Introduction
Having women in leadership strengthens innovation and support for the workforce. Women often excel in emotional intelligence, communication, and self-awareness.1,2 These skills are essential for running teams that range from small groups to large organizations. Despite the demonstrated benefits of gender equity in leadership for organizations, inequity persists in the upper echelons of academic medicine. Women more often hold local leadership positions, such as clinical or education program directors, whereas men more often hold “high-level leadership” positions as department directors or in the dean’s office or C-suite.3–6 Although women comprise nearly 50% of full-time medical school faculty in the United States, only 27% of medical school deans and 24% of department directors are women.4 Similar disparities exist in other American fields. Law firms,7 government,8 and Fortune 500 companies9,10 also have disproportionately low numbers of women in high-level leadership positions, including equity partner, members of congress or state legislature, and chief executive officer. This raises the question: how can more women achieve high-level leadership and close this gender gap?
The answer may partly lie in recruiting today’s early career women, who comprise the future candidate pool, into tomorrow’s high-level leadership. But research about women’s perspectives on leadership in medicine often focuses on those who are already leading,2,11–17 including the impact of low confidence and home responsibilities.2,11,18,19 Additional perspectives remain unexplored, especially the experiences of early career women who have not yet entered into leadership. Most studies about early career faculty and leadership focus on evaluating programs20–23 or surveys24 without in-depth explorations on how early career women view joining high-level leadership. Filling this knowledge gap could help clarify factors that encourage or dissuade early career women from pursuing high-level leadership to help mentors, leadership development programs, and institutions support women in attaining future appointments. Importantly, leadership positions must appeal to the candidates who institutional search committees want to attract. The tension between personal and professional priorities experienced by many women is exacerbated by gendered expectations in medicine, including masculine leadership styles.25
In this study, early career women graduates of a leadership program at an academic medical center were interviewed with the objective of exploring factors that influence women’s intentions to advance as leaders. Because these faculty enrolled in the program to advance their leadership skills, they represent a potential future candidate pool for leadership recruitment. This study sought to address the question: what are the priorities and concerns early career women have about becoming high-level leaders? The results can inform institutional efforts to recruit and retain women leaders.
Methods
Participants and Setting
The Early Career Women’s Leadership Program (ECWLP), offered by the Office of Faculty in the Johns Hopkins University School of Medicine (JHUSOM) Dean’s Office, supports the professional development of women who have been assistant professors for less than 5 years. The JHUSOM has 3200 full-time faculty (47% women). Faculty could self-nominate or be nominated into the ECWLP. The 2023 cohort of 51 women met twice per month for 11 seminars over 5.5 months. Curricular content domains included self-awareness, resilience, navigating academic medicine, communication, negotiation, prioritization, aligning core values with leadership identity and purpose, mentorship, well-being, and self-promotion plus a panel discussion with high-level JHUSOM women leaders. Members of the JHUSOM Dean’s Office or C-suite and professors who were content experts facilitated the seminars.26
Data Collection
In 2023, the investigators conducted in-depth interviews with a subset of ECWLP graduates. In-depth interviews were selected as the data collection strategy to gain detailed, personal insights on women faculty’s experiences, thoughts, and feelings. Because some of these elements may be highly personal and sensitive, early career women faculty might not be comfortable sharing such information with colleagues in a focus group discussion. Additionally, in-depth interviews provided participants greater control over which topics to prioritize when sharing their experiences.27 Since women’s perceptions and experiences related to leadership may differ based on demographic and professional characteristics, participants were purposively recruited to ensure representation across degrees (MD, PhD, or MD/PhD), race and ethnicity, and career category (clinical research, basic, or translational science, clinical programs, or education). Potential participants were contacted by e-mail, informed of the study, and invited to participate. A sample size of 25 participants was determined based on the literature regarding sample sizes and thematic saturation.28 Invitations were sent to 31 ECWLP graduates; 1 person declined to be interviewed and 5 did not respond. A woman early career faculty member who participated in the ECWLP (JH) or a woman medical student (OL) conducted the interviews.
The interviews followed a semi-structured format. Participants were asked about a range of topics, including work-life integration (WLI); support from family, friends, colleagues, mentors, and leaders; leadership values; influence from women leaders; experience with pursuing leadership or having a leadership role; and considerations about applying for future leadership positions. The interview guide was developed using three sources: a conceptual model relating the tension between women’s personal and professional aspirations and gendered norms of behavior and roles;25 the experiences of senior women leaders;11 and the investigators’ experience in leadership. Three investigators (JH, OL, JKL) tested the guide and edited it for brevity. Appendix 1 shows the final interview guide.
Interviews lasted up to 50 min and occurred over Zoom (Denver, Colorado). The interviewer recorded the audio with participant permission. Participants did not receive compensation for participating. The participants’ years at rank, self-reported racial and ethnic demographic data, and information on doctoral degrees were obtained from the JHUSOM Office of Faculty Information. Racially or ethnically underrepresented groups in medicine (URiM) were defined as Hispanic; American Indian or Alaska Native; Black or African American; or Native Hawaiian or other Pacific Islander.29 The JHUSOM Institutional Review Board approved the study, and participants provided oral informed consent (protocol 00340091).
Analysis
Audio recordings were transcribed verbatim, and transcripts were cleaned of identifying information, including names and departments. The authors analyzed the transcripts using an iterative, thematic constant comparison process informed by constructivist grounded theory.30,31 Four research team members (OL, JH, MOH, and JKL) developed an initial coding framework by independently reading two transcripts each (four transcripts, each read by two investigators) to create a preliminary coding framework via open coding. The initial codebook was developed by merging the preliminary coding frameworks, removing duplicate items, and collapsing codes from the open coding list based on similarities and differences. Multiple iterations of the codebook were created through coding additional transcripts and subsequent reflection and discussion by three coders (OL, SMG, and JKL). Using the constant comparison method, codes were compared within a single interview and between interviews. This iterative process facilitated the refinement of existing codes, identified emergent codes, and illuminated potential relationships between codes.30,32,33 The three coders independently applied the final codebook systematically to each transcript using ATLAS.ti software (Berlin, Germany) such that each transcript was double coded; JKL resolved discrepancies. When the coding was complete, the research team reviewed, discussed, and aggregated the coded text into thematic categories based on how the codes related to one another. The final thematic framework provided a higher level of contextual framing of the codes and coded text. Qualitative data are presented using participants’ direct quotes and their URiM or non-URiM status, which may influence their perspectives.
OL is a medical student, JH and SMG are assistant professors, and MOH, RBL, and JKL are professors and leaders in the JHUSOM Office of Faculty within the Dean’s Office. All investigators self-identify as women. Through regular meetings, the investigators employed a team approach to the data analysis whereby different analysts with different perspectives provided feedback on emerging interpretations and checked emerging categories against the raw data, allowing for discussion and reflexivity. Additionally, the investigators kept discussion notes and records of decision-making (ie, codebook versions), thereby creating an “audit trail” of the analytic process.34,35
Results
Twenty-five ECWLP graduates were interviewed. Participants self-identified as women and had been assistant professors for a mean of 1.8 years (standard deviation: 1.4; Table 1). The investigators identified four main themes: (1) the importance of being seen and valued as a whole person, (2) balancing an interplay between the individual and the collective, (3) discomfort with the unknown: a desire to fully understand a leadership position and its future impact on personal and professional life, and (4) representation matters: the importance of having women leaders who have experienced similar challenges as the participants. No differences were observed between the career paths. Supporting quotes are provided below and in Box 1.
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Box 1 Additional Representative Quotes by Theme |
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Table 1 Description of 25 Women from the Johns Hopkins University School of Medicine Early Career Women’s Leadership Program Who Participated in Interviews |
The Importance of Being Seen and Valued as a Whole Person
The desire to be recognized and appreciated as a whole person—rather than separating professional from personal life—manifested in receiving mentorship. Participants described how mentors with the greatest impact showed genuine care about their personal lives, WLI, and happiness while helping them achieve their professional goals. Participants more often attributed the provision of personal and professional support to women mentors than men mentors though participants described many valued characteristics in men mentors. Relationships with men mentors typically centered around work-related goals, such as grant writing, whereas women mentors more often helped participants integrate professional and personal goals. One participant described how she discusses the intersection of career and parenting with her woman mentor:
I talk to [my woman mentor] about… what is it to be a mother and also do this type of career? What did you do and what did you learn?… It’s a different type of relationship [than with my man mentor]… It’s nice to have these real conversations [with my woman mentor] about how do you balance getting the laundry done and doing what you do [professionally]. (non-URiM)
Influential mentors took time to understand the participants’ professional and family goals while sharing their personal experiences.
Participants wanted only part of their identity to center around work. Many wanted to emulate women leaders who openly discuss family life:
[A woman leader I respect] talks about her family, the challenges of being a mother, and the challenges of running her household. It’s like you’re like a real person with a real life, and this [leadership position] is just one part of your life and it’s a really awesome part of your life. But this isn’t your whole personality… There are some assumptions that women are either a family person or a job person. The fact that she can [say], “No, that’s not the case. This is who I am. I’m all of these things”. (non-URiM)
Participants sought recognition for their talents and goals. Some expressed frustration that the personal attributes they take pride in and believe are essential in leadership, such as generosity, hinder career advancement:
[To be a good leader], I think the idea is to be fair and measured. Generous would be good as well. But then opportunities in academic medicine are few and far between. So it’s easy to become greedy for those opportunities [and] to insert yourself into situations where maybe you aren’t the best candidate but you can probably do it. But you could have passed that invitation along to somebody else, but it felt like you really needed it. I don’t want to be like that. (non-URiM)
Balancing an Interplay Between the Individual and the Collective
Participants described a spectrum of considerations when thinking about advancing as leaders.
The Individual Perspective
Nearly all participants desired better WLI. They discussed struggling to find time for sleep, healthy eating, exercise, and other self-care activities in their current jobs. Many seemed unwilling to sacrifice more of their personal, family, and home lives for the sake of leading. This included the belief that some high-level leadership positions require being available nearly 24 hours per day, 7 days a week, which for some was not acceptable:
I want to have the power within a week, [if] I want to do something Saturday afternoon or I know I’m going to need to leave a little bit early… I can come in early to make up for it… Just having some wiggle room… Work is important, the things that I do are important, and people rely on me and it’s meaningful. But also I don’t have to be available 24/7 in order for [work] to keep moving. (non-URiM)
Participants reported being wary of situations that could require leadership styles that contradict their personal values of humility, compassion, and kindness. They expressed feeling discouraged from seeking leadership roles that would require behaviors that oppose their personal values, such as making unilateral decisions.
Some of the things that I value the most are clear, honest, and direct communication… [As a future leader, I want to] have a vision that is informed by the people that I’m working with. Not just me dictating. (URiM)
Most participants preferred to lead in environments with a desirable work culture. Some worried that institutional financial interests conflicted with their personal goals for patient care or that they might feel pressured to compromise their values should they become leaders.
The Collective Perspective
Many participants preferred to work on teams rather than alone. They believed that inclusive teams achieve better results by incorporating different perspectives, experiences, and skillsets that contribute to a shared goal:
So when I think about collaboration, it’s people coming together each with their unique expertise. Create something new. (non-URiM)
They sought to lead in a manner that ensures every team member’s opinion is considered, all members feel supported, and collaborations benefit everyone. A participant described her goal for becoming a department chair:
One of the things I get really excited about is enabling other people to do great work… I think that one of the roles of a [department] directorship position is to look at the portfolio of the whole department and see what needs more support… create partnerships and collaborations. Elevate everybody. Support everybody so they can do great work and make an impact on the field. (non-URiM)
The participants’ emphasis on teamwork connected to their desire to be valued as a whole person while also recognizing others as whole people. This included allowing people to be themselves; recognizing diverse perspectives, experiences, and skills; and acknowledging people’s needs and priorities. The importance of fairness as a feature of collaboration and teamwork was reflected in wanting the most qualified person to lead, knowing that a single person cannot always be the best leader for all situations, and recognizing the team’s contribution to the leader’s success. Motivations to lead included recognizing the work of other people and helping trainees and colleagues advance.
Discomfort with the Unknown: A Desire to Fully Understand a Leadership Position and Its Future Impact on Personal and Professional Life
Participants described uncertainty, insecurity, and even fear about what might occur should they advance as leaders. Many sought clarity about the types of changes they could realistically make in the workplace and whether other leaders and colleagues would respect their decisions. The participants wanted to know whether their goals would motivate and align with those of their future leadership team and the degree of support they would receive from their own leaders. They also wished to know who would be on their team and whether the team’s dynamics would support them as new leaders. Moreover, participants wanted to know if they would have the authority, influence, and resources to make decisions and changes for populations they hoped to impact:
[I want to] actually make progress on [an] agreed upon problem or situation rather than just maintaining a system… figure out how to do something better or in new ways. (non-URiM)
A participant noted the importance of her work being recognized and compensated, understanding that this is often not guaranteed:
I want the time that I’m putting in to be seen and valued by others. I also appreciate being supplemented with effort and money. (non-URiM)
Many wanted clarity about their future WLI and how time with family would be impacted should they be appointed to high-level leadership. This included concerns about needing to work late at night and on weekends, resulting in loss of family time. They wanted to know whether how they choose to spend their time would be respected by colleagues and other leaders. They expressed caring deeply about protecting time with their families in addition to achieving their professional aspirations:
I think a lot of leadership roles come with a lot of work. And given that my plate feels full and I’m still not in a leadership position right now, I would want to make sure that that time [to do the leadership role] comes from somewhere that’s not my nights and weekends. (non-URiM)
Accordingly, the women desired full support from their family when considering leadership positions.
Some participants were uncomfortable with not knowing exactly what skills they would need in a new position. This led to the desire to be overly prepared for any situation or challenge that might arise before applying for a leadership position.
Men will go forward before women and say, yes, I’m ready [to apply for a leadership position]. And women will be qualified with 14 certificates under their arm and still say, well, I think I just need one more. (non-URiM)
Representation Matters: The Importance of Having Women Leaders Who Have Experienced Similar Challenges as the Participants
Participants valued seeing women leaders succeed using attributes that are traditionally considered communal, including compassion and empathy. One described seeing a woman leader navigate gendered expectations:
She’s a woman and she fulfills this role of being kind and warm, but at the same time she can be really clear about what’s expected and when something is not correct. It’s a really impressive line that she walks. Because sometimes women in leadership positions… if you tell it like it is too much, there can be some backlash. But somehow she has found a way to just be very upfront but also still a warm person that people want to work with and be around. (non-URiM)
They were also inspired by high-level women leaders who have family care responsibilities, as many felt they were viewed differently as working mothers compared to working fathers. One described a dichotomy in how mothers and fathers in leadership are often viewed:
It’s pretty common for people to think that [a woman is] either a family person or a job person… Whereas with a man, of course they have a family and of course they have a job – that’s just normal. (non-URiM)
Having URiM women in high-level leadership serve as mentors and role models positively and significantly influenced the confidence of URiM participants. Seeing other women who are URiM succeed in high-level leadership showed that this is possible for them, too:
[A black woman leader] has been a really amazing mentor for me… I’ve only met a few other black women faculty. To see someone who’s like me, who’s doing so well so quickly, it just helps me realize that it’s possible. It gives me the courage to be unconventional. If I’m aspiring to get promoted in this short timeframe… there’s no real rule that I can’t, so let’s aspire for that. And then [mentor] moved into a [high-level leadership position]. I never even knew that was a possibility. If I wanted to explore something, now I know I have the possibility of doing that. (URiM)
Discussion
Gender inequity persists within high-level leadership in academic medicine.4 The perspectives of early career women, many of whom could become our future leaders, must be understood to recruit and retain women in the upper echelons of leadership. This study identified four themes in interviews of ECWLP graduates that can inform institutional practices and improve gender equity. First, early career women want to be seen and valued as a whole person with integration of their personal and professional identities. Second, they balance an interplay between the individual and the collective when considering a future in leadership. The individual perspective included desiring better WLI and wanting to lead in a manner that aligns with their personal values. The collective perspective centered around teamwork, inclusivity, and fairness. Third, participants felt discomfort over preparing to lead, whether they can realistically improve systemic problems, and how a leadership role would impact their lives. Finally, participants stressed the importance of meeting women in leadership, especially those who have experienced similar challenges as the participants, to serve as role models.
These findings align with a model describing the tension women in medicine experience from competing professional and personal priorities, masculine leadership norms, and stigma around WLI by Winkel et al.25 In the current study, participants described factors that help alleviate some of these conflicts. Based on the study’s findings and existing literature, the authors provide recommendations that could benefit faculty of all genders (Box 2).
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Box 2 Recommendations to Support Faculty of All Genders |
Women are more likely than men to suffer career consequences after discussing their families at work.36 The study results show that early career women disagree with the expectation that people only show their professional sides at work. They instead want to integrate the professional and personal aspects of their lives. The authors recommend that institutional policies for childbirth and parental leave be combined with methods to help faculty access high-quality childcare to support work productivity and satisfaction. Additionally, workplace cultures should encourage people to share personal and family information to foster a sense of connection and belonging. This could enhance well-being for everyone, including men with caregiving responsibilities,37 amidst the productivity-driven culture of medicine.38 When possible, flexible working hours, which were mentioned as important by the study participants, can support faculty in optimizing when and how to maximize their work productivity while still meeting their family obligations. Such initiatives could help retain talented physicians and scientists of all genders in academic medicine and make leadership more desirable and achievable.
Stigmas against faculty who are undergoing fertility treatment, are pregnant or lactating, or have childcare responsibilities must be stopped.39 Efforts are underway to protect time for prenatal visits for medical trainees;40 similar policies could be developed to support faculty. Using moonlighting physicians or advanced care practitioners or providing additional compensation to colleagues who cover some clinical duties of pregnant faculty, such as overnight shifts during the third trimester, could mitigate potential feelings of unfairness by colleagues.39
Participants described how influential mentors genuinely care about their WLI alongside professional productivity. This adds a nuance to common views of mentorship, which often focus on the mentee’s professional accomplishments and scholarly work.41 Early career women want mentors and leaders to consider their whole life and identity. Few participants mentioned plans to pursue higher leadership once their children reach adulthood. For women who do not want to pursue leadership while they have many caregiving responsibilities, mentors could help them adjust their milestone goals for faster professional advancement later in life. This requires that age discrimination42 not be tolerated in leadership searches. Moreover, faculty must proactively seek multiple mentors to meet their varying needs.
An interesting interplay emerged between the priorities of the individual and the collective. Gendered characteristics and language, which have long affected career advancement,43,44 manifested in the individual perspective. Participants emphasized specific attributes, including empathy, compassion, and humility. While these values are essential in leadership,45 they fall into the category of traditional feminine descriptors.43,44 By contrast, desired leadership attributes are often described using traditional masculine terms, such as independence, confidence, ambition, and decisiveness.43,44 Job descriptions with mostly masculine words dampen women’s interest in applying.44 Accordingly, participants were opposed to taking leadership roles that could require behaviors that contradict their personal values. Women may view leadership opportunities more favorably when the job description’s language reflects their values. The search process for leadership positions should be guided by an understanding of how gendered language influences the candidate pool and how candidates are viewed.43,44
The individual perspective also showed participants’ desire to lead in idealized organizations that would, for example, balance employee WLI and patient care alongside revenue. There was low interest in spearheading change within difficult environments, such as dealing with growing financial challenges in medicine.46 However, high-level leaders must commit to difficult endeavors in suboptimal situations. This includes leading culture and system changes that people may initially resist but that result in long-term benefit.47 The authors suggest that leadership programs emphasize strategies for building resilience and leading change in challenging environments to prepare and empower physicians and scientists as future leaders. For instance, incorporating coaching into leadership programs may help participants strengthen their resilience48 and commit to change-oriented behaviors.49
The collective perspective on leadership emphasized teamwork. While being team-oriented may enhance productivity, faculty should also be educated on the pitfalls of being excessively team-oriented. For example, an overly team-oriented leader might distribute too much responsibility to others and dilute personal responsibility. Women who are uncomfortable with self-promotion50 may give too much credit to their team without obtaining personal recognition. Thus, leadership programs should teach effective self-promotion alongside team leadership skills.51
Few women mentioned desiring a prestigious title with higher salary, as this was not key to their core values. Only some noted needing effort and salary for their work; most did not mention this at all. The infrequent discussion of salary could be related to several factors. Low confidence deters many women from pursuing leadership.11 Accordingly, some women may feel the need to achieve significant success before being comfortable stating that they deserve a leadership appointment with commensurately high salary. Gender inequity in salary,52 consequences for women who negotiate,53 and lower salary for women in the same high-level leadership positions as men54 may also contribute to women’s low salary expectations. We encourage leadership programs, department chairs, and division chiefs to normalize ambition, negotiation, and allyship for gender and pay equity. Importantly, institutional transparency about compensation for leadership roles would support faculty of all genders in negotiating for salary.
Many participants were uncomfortable with the unknown aspects of leadership. This included questioning whether they would have the authority and resources to make meaningful change and the impact becoming a leader could have on their WLI. Their desire to have all the necessary skills before applying for a position, rather than learning skills “on the job”, reflected how women tend to wait until they are overly prepared to apply. In contrast, men often apply with fewer qualifications.55
To demystify how various leadership roles work, the authors propose that job descriptions and interviewers clearly communicate information about workplace culture, typical working hours, and available resources, training, mentorship, and coaching. Rather than negatively judging candidates who seek this information, these candidates should be viewed as preparing to succeed in the new role. Additionally, creating opportunities for women to meet high-level leaders during leadership programs is essential. Hearing leaders share personal stories of failed endeavors would foster an appreciation for perseverance and resilience. Leaders could describe how they accept that they can address some, but not all, problems, and how they continue to receive mentorship and coaching.
Finally, the study’s findings show the importance of having women in high-level leadership, especially those who experienced similar challenges as the participants. These women inspire others with shared experiences. For instance, many women of color56 or who have a different sexual orientation57 or a disability58 must navigate discrimination and historic institutional racism59 successfully. Additionally, organizational skills from being a working parent often help prepare people for leadership. Research at other institutions similarly highlights the need for more women leaders as role models.15
This study had several limitations. Data were collected from women who participated in the ECWLP at a single academic medicine institution. Future research should include women at different institutions and from different career stages. All participants applied for and participated in the ECWLP. Their perspectives may differ from people who did not participate in the ECWLP or who do not work in the JHUSOM, and the program may have influenced their views. Participants were very early in their careers; more experience might influence their decision-making on leadership. Future longitudinal studies would enable an exploration of how factors that influence women’s intent to pursue high-level leadership change over time. The sample size may not have allowed us to fully explore diverse perspectives and experiences, and the findings may not be generalizable to all women in academic medicine. As with all qualitative research, the research team’s experiences may have influenced the interpretation of the results.
Conclusions
The current perceptions of early career women must be considered to recruit and retain women as future high-level leaders. The study identified details about how women wish to lead and clarified factors that encourage or dissuade them from leadership. This included the importance of women knowing that they are professionally and personally valued and being able to lead in inclusive work environments that respect people’s personal values. Demystifying the realities of leadership early in the job application process by describing available resources, mentors, and coaches may improve the recruitment of women into high-level leadership. Moreover, women who are high-level leaders could serve as role models to inform future leadership candidates about the aspects of their job that they find rewarding and challenging, how they address obstacles, and how they manage their WLI.
Abbreviations
ECWLP, Early Career Women’s Leadership Program; JHUSOM, Johns Hopkins University School of Medicine; URiM, underrepresented in medicine; WLI, work-life integration.
Data Sharing Statement
Data will be made available upon request by contacting the corresponding author at [email protected].
Ethics Approval and Consent to Participate
All study procedures were approved by the JHUSOM Institutional Review Board, and informed consent to participate in the research was obtained, including consent to publish anonymized responses (Protocol 00340091).
Funding
There is no funding to report.
Disclosure
JKL consults for the United States Food and Drug Administration and Erickson Coaching International, and owns Asclepius Coaching and Consulting, LLC. MOH has funding from Takeda Pharmaceuticals, Pfizer, and PredictImmune and consults for Takeda Pharmaceuticals and Janssen Research and Development. RBL consults for the Association of American Medical Colleges. The authors report no other conflicts of interest in this work.
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