Episode 47: Seeking Gender Equity in Healthcare Leadership
Although the healthcare workforce is overwhelmingly female, women are underrepresented in leadership roles. This month, Mike and Heather discuss this phenomenon with Gayle Capozzalo of the Equity Collaborative. A former executive at Yale New Haven Health, Gayle provides insights into the cause of the disparity and offers a leadership pathway for women.
Mike: And I'm Mike Clark. Heather and I are practicing physicians who participate in the MaineHealth ACO.
Heather: In this episode, we explore solutions to a persistent issue in managing health care systems, the lack of gender diversity among leaders, and the barriers faced by women seeking leadership positions.
Mike: Yes, this is definitely a meaty topic, so let's dig right in.
Heather: As we have been celebrating the International Women's Day and Women's History Month in March. And I was observing what was going on around me, I started thinking about the role of women in medicine and health care. Women have really made great gains among the ranks of health care providers. The percentage of physicians who are women have grown from 7% to 36% in the last 50 years. And certainly, in my graduating class, we were about 50/50. But in 2021, only 15% of health care CEOs were women. And let's not forget about the entire health care workforce as a whole is 76% women. So, the question is, where are the women leaders?
Mike: Yes, a critical question. And to explore this, we've invited a special guest to the show. Before her retirement, Gail Cappuzzello was executive vice president for strategy at Yale New Haven Health. Today, she's the executive director of the Equity Collaborative, a program of the Carroll Emmet Foundation. The Equity Collaborative is a learning community of large leading healthcare organizations committed to gender equity within their own organizations and across health care. Members of the collaborative include Tufts Medical Center and Dartmouth Health.
Heather: Hi, Gail. Thank you so much for joining us. It's an honor to have you here.
Gail: I'm delighted. Thank you.
Heather: Wonderful. I was hoping that we could start with really talk about what inspired you to do this work on solutions to gender inequity in health care leadership.
Gail: That warms my heart that you asked me that question, Heather, because this is something that I have been involved in my entire career. I was very blessed with having women help me. I worked for Catholic Healthcare, so it was primarily when I entered Catholic Healthcare way back in the 70s. I used to call it the nuns and their boys because the only there were no women laypeople. And so, as I started with the healthcare system, I became Sister Gayle in no time. But those women mentored me. They showed me the importance of helping each other out. They showed me the importance of spotlighting each other. And so, I gathered a group of women as I built networks and said: health care is really, really a good, a wonderful, wonderful calling. And everybody's called to health care. Whether you're an administrator like I am, or a physician like you are, or a nurse. So, all of that was 76% of women, of health care workers being women, it was easy to find people to mentor. And it became something that I was really excited about, involved in, to help spotlight, amplify and give women the opportunity to move forward more quickly.
Heather: Fantastic. That's really inspiring.
Mike: I'm wondering also, Gayle, you know, we know implicitly we understand that diverse leadership is really critical for organizations to really thrive and for the people within them to thrive as well. How would you describe the benefits sort of implicit to leadership diversity?
Gail: Mike, that's such a good question. And fortunately, a ton of research has been done about it. So implicitly when you just think about it, when you have people in leadership that are diverse, more employees can look up and see someone that looks like them, that talks like them. That helps in employee engagement automatically. And you think about that. You think about any time a leader runs for office, you know, you identify more if they look more like you. But the data show that, in truth, diverse leadership number one for business has much better financials, much better return on investment. But why does it have that? Because employees engage more, because employees feel better about themselves. And when they engage more, they're more conscious about the patient. And when patients see employees that look like them and see the leaders that are rounding that look like them and see the physicians taking care of them that look like them, it produces in them a feeling of confidence. And Heather knows better than I, when a patient's attitude is right, it helps in the quality and how quickly they get, they get well. So, what we know is diverse leadership helps financially, patient care experience, patient care quality. And that's because employee engagement is so much higher.
Mike: Mm hm. That makes so much sense.
Heather: It really does. That is so interesting. And, you know, one of the things that I have experienced recently is that I've been part of a physician leadership team where I noticed that I was one of only two women who were part of this leadership group. And when I hear you talk about the importance of having diversity and getting employee engagement, I'm just wondering, one, how typical is it for physician leadership to have a small representation from women and really the impact of that?
Gail: How typical is it? At least you weren't an only because before you got on that team, there was an only.
Heather: That's right.
Gail: It's really hard to be an only, whether that's in gender, or race, or language anything, it's hard to be an only because automatically you represent everyone. And the reality is you don't. You represent you, but your colleagues put on you the fact that you represent everyone, which causes a lot of responsibility and causes people to be feel that they have to watch every move they make and aren't really their authentic selves. But is your experience unique? Absolutely not. When you look at the surveys, 76 to 82%, depending upon which survey you look at of the health care field, industry, is women and more and more of those are clinicians, our physicians. And yet as you climb up the ladder to manager, to leader, to director, to executive director, to vice president, to senior vice president, on and on up to CEO. Women decline dramatically. And if you look at the average C-suite for health care system or large medical group, roughly the same between 20 and 24% are women. But if you look at diversity, it's less than 3%. If you look at black people or people of color, especially women of color. But when you think about that, that lack of representation has to be addressed objectively, because you can't just continue the old ways and expect it to change. It just doesn't happen. The only group, and you can guess, but the only group (demographic group) that grows in size, from entry level of the health care system to senior level of the health care system, are white males. Everybody else declines. So, it is something that we have to really work on, but it is typical.
Heather: That's so interesting.
Mike: Yeah. So, building on that, what do you think then are the biggest or most important barriers to women becoming leaders in health care organizations today?
Gail: I think there are two sets of barriers, and we can talk about them because one is really organizationally focused, and the other is what society says to women, particularly women who work outside the home. And even though it's not the 1950s anymore, and even though women have been working out of necessity, far less out of career development and career growth, there is the constant idea that women must have two jobs. That women must, if they're going to work outside the home, they better be prepared to work inside the home, and they better be prepared to organize the children. And they're the ones responsible for that niceness of the home for the family, and how well the family gets on, and how well the kids do in school. And it's something that society has done to women forever. And it causes a feeling of when you're on your own and not married, you don't have that family feel but you have this thing about: oh my God, do I need to get married and have kids? Because society again says you've got to be pregnant between 24 and 32. So all of these issues that society, particularly American society, puts onto women, makes it more difficult. And when you think of the hierarchy in medical groups and the lack of support in medical groups for women to climb that leadership ladder, it's even harder. There's nothing more hierarchical than medical schools and medical groups, and it takes even more inner strength and networking, networking among women, to move forward and make a change in that.
Heather: I would say, too, even beyond networking, is to know that it exists. You know, my experience in med school had nothing to do with any of this. And when people asked me about moving into leadership, honestly, part of me was just like, you know, didn't realize that that opportunity was even there.
Gail: Your point is so well made, Heather. Hence, if you look until recently, if you look at medical leadership, they were white old men that are finished; You know, "It's too painful taking care of patients every day. It takes too much out of me or maybe I'm not at the same capability I was to be a surgeon." And we always tease the pediatricians: just couldn't take kids because they have two patients every time, they talk to someone. So, they're the ones that go into leadership. It's not taught in medical school; it's not taught in residency. And so, it was an evolving thing. Lots of older, primarily male physicians, entered that. And without MBAs and the way you all are taught, or you particularly were taught, the curriculum is changing, but the way you were taught it wasn't about leadership skills, team skills. It was the buck stops here, which is not the best way to solve a leadership problem.
Gail: We have to change what medical students and residents are exposed to as they work through their medical education to make them aware of it, and to make the idea of medical groups and the piece of your income to come from leadership. Right now, up until about ten years ago, you had to give up patient care; that was your primary way of making money. And even, we used to charge RVUs to the leadership time you spent, which trading RVUs rather than putting someone on salary, or how we decided what that salary would be based upon how many RVUs they had to give up, to move in. And guess what? The surgeons and the people that are paid higher, made more money. So, it didn't encourage the cognitive specialties to move toward leadership.
Heather: Wow, interesting. You know, one of the things that you and I had talked about in a separate conversation was mentorship versus sponsorship. I wonder if you could talk about that for a little bit here.
Gail: Sure. There's a saying that women are over mentored and under sponsored. So first, what's the difference between mentoring and sponsoring? The easiest way I like to talk about it is: mentoring is a mutually beneficial relationship that you learn from each other, and it's internal. And a mentor will say, you know, "Heather, how are you feeling today? What's your challenges?" And help you solve problems together. But they're focused on each other, and very often if I were mentoring you, I'd learn a lot from you by understanding the issues that you're raising. But a sponsor is different. A sponsor is someone that knows you. You can't sponsor someone without knowing them, but their job is to amplify you, and to tell the world about you, and to give you opportunities to do things within the organization that you don't, that you wouldn't be able to do. For example, to put you on a committee, put you on a selection committee, put you on a special project, that shows the hierarchy within your organization "Wow. Look at this. She's really good." And then to talk about you when it's time for promotion. "What about Heather?" That men have been doing forever. It's they go golfing together. They talk about work together. Women's networks usually talk about personal lives rather than work. And men's networks do both that they much more talk about work stuff. And so that creates the idea of "Oh, CEO wants me to go golf with him. Charlie, you want to come along? We need a foursome." But it's rare that: "Hey, Heather, you want to join us." So, that sponsorship is really important, and it has to be intentional for women. It has to be real. And for people of color. It has to be intentional.
Heather: That's interesting because it sounds to me then, that sponsorship is one of the important parts of creating pathways for women to make strides towards more leadership positions. Are there other things that are important as well?
Gail: Yes. Sponsorship and mentorship both are terribly important. But there's a lot of other things that an organization, regardless of the social pressure on women that we just spoke about, an organization has to choose to do differently if they wish to have greater diversity in leadership. And the number one thing is: when you are hiring, selecting and promoting people, you can't use the word, which I'm sure you've heard a million times, 'cultural fit.' They just don't fit. Or, wow, this person fits. Because guess what? If you fit in an organization that primarily male dominated, you're going to be a male. The same thing goes for race. So, organizations have to first just take the selection process. When you put a selection committee together or you're training your managers to recruit and select people, you need to make sure they have bias training because people don't recognize how bias, that affinity bias, so liking someone that has my background, my experience, is so strong inside. "You connect," Quote unquote, much more than if you're talking to somebody that came from China, or somebody came from Minnesota, and you're from Florida, and they have completely different life stories. The reality is you have to do bias training with that group doing the hiring, and then you have to say: what are the competencies and skills we want to hire on? Competencies and skills and values, not fit. And you have to take that information, translate that information into questions, and then you have to objectively ask the same questions of every candidate. And when you do that, and you literally score as opposed to: "Boy, I really liked her. I connected with her." All of a sudden, it's hard to defend your choice if you didn't score it objectively. And we have found, over and over, and over again, all of a sudden, organizations are hiring more women, more women of color, and more people of color whenever they do that, because it takes away that "they're just like me" and addresses that affinity bias.
Gail: Another thing you can do, and organizations are beginning to do it, is do diversity and bias training for everyone, but then hold them accountable in their performance reviews to do something different about that. How is your leadership skills changed? What questions do you ask of your staff today that you never ask before? How present are you for them? What do you know about your staff? What leadership pipelines are you putting together within your department? All of those kinds of definitive, deliberate actions will change the organization in leadership, but it will only do it if the leadership of the organization makes that true commitment that we're going to set our goals. And we're going to have goals that are process goals, not just outcome goals. Because if you don't change the process, the outcome can never change. And just putting quotas on it without changing the process, doesn't really end up where you want to be in changing the culture. So those kinds of goals and holding leadership accountable for attaining those goals, and training but training with action can really make a difference.
Heather: That's so interesting. I'm curious if you have an example of where this has already been successful or is moving towards being very successful in creating some more gender diversity, even if you don't want to use exact names, but just an example of how this would work?
Gail: Yes. So I will tell you first I'll start just broad. We have the Leadership Collaborative, which I have told you about. It's a group of 14 large health care systems that about five years ago came together and said, we really want to work on gender and racial diversity within our leadership. We're too white or too male, and we're going to do something differently. So we put together this collaborative. They meet four times a year. They talk about things that are important to them. They decide what to talk. It has to be a C-suite person from each one of these health care systems. And they're large. They're big academic health care systems, big community health care systems. They're like Yale, New Haven and Tufts and University of Chicago and Sutter and HCA and City of Hope and Marshfield Clinic. They're all over the country and certainly not telling you everyone just because I can't remember off the top of my head. But anyway, their leadership said: we want to do this. So they started using, many of them put into place that objective hiring process I just told you about. Others looked at all of their health care, their human resource policies, and we brought in a specialist to say: Whoa, these policies are so unfriendly to women and to people of color.
Gail: And they revised their policies and then we measure. So each year we measure the representation of leadership across their entire system. And those with large medical groups do separate survey within their medical groups. So who's in management, who's in senior leadership? Who what do they look like from a representation of gender and race? And each year we measure it and we now have everybody's gotten better. And that group from this, we use the Women in the Workplace survey from McKinsey, and that group outperforms all of health care. So it can be done. It really can be done, but it can't be done serendipitously. It has to be done with intention. And I think when you look at who's graduating from medical school, when you look at who's who, employees want to see lead. And now as you take on generations of people that are not running at that, you do it and you do it because I told you. We didn't raise kids like that, and my kids didn't raise kids like that. It has a very different perspective. Women are much, much more able. The data show us to network, to cross generations, to create an environment of collaboration rather than top-down leadership. And that's what people want to be engaged and that's how patients want to be treated.
Mike: So, Gail, as I think about my interaction and engagement as a as a male. What advice do you have? I mean, I like many you know, I want to do the right thing. I whole heartedly endorse this, but I know we all have blind spots or we all have, we all stumble on our efforts to change or to reach out and engage with people. Do you have any advice for people like me?
Gail: Oh, Mike, thank you for that question, because we certainly can't do it just as women, male allies are essential to changing and increasing the diversity in leadership. And by being a male ally, you are the white male ally that we need the most because you're in power. The reality is you have the power and you have to create a situation where you personally recognize that. So the men that are the best allies that we're working with in the equity collaborative have all done real bias training. They all look and ask the questions: Is this person being promoted? On what criteria? On how they're inclusive. They're willing to say, I need to change my management style. I need to reach out and not just rely on my typical network. I need to have women in my network. I need to have people of color in my network. And boy, every one of the organizations, the vast majority of the organizations now and the equity collaborative are led by men, but they are allies. And I hope that every man in health care can become an ally and medical school because it's so important to recognize the change over time and be the leader that you always have been and just the different style.
Mike: Great. Thank you.
Heather: Gail, thank you so much for joining us. We have learned a ton in this short period of time and really look forward to hopefully future conversations so that we can continue to grow and develop our own organization here. Thank you.
Gail: You're so welcome. Thank you for the opportunity. It was just a pleasure.
Mike: So thanks for listening to BACON this month. You can find all our episodes on your podcast app and at our web page, MaineHealthACO.org/BACON. And if you have questions, comments or suggestions, we really would love to hear from you. Please email us at email@example.com. That's firstname.lastname@example.org.
Heather: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us. See you next time.
Mike: See you next time.