Carol Emmott Fellows share their insights on the glass ceiling, isolation vs. integration in addressing gender equity, helping rural minority populations, motivating front-line managers and providing support functions with a fresh perspective.
It’s not the ceiling, It’s the floor
Author: Carol Emmott Fellow Thomasine Gorry, MD, MGA, University of Pennsylvania
We have newly designed office space at work. The conference rooms are now elegant glass enclosures with subtle glass doors at their center. One day I sat in a meeting and watched a female colleague approach the doors at full speed, coffee in one hand, papers in the other. She was running late but had arrived at the right room. She was where she was meant to be. I glanced back at the table, preparing to present my work, when I heard the loud thud. I looked up just in time to see the woman collide into the glass door. Papers flew into the air and coffee fell to the floor. She looked stunned, as did everyone in the conference room. We looked down politely as though it never happened. The woman laughed nervously, made the appropriate expression of self-deprecation (from behind the glass) and then retreated. We proceeded with the meeting. No one noticed or acknowledged that she did not return.
That is how most women understand the glass ceiling: as a witness to others’ mishaps. Most women in medicine know the ceiling exists but never get high enough to swing at it. A few women at the top collide into an invisible barrier and go no further. The majority of women simply find themselves on uneven footing, as though always standing in mud. For most women (though not all), it is not the ceiling that holds them back; it’s the floor that sinks beneath them.
Why do women work so hard just to stay above the surface? Why aren’t women positioned on a crisp dance floor on which to show off their talents and from which to advance to the next level? How is it that women often churn without advancing?
It is the cumulative effect of reticent negotiations. Women are reluctant negotiators for a variety of reasons: First, we are uncomfortable asking for our worth − even elevating it (as negotiation requires). This best strategy for men is unseemly for women. Second, we rightly fear retribution for asking for or receiving a pay increase. Women seeking raises may face resentment. One pay increase may halt career progression and even end professional relationships. “Who does she think she is?” The fear of advocating for themselves is not completely unfounded so the pay gap in medicine endures. The opportunity cost of each failed (or avoided) negotiation accumulates over a woman’s career at great expense. The floor slips beneath them.
Women often assume (or are expected to assume) supportive roles even if they are not in support positions. Even in medicine, female physicians, are more likely to generate referrals than to be the sub-specialist who thrives on them. If women work hard to prevent bad outcomes and care for the team, that work is not quantified and, therefore, not rewarded. High performance at supportive roles is simply not recognized. In the healthcare and most industries, everyone rewards the high scorer. No one counts the assists. The floor gives in again.
Women inhibit themselves in the belief that they are protecting their children. That is, women fear that every professional step up is a personal step away from our children. This may indeed be true. (The floor slips again.) Our world still orients around the same rigid lines: Are you full time or part time? Do you stay at home or do you work? When women are seen as standing on one side of a given line, they are necessarily absent from the other side. If they perceive that their children sit on the opposite side of that line, women stand down. The cost is too high. The workplace must evolve so that these rigid lines become false choices. Lines should be replaced with creative work design that rewards the contributions of talented, strong, women with fair pay, equal promotion, and earnest dedication to family. The overall culture must shift so that children of talented, strong, professional women are also entitled to their mother’s gifts. Can we find a solution that makes these both true? Can we change the workplace structure for women, not the structure of women’s lives?
Finally, and most importantly, the unconscious is hard at work in healthcare. Everyone − men, women, minorities − have some pre-existing identity in our minds. This is commonly referred to as “implicit bias.” Within this bias, women are not seen as strong leaders. The result: women must first work to undo that assumption and then work to execute the basic tasks of leadership. Worse, women may even carry an implicit bias against themselves. “I’m just not that person.” (Again, the floor sinks when it should rise.) The responsibility to change the implicit, “I just don’t see her that way,” bias should not fall on the individual. Organizations should actively seek to place women in leadership positions and begin the slow process of normalizing women as leaders. Eventually, organizational work will erode the bias that individual women now work to undo.
How do we keep women from churning in place? It requires a willingness to disrupt culture from the bottom up. We must normalize the identity of women as leaders, make it possible to succeed as a professional and as a mother − neither one at the expense of the other − and allow women to take the calculated risk of professional negotiations. Women themselves must believe (without fear) that they are entitled to their own best shot. Make the floor beneath women an unyielding foundation and they will advance under their own power.
Then we’ll discuss the ceiling…
Thomasine Gorry, MD, MGA, is Vice Chair for Quality at Scheie Eye Institute; Associate Professor of Clinical Ophthalmology and Cataract Surgery at Perelman School of Medicine at the University of Pennsylvania; Medical Chair for Quality in Clinical Operations for Clinical Practices at the University of Pennsylvania.
Integration vs. isolation: Walking the fine line to gender equity
Author: Carol Emmott Fellow Barbara Fonte Ronda, MHSA, University of Miami Health System
The healthcare landscape has been undergoing a period of unprecedented transformation and the evolution has confronted the status quo. Change can be perceived positively or negatively but in either instance, transformation is generally accompanied by opportunity. It appears that with each swing of the pendulum, the newly dressed landscape offers a broad and inspirational bouquet of prospects that tests an individual’s commitment to the health administration and delivery renaissance through the reinvention of roles and positioning.
For the female executive, embracing opportunistic change often represents a notable challenge. Studies show that men will raise their hand to a new job before a woman. Once in leadership roles, men will secure much healthier employment terms and salaries, when comparing apples to apples. These and other causes have led to a significant disparity between the numbers of women who enter the health services administration career path to those that ascend into a senior leadership capacity. Those very disparities have contributed to the rampant gender and wage equity issues that plague the health industry today.
Women are rising in response to this widespread crisis. We are learning of these differences and are focused on finding solutions. The past decade has brought increased awareness to women’s issues and a number of platforms have emerged as a result. Women must accept their role and responsibility in leading change if progress is to be made in our lifetimes. Additionally, the disparity crisis has given way to formidable “for women by women” advocacy groups such as the MomUp Campaign, Women in Health Care Leadership Project, and The American Medical Women’s Association; all of which fervently challenge equity issues.
Evidently, we the afflicted, are rightfully answering a call to action. However, success in the form of significant change is slow to come. There is an inherent flaw in the “for women by women” philosophy. Action must be measured and mindful. The homogeny of such groups can lead to a one-sided viewpoint. A one-dimensional perspective may lack a competitive perspective, and the narrow gate of entry only allows for like-minded philosophical beliefs and attitudes to squeeze through. This platforming also walls out differing ideology which promulgates stagnation. Creative solutions to the gender and wage gap will require an integrated approach. The solution cannot exclude our male counterparts.
Aren’t we seeking integration and equality? Then I submit that it is unrealistic to bridge the gap without engaging the “other side.” Let’s work together, men and women of all race and ethnic backgrounds, to create integrated groups reflective of the communities we serve and to create the change we wish to see.
Barbara Ronda, M.H.S.A., associate vice president and chief administrative officer for UHealth – the University of Miami Health System. She serves as a Board Member for The Health Foundation of South Florida and was recently recognized as a 2017 Public School Alumni Achievement Award Honoree.
The time is now: Addressing health inequities in rural minority populations
Author: Carol Emmott Fellow Marva Williams-Lowe, PharmD, M.H.A., Dartmouth-Hitchcock Health System
In 1966 Dr. Martin Luther King Jr. gave a speech to the Medical Committee for Human Rights and said “of all the forms of inequality, injustice in healthcare is the most shocking and inhumane.” In 2017 inequality in healthcare still exists and the consequences are striking.
Health inequities or disparities in urban communities are well known and in some cases more resources may be available to address them than in a rural community. In rural previously homogenous communities these issues are even more significant as the minority community begins to grow but the healthcare systems have not changed or are not moving fast enough to keep pace with diversity.
Ethnic disparities in healthcare cost the U.S. billions of dollars. African Americans, Hispanics, and Native American Indians experience higher rates of chronic diseases like diabetes and hypertension than other populations. In many cases, these increased costs and reduced quality of life and mortality are preventable with wellness programs or disease state management that takes into account the specific population needs.
A May 2017 data summary from the Centers for Disease Control and Prevention (CDC) shows African Americans ages 18-49 are twice as likely to die from heart disease than whites and African Americans ages 35-64 years are 50 percent more likely to have high blood pressure than whites. The data shows that African Americans are dying younger from diseases like cancer, diabetes and heart disease than whites.
The US spends trillions of dollars on healthcare each year yet not everyone can afford to access healthcare when they need it and some populations are more challenged than others in accessing care. If you are able to seek care when you need it, you may or may not be able to afford your medications. If given the choice between paying rent, buying food, or getting medication for a chronic illness, some patients will choose not to fill their prescriptions. If the prescriptions are filled, in some cases they will not take them consistently if they believe they can save money in the short term. Drug prices and the impact on patients when they cannot afford medications is a significant issue for our country and contributes to the long term increasing health costs and poor health outcomes. This adds an additional complexity to the rural locations, poverty, race, and issues that contribute to an unequal distribution of preventative care, disease management, and access to overall healthcare.
Our neighborhoods and communities affect how we live, our daily lives, and our well-being. In rural communities where the minority populations are growing and they are underrepresented in healthcare professional and provider positions, gaps are likely to exist. In these communities, healthcare providers are often not aware of the challenges that these minorities face to access healthcare or the challenges they face when they meet a provider who is not aware of their economic, environmental, social, or cultural challenges.
Consider the story of Janice, an African American who visited a healthcare provider in a rural community. Janice rarely accesses the healthcare system and when she does, her experiences have not given her confidence that the providers recognize the importance of her difference as a minority. On her last healthcare visit, the provider was not familiar with a rash that she had on her skin which she describes as commonly seen in the African American population. When Janice previously saw a provider in a city well populated with minorities, the provider was familiar with her skin condition, was able to assist and Janice had a positive outcome.
Roberta is an African American who was seen for the first time by a gynecologist in a rural community. After the visit, Roberta reviewed her chart and noticed that the provider incorrectly documented her as Caucasian. Roberta wondered if this was a default setting in the electronic medical record since she lives in a community that was primarily white but is now experiencing a growing population of minorities. Roberta wants her provider to “see” her and recognize her difference, as she knows that race can play an important role in how some disease are diagnosed and treated.
While these are not major examples of issues with healthcare interactions in a rural community they do provide an inside view of why minorities may be hesitant to visit a provider, may not be confident that they will be understood or that their differences will be recognized. Ethnic and racial differences have a significant impact on health outcome. The challenges faced by minorities in seeking care can negatively affect their ability to lead healthy lifestyles.
To begin to address these issues we need to create equal opportunities for health at the community level as it affects the overall health status and costs for our nation. Community engagement and partnership with key stakeholders will be a necessary element to create and sustain change. Understanding specific populations, individual culture, and barriers are necessary components to establish healthy communities to reduce and one day eliminate inequities in health.
The journey to health equity in the rural locations will require community partnership with healthcare organizations and the development of programs and policies to address access to services for minority populations. Community discussions, assessments, and the development of cultural competencies will be key elements for this journey in rural populations. It will require the creation of equal opportunities for all races and populations to access and participate in healthcare and to experience no gaps in health outcomes. It will be a worthwhile journey to a worthwhile goal.
Marva Williams-Lowe, PharmD, M.H.A., is the regional pharmacy director for the Dartmouth-Hitchcock Health System. She has responsibility for hospital pharmacy practice and operations including purchasing and inventory management, budget, personnel, medication-related policies and procedures and regulatory compliance.
 (2017, May 2). National Center from Chronic Disease Prevention and Health Promotion. African American Health. Retrieved from https://www.cdc.gov/vitalsigns/aahealth/index.html