Women have made great strides in dermatology. In the 1970s, only 6.9 percent of practicing dermatologists were women.¹ By 2015, women represented 47.1 percent of practicing dermatologists² and the majority— 64.1 percent—of dermatology trainees.³ Women have since attained leadership positions in many of our societies, including the American Academy of Dermatology, American Board of Dermatology, and Society for Investigative Dermatology, and we even have a society dedicated to promoting the development of women dermatologists: the Women's Dermatologic Society.

But despite these advances, women are still not equally represented in academic dermatology or dermatology leadership. Women are entering the workforce in record numbers. In the case of academic dermatology, women made up the majority of junior faculty as of 2015, with 61 percent of instructors and 56 percent of assistant professors being women. But by the time we reach full professor level, only 31 percent are women, and there are even fewer female dermatology chairs—only 16 (fewer than a quarter of all dermatology chairs) in 2015.⁴

Table 1. In 1993, women respresented 38 percent of the academic dermatology workforce at the assistant professor level and 34 percent at associate professor level, compared to 61 percent and 46 percent, respectively, in 2015.⁴

What's the problem with gender inequity in dermatology leadership? In addition to issues of underrepresentation and unfairness, there are tangible benefits to achieving gender (not to mention other kinds of) diversity. We can turn to the business world for some guidance. In a 2011 survey of more than 7,000 leaders, women outperformed men in 75 percent of the leadership competencies that were assessed.⁵ This leadership competence also leads to better financial performance. When reviewing past data on the performance of Standard & Poor's Composite 1500 list, female representation in top management improved firm performance, with an average increase of $42 million in firm value when the firm was focused on innovation.⁶ Women have the capacity to perform at high levels in leadership positions. Why aren't they doing so?

The Leaky Pipeline is Still Leaking

With so many women entering the academic dermatology workforce, why haven't more women attained senior leadership positions? Perhaps we just need to give it more time. If we wait long enough the numbers will equalize (“more in, more up”). With the majority of junior faculty being women, the numbers should slowly equilibrate over time as this new generation of junior faculty rises through the ranks. Indeed, the numbers are improving: between 1993 and 2015, the proportion of female full professors rose from 10.7 percent¹ to 31 percent.⁴ But the numbers don't seem to be increasing at the expected pace—likely due to attrition along the way, or what's referred to as the leaky pipeline.

Consider the number of women completing dermatology residency over the past decade. The proportion of women completing dermatology residency has been relatively stable at just over 60 percent. Meanwhile, the proportion of women entering academics has increased significantly. In 1993, about 38 percent of those entering the academic dermatology workforce at the assistant professor level were women, compared to 61 percent in 2015.⁴ At the same time, the proportion of associate professors has increased at a far slower rate—34 percent in 1993, 46 percent in 2015.⁴ This suggests that we are seeing more coming in…but not as many moving up. One reason may be that women are not promoted at the same rate as men; only 30 percent of those promoted from associate to full professor are women.⁴ Couple this with lower job satisfaction compared to men,⁷ and at least some of the reasons for the holes in the leaky pipeline are revealed.

Why are academic women dermatologists not promoted at the same rate? It's not because women aren't capable and productive. Women dermatologists work similar work hours to men.⁷ Women physicians may provide, at least in some instances, superior care to men; a large study of hospitalized patients showed that those who were cared for by women physicians had lower mortality and lower readmission rates.⁸

A main “currency” of academic productivity is publishing, and there is a gender difference in publication rates. Women publish slightly fewer research papers in dermatology journals overall compared with men (47.2 percent versus 43.0 percent of all authorships, respectively),⁹ and are first or last author less often than men.^9-11 Women are also underrepresented as journal editors; 45.8 percent of journals had not yet had a female editor as of 2017.¹²

Why else would women leave leadership tracks at higher rates than men? One major reason is lack of financial support. Women in academic medicine generally perceive that a lack of gender equity in pay (as well as other academic resources), and lack of transparency about pay, contribute to a climate of inequity.¹³ The data suggest that this is not just a perception, but a reality. Women receive fewer NIH funded grants compared to men.¹⁴ Women dermatologists receive lower salaries than men. A 2012 survey study confirmed that women academic dermatologists make less than their male counterparts despite normalizing for age and rank (around $20,000 annually), and 55 percent of women surveyed identified “higher salary outside of academia” as one of the reasons to consider leaving academics.⁷

Another frequently cited reason for women leaving academic medicine at a higher rate than men is burnout. To be clear, burnout is not a problem unique to dermatology or to women. Lack of work-life balance and burnout are at epidemic rates in medicine. But these issues seem to affect women more than men. In the 2018 Medscape National Physician Burnout & Depression Report, 48 percent of women physicians reported burnout compared to 38 percent of men.¹⁵ In general, job related issues (job, finances) contributed more to this burnout than health or home life.

A frequently cited reason for leaving leadership positions and academia in particular is a lack of work-life balance. Work-life balance, as a concept, is slippery and difficult to define, but it is certainly intimately associated with burnout, and affects all genders. Satisfaction with work-life balance is generally worsening for US physicians.¹⁶ Women are particularly affected by the competing demands of work and home life. In dermatology, women make up a nearly equal portion of the workforce, but take on more parenting duties than their male counterparts. A 2002 survey study of recent dermatology residency graduates found that 70 percent of women parents decreased their work hours because of child care responsibilities compared to just 11 percent of male parents.¹⁷ A more recent study of NIH physician grant recipients had similar findings. Not only were women physician scientists less likely to have a stay-at-home partner, women spent 8.5 more hours per week on domestic activities and were more likely to take time off for childcare. Although women are out in the workforce and no longer staying at home running the household, women still end up with many of the traditionally “female” tasks of childcare and household management. As Amy Westervelt says, “This whole ‘having it all' business has been grossly misinterpreted by our society at large...Doing all of it at the same time was never the idea.” She sums it up with the title of the blog post: “Having it all kinda sucks.”¹⁸

Solutions to the Gender Gap

Given the multidimensional arenas that have contributed to the gender gap, solutions will not be simple. Fixes need to come not only from women, but more importantly from above and around women: those who support, sponsor, and mentor women.

The following touches on just a few of the arenas that contribute to the success of women in dermatology leadership, both from the literature and from the personal experiences of successful women in dermatology leadership. Many of these topics have been presented and discussed by speakers at the American Academy of Dermatology forum, “The Gender Gap in Academic Dermatology and Dermatology Leadership: Problems and Solutions,” with topics ranging from work-life balance, time management, mentorship, negotiating skills, conflict resolution, and unconscious bias.

Role Modeling and Mentorship

Having a woman dermatologist as a leader positively correlates with the number of women on faculty.¹⁹ This means that just having a woman in a dermatology leadership position provides a kind of scaffolding for the successful recruitment of other women faculty. This makes sense when considering that successful women leaders serve as role models, particularly for young female faculty and trainees. As a role model of my own, Dr. Lynn Cornelius commented, “The importance of having physician and senior investigator ‘role models,' particularly early in one's career, cannot be overestimated.”²⁰ On the flip side, not having women in these leadership positions creates a self-perpetuating problem, with a paucity of role models and mentors. On this front we may be making some strides. A recent survey study indicated that women now account for nearly half of dermatology residency program directors,²¹ a key position for mentoring the next generation of dermatologists (though, as Alexa Kimball, MD points out, “We need to promote women to be both program directors and chairs.”²²)

One of the best actions women can take for themselves is to find effective mentors and sponsors. A mentor-mentee relationship is a long-term pairing whose purpose is to develop the mentee both professionally and personally. Mentorship traditionally pairs a senior mentee with a junior mentor, but other mentoring models, such as peer mentoring, can also be very effective. Mentors can be identified through informal channels, or through formal means, such as through Departmental mentorship programs or the American Academy of Dermatology Academic Dermatology Leadership Program (ADLP). Kim et al described recommendations from several participants of the ADLP for both mentees and mentors, and highlight what I believe to be one of the most essential points for mentees: be prepared. Entering mentoring meetings with specific questions or topics to discuss maximizes the value for both parties.²³ Sponsors serve to make key introductions or promote the sponsee in professional settings. Effective mentors are not always effective sponsors (though some serve both roles); there are excellent mentors who are not in positions of power or do not have access to the networks needed to promote sponsees.

Women do not need to be mentored exclusively by other women, nor should they be. One of my mentors, Dr. William James, believes that mentoring women is a key way men can contribute to closing the gender gap. He states, “Women's admission into leadership positions in our specialty lag below expectations, and men can facilitate entry to mentorship and sponsors at the senior level. Men have access to different networks and opportunities to assist accomplished, talented women gain positions of high visibility and responsibility.” Dr. James suggests one specific way that men can accomplish this is through sponsorship: recommend women for committees of power and influence, editorial boards, or positions that will increase their visibility. Men can also help ensure women are able to perform in a most impactful manner by assuring inclusivity is encouraged and that unconscious biases and micro-aggressions are called out and addressed positively. “Hear something, say something!” Dr. James provides the example: “If a woman is being interrupted I might say, ‘Wait a minute I would like to hear what Mary has to say,' or if I hear the interrupter out I could say ‘I still would like to hear Mary's idea'.”

Work-life Balance and Time Management

Given that the majority of women do not have a stay at home partner, Dr. Karolyn Wanat offers some suggestions for both men and women navigating the two-career household. She emphasizes that having a plan and communicating is critical. A simple intervention is sharing calendars, so that schedules can be coordinated. It's also important to be flexible and to try to accept that when families, and particularly children, are involved things often do not go as planned. Alternate scheduling for parents can be helpful. For example, if parents want to participate in school activities, have one parent work mornings and the other afternoons to accommodate school/childcare drop offs and pickups. Do not be afraid to ask for help, and outsource whatever you can, including grocery shopping, meal planning and preparation, and cleaning. Lastly, Dr. Wanat emphasizes that a key component of time management for any working parent is prioritizing. Whenever you are asked to do something, ask yourself, “Is this worth being away from your family for? Would you say yes to this if it were due tomorrow, instead of next month?” If the answer is no, then say, “No,” but suggest someone else. Suggesting someone else for a task tells the person who asked you that you value the request and gives you an opportunity to serve as a sponsor for someone else.

Summary

Women will soon reach equity in the dermatology workforce. Although women have the skills to perform at high levels in leadership in dermatology, there are many limitations still in play, including lower pay, lower job satisfaction, higher rate of burnout, and worse satisfaction with work-life balance when compared to men. Closing the gender gap in dermatology leadership is going to take time, and efforts not only by women but also by then men who support them.

Dr. Shinohara has no relevant discolosures.

This work stems from Dr. Shinohara's session at the 2018 Annual Meeting of the American Academy of Dermatology entitled “The Gender Gap in Academic Dermatology and Dermatology Leadership: Problems and Solutions.”

1. Pincus S. Women in academic dermatology. Results of survey from the professors of dermatology. Archives of dermatology 1994; 130(9): 1131-5.

2. AAMC Physician Speciaty Data Report. 2016. https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html.

3. Bae G, Qiu M, Reese E, Nambudiri V, Huang S. Changes in Sex and Ethnic Diversity in Dermatology Residents Over Multiple Decades. JAMA dermatology 2016; 152(1): 92-4.

4. AAMC. The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership, 2015-2016. 2015. https://www.aamc.org/members/gwims/statistics/ (accessed 10/25/18.

5. Zenger JF, J. Are Women Better Leader than Men? Harvard Business Review; 2012.

6. Dezső CLGR, D. Does Female Representation in Top Management Improve Firm Performance? A Panel Data Investigation. Strategic Management Journal 2012; 33(9): 1072 - 89.

7. Sadeghpour M, Bernstein I, Ko C, Jacobe H. Role of sex in academic dermatology: results from a national survey. Archives of dermatology 2012; 148(7): 809-14.

8. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of Hospital Mortality and Readmission Rates for Medicare Patients Treated by Male vs Female Physicians. JAMA internal medicine 2017; 177(2): 206-13.

9. Bendels MHK, Dietz MC, Bruggmann D, Oremek GM, Schoffel N, Groneberg DA. Gender disparities in high-quality dermatology research: a descriptive bibliometric study on scientific authorships. BMJ open 2018; 8(4): e020089.

10. Feramisco JD, Leitenberger JJ, Redfern SI, Bian A, Xie XJ, Resneck JS, Jr. A gender gap in the dermatology literature? Cross-sectional analysis of manuscript authorship trends in dermatology journals during 3 decades. Journal of the American Academy of Dermatology 2009; 60(1): 63-9.

11. Zhang S, Kim HY, Hill RES, Veledar E, Chen SC. A ten-year comparison of women authorship in U.S. dermatology literature, 1999 vs. 2009. International journal of women's dermatology 2017; 3(1 Suppl): S58-s61.

12. Gollins CE, Shipman AR, Murrell DF. A study of the number of female editors-in-chief of dermatology journals. International journal of women's dermatology 2017; 3(4): 185-8.

13. Carr PL, Gunn CM, Kaplan SA, Raj A, Freund KM. Inadequate progress for women in academic medicine: findings from the National Faculty Study. Journal of women's health (2002) 2015; 24(3): 190-9.

14. Cheng MY, Sukhov A, Sultani H, Kim K, Maverakis E. Trends in National Institutes of Health Funding of Principal Investigators in Dermatology Research by Academic Degree and Sex. JAMA dermatology 2016; 152(8): 883-8.

15. Medscape. Medscape 2018 Physician Burnout Report. https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235 - 5 (accessed 10/25/18.

16. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clinic proceedings 2015; 90(12): 1600-13.

17. Jacobson CC, Nguyen JC, Kimball AB. Gender and parenting significantly affect work hours of recent dermatology program graduates. Archives of dermatology 2004; 140(2): 191-6.

18. Westervelt A. Having It All Kinda Sucks. Huffington Post; 2016.

19. Shah A, Jalal S, Khosa F. Influences for gender disparity in dermatology in North America. International journal of dermatology 2018; 57(2): 171-6.

20. de Guzman Strong C, Cornelius LA. Preparing the next generation in academic medicine: recruiting and retaining the best. The Journal of investigative dermatology 2012; 132(3 Pt 2): 1018-25.

21. Shi CR, Olbricht S, Vleugels RA, Nambudiri VE. Sex and leadership in academic dermatology: A nationwide survey. Journal of the American Academy of Dermatology 2017; 77(4): 782-4.

22. Kimball AB. Sex, academics, and dermatology leadership: progress made, but no more excuses. Archives of dermatology 2012; 148(7): 844-6.

23. Kim CC, Kim EJ, Curiel-Lewandrowski C, Marks V, Maloney M, Frieden IJ. A model in dermatology for long-distance mentoring. Journal of the American Academy of Dermatology 2013; 68(5): 860-2.