continued recruitment until we had 2 equal groups of women and men interviewees.
We developed a 9-item semistructured interview guide through iterative review before piloting the interview with dean's cabinet leaders (associate and assistant deans) who had similar career aspirations and trajectories as the deans but were not part of the study population (eAppendix in Supplement 1).This pilot interview served as 1 method of data verification, methodological coherence, wherein the questions match the research method, which in turn matches the data and the analytic procedures. 22The interview guide also asked for demographic information, including self-identified gender and race and ethnicity (see the eAppendix in Supplement 1 for items).We assessed race and ethnicity to understand if possible intersectional identities played a role in paths to deanships.A single interviewer (M.S.I.) conducted telephone interviews with participants between June 15 and November 9, 2023.Interviews were securely recorded, deidentified, and transcribed (TranscriptionWing; 2024).

Statistical Analysis
Although the study focus was on the qualitative interviews, we used statistical analyses to confirm that our sample of women and men deans were demographically similar on several key variables, including number of years to attain deanship, number of years as dean, deanships applied for, deanships nominated for, unsolicited applications offered, times as a finalist, and highest salary during their careers.We summarized demographics using descriptive statistics and used independent t tests and effect sizes to compare genders. 23We controlled for type I error rates using a Bonferroni correction to set P values considered significant at .05 / 9 = .006. 24ree authors (M.S.I., D.B.K., and D.P.W.) held group discussions to become familiar with data, identify initial themes, generate initial codes, and create a codebook.These authors independently One author (M.S.I.) prepared a textual narrative to summarize findings, while other authors confirmed these narratives.Creswell states that qualitative research's rigor depends on verification-"the process of checking, confirming, making sure, and being certain and refers to the mechanisms used during the process of research to incrementally contribute to ensuring reliability and validity." 25 verified the data by ensuring methodological coherence, collecting and analyzing the data concurrently to reflexively adjust, interviewing the correct sample population up to thematic saturation, and thinking theoretically, which "required macro-micro perspectives, inching forward without making cognitive leaps, constantly checking and rechecking, and building a solid foundation." 22
There were no statistically significant differences observed between women and men participants with regard to demographics, such as number of years to attain deanship (mean [SD], 2.7  1). 23,24 Eleven participants had held interim dean positions for a median of 12 months (IQR, 11-18 months [range, 7-34 months]).There was considerable variability in the number of years participants held deanship roles (median, 4.0 years [IQR, 2-11 years]; range, 1-18 years).
In their personal lives, more women (n = 5) than men (n = 2) reported taking leadership positions, including a deanship, even when it meant living separate from their partner or spouse.The women considered this sacrifice necessary due to the limited availability of high-level leadership opportunities and also their partners' or spouses' established careers.One man lived apart from his partner because she held a similar influential academic leadership position.Women did not report that living apart from their partner or spouse affected their lives.Universally, both women and men reported that unwavering partner or spousal support played a pivotal role in their career advancement and taking on the dean role.None of the participants had caretaking or geographic restrictions that affected their decision to take on the deanship.All participants with children reported that their children were of adult age by the time they became dean.
The qualitative results revealed 3 substantive gender differences in the path to deanship.First, women emphasized that they had to work very hard and be proactive in promoting themselves to attain the decanal position, whereas men often discussed being nurtured for this role.One woman dean stated, "Nobody's ever taken me under their wing to say, 'Let me help you get there'" (participant 23), exemplifying that she had to have significant self-determination to attain the deanship, as compared with a man dean who stated, "I certainly knew that I was on the pathway to becoming a dean" (participant 22).Unlike the men, the women suggested that they were rarely recruited for opportunities that would prepare them for a dean's position.For instance, 1 man pointed out that he "did not apply to be a board member for [X], they asked me to apply" (participant 7).This individual also attributed these opportunities to his mentors: "I've had phenomenal mentors who see things in me and see positions that I should be considering that I would not otherwise have considered."Men deans also reported that they were offered stepping-stone leadership positions early in their career, indicating that early career cultivation may have played a role in eventually attaining the deanship.In fact, one male dean stated that he was "early in his 40s, when [a senior mentor] started promoting leadership opportunities for me" (participant 26).
Women deans, unlike men, uniformly expressed both an obligation and a strong desire to participate in leadership development programs to advance their careers.One woman dean stated, "I was in the first ELAM [Executive Leadership in Academic Medicine] class.Many years ago, I saw the ad for the program and went to my dean and said, 'I want to do this.'He did not object, so I did it.The ELAM experience was pivotal in preparing me to become a dean" (participant 15).On the other hand, illustrative comments from the men deans suggested the feeling that they did not need professional development, including one who said, "I'm going to be honest, and on many days it shows, but I did not participate in any professional [leadership] development programs" (participant 9), or another man who stated, "I've been a leader literally throughout my whole life.I was a serious athlete, and I think I still am in a way.I was always captain of the team, so I never took a leadership course or anything like that" (participant 17).
Finally, women commonly described gender bias emanating from search firms.In fact, all women in this study went through national search processes to attain their positions, and many described facing tokenism based on their gender and/or race and ethnicity.A few women reported a Bonferroni correction for pairwise comparison: P = .05/9= .006. 24Cohen d effect size: 0 through 0.1, no effect; 0.2 through 0.4, small effect; 0.5 through 0.7, intermediate effect; and 0.8 or more, large effect. 23hat they did not receive complete preparatory information from search firms.For instance, one woman (participant 12) stated, "Once I had a very senior White male tell me how it works…that I would walk in loaded with all the information I could gather.You needed to answer the questions, and that's a totally different game and one that women don't necessarily get [or win]."On the other hand, few men participants complained about search firms, and many reported that there was "no search" involved during their deanship appointment, with one man dean stating, "Actually, I didn't even go through an interview process because [a senior leader] knew me so well" (participant 17).Table 2 provides illustrative quotes of these 3 themes.

Discussion
We found substantive qualitative gender differences associated with career preparation for medical school dean positions, echoing Sandburg's observation, "Men are promoted based on potential, while women are promoted based on accomplishments." 26Men deans were more commonly asked early in their careers to assume foundational leadership roles that provided stepping stones to position of dean.This nurturing extended beyond typical sponsorship and involved established leaders preparing and shaping men deans for specific roles through continuous development, mentorship, training, sponsorship, and strategic career moves. 27In some instances, men were fast tracked into leadership positions within a few years of completing subspecialty training.
Conversely, women deans reported that their career paths were not mapped out by senior leaders and especially not as early in their careers.This notion of not receiving similar cultivation of their leadership potential is supported throughout the literature.Studies show that women are less likely than men to be asked to serve in leadership roles, such as department chairs or division directors. 28For instance, among emergency medicine department chairs, men commonly stated that sponsorship from senior leaders affected their career advancement, whereas women chairs "advanced through their own hard work and effort." 29Women are also infrequently encouraged by superiors to run for institutional elected positions that would contribute to professional advancement. 30Simultaneously, women might not be seen as effective leaders by potential sponsors for myriad reasons, including role congruity. 31As stated in the study by Hastie et al, "For women in academic medicine, positions of leadership are achieved, despite the presence of challenges, not because of their absence." 32cause the women deans were more likely not to have had their leadership cultivated or been given early access to pivotal sponsors, it is unsurprising that they felt more obligated than men to participate in career development programs to level the playing field.Many of the women deans participated in programs such as the AAMC Mid-Career Women Faculty Professional Development or the Hedwig van Amerigen ELAM programs. 33,346][37] Women who participated in such programs were as likely as men and more likely than nonparticipant women to be promoted to full professor within 10 years. 38,39Leadership development program participation also expanded participants' networks and increased visibility, both within and external to their institutions.0][41][42] Among all current women deans, 63% were graduates of the ELAM program. 34Nevertheless, because extramural leadership development programs require the approval and financial support of the home institution, they cannot be a replacement for consistent, deliberate, intramural career development for guiding individuals through the ranks.
Additional hurdles faced by women deans in our study were inherent biases during searches for deanships, including the feeling they were just token candidates.Studies have shown that executive search consultants exclude women candidates, particularly women from racial and ethnic minority groups and those with intersectional identities, at each step of the search process, from identifying and profiling, to shortlisting, and presenting candidates to institutions. 43,44On the personal front, more women than men had to make the decision to live separately from their partner, spouse, or family when they attained the deanship.In addition, women deans were more likely to be part of dual-career households and had less flexibility because of their partner's or spouse's careers, thus accepting "commuter relationships." 45r results suggest that efforts to cultivate leadership potential should be specifically targeted toward aspiring midcareer women leaders. 16,46As compared with early-career women, midcareer women risk becoming invisible because of waning professional attention and support. 47One possible explanation is that as midcareer women gain experience and accomplishments, they become more threatening and are subsequently dismissed based on a variety of gender stereotypes. 48[52][53][54] The consequences of women constantly needing to be proactive and solely responsible for advancing their careers includes burnout, decreased job satisfaction and sense of belonging, transitioning to part time, poor work-life integration, and attrition. 53,55,56Research suggests that women are more likely than men to leave academic medicine. 57,58[60] In response, institutions, funding agencies, and professional societies should invest in the development of all faculty, paying particular attention to midcareer women.For example, in the United Kingdom, the Athena Scientific Women's Academic Network (SWAN) Charter holds institutions accountable for efforts in advancing women in science, technology, engineering, math, and medicine, and institutional support from some funding bodies is tied to the level of Athena SWAN awards held. 61Medical schools might consider strategies such as implementing term limits to allow for women to successfully attain experiences that position them well for deanships, while also promoting diversity, equity, and inclusion within their school. 2,62,63The NIH introduced a 12-year term limit for intramural laboratory and branch chiefs to diversify leadership by opening up positions for women and members of racial and ethnic minority groups, which is another positive step. 64nally, to mitigate some of the barriers women face, institutions should formally sponsor women for stepping-stone leadership positions and incorporate metrics such as the gender proportionality principle (which advises that a given level in an organization should reflect the gender composition immediately below it). 65,66

Limitations
This study had a few limitations.Although we had participation success with an often hard to reach population, we were not able to interview every US medical school dean in 2023.Therefore, the results may not be generalizable, although we recruited nearly half of all women deans.Although we strived for equitable representation, based on our sampling strategy, we were also not able to interview every one of the few deans belonging to a racial and ethnic minority group.We also did not interview candidates who never attained a deanship, who very well may have experienced differences in their treatment or qualifications associated with gender.Finally, our study was underpowered to perform inferential statistical tests, including evaluating whether there were differences between women and men in their spheres of responsibility in dean roles.Subsequently, our quantitative analyses should be interpreted only within the context of confirming the findings of others' comparisons of gender associated with deans' demographics.
Role of the Funder/Sponsor: The ELAM Innovations Fund had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

eTable 2 . 3 .
Deans' Prior Leadership Roles and Current Spheres of Responsibility eTable Number and Percentage of Deans by Clinical Specialty and Gender

Figure. Population of US Medical School Deans Based on 2023 Association of American Medical Colleges Council of Deans List
.S.I. and D.B.K.) coded all the transcripts, and another author (D.P.W.) arbitrated discrepancies.All study authors reviewed final themes to verify accurate representation.

Table 1 .
Demographic Characteristics of Women and Men Deans

Table 2 .
Gendered Differences in the Path to Deanship