Bringing Gender Diversity to Medical Education Leadership - Dr. Nancy Spector, Executive Director of ELAM

Michael Carrese: Hi everybody. I'm Michael Carrese. Even though women are the backbone of the healthcare system in the United States, comprising 77% of the patient-facing workforce, studies have shown they're not paid or promoted equitably and this gender equity problem extends to Medical education as well. 

Well, our guest today, Dr. Nancy Spector, is focused on improving this situation through her work as executive director of the Executive Leadership in Academic Medicine or ELAM program, which has been making an impact in this area for many years now.

Approximately half of all female deans at U.S. medical schools are graduates of the ELAM program. Dr. Spector has also been a professor and senior leader at the Drexel University College of Medicine for over a decade. We're very happy to welcome you to Raise The Line, today.

Dr. Nancy Spector: Oh, thank you. It's wonderful to be here with you. 

Michael: So, I want to start first just by learning more about you. What first got you interested in medicine and particularly Pediatrics?

Dr. Spector: Sure. I came from a family of educators. I was the first person to go to medical school in my entire family. I only had one brother. My parents were history majors. My brother was a history major. All day long, we talked about history and english and the conversation was about everything they were doing related to those subjects, and I was a science person. So, I felt like the odd person out. 

And so over time I thought, wow, I really like science, but maybe I'll be a science teacher. Then my parents, who both started as educators in the 1960s, said my brother and I could do anything we wanted in our lives and our careers, but we could not be teachers. They felt that teachers were underappreciated, undercompensated, not as well regarded as they felt they should be. So, they encouraged us to look into other things. My brother became a corporate lawyer and I went into medicine.

And I went into medicine not even knowing what medical school was. I remember in my first year of medical school learning that in your third and fourth year you did rotations and I had never heard of that before. So, I had a lot of growth and learning to do in medical school. Luckily, I went to a school that was very nurturing and encouraging and along the way, I found that I was incredibly drawn to children. I loved just thinking about their development over time. I loved how resilient they are when they're sick and having the opportunity to do preventive care, healthcare over time, was really what drew me into Pediatrics.

Then, my eyes opened up to academic medicine when I became a resident. I did my first inpatient medicine attending with a person named Dr. Daniel Schidlow, who is the dean emeritus of Drexel. He was my boss for over thirty years, and he was my first attending. He said to me at the end of the month with him, "You should do academic medicine." And I said, "I have no idea what that means." Again naive.

He taught me what that was, and I was encouraged to think about medical education, academics, and along the way, I met many people who were tremendous leaders who influenced me and helped me see a path in academic leadership and that's how I sort of had my entree into academia.

Michael: On the leadership side of things, what was it that drew you? You had these people there around encouraging you, but what drew you to the idea of being a leader?

Dr. Spector: I knew I wanted to be a medical educator. So, despite my parents telling me not to be an educator, I was drawn back to it, and they were actually thrilled when I found that niche area. I needed to learn how to be a medical educator. I was interested in medical education before there were master's degrees in medical education, before there was lots of formal training that we have today. So, I was directed to speak to other medical education leaders. One of the people I was encouraged to speak to was a person at my own school, Dr. Page Morahan, who told me a lot of the tricks of things to do to be a better educated medical educator, but one of the things she said to me is, "Nancy, if you want to make an impact and have influence, you need to have leadership training at every stage of your career and you need to learn how to do big change management."

Interestingly, the year I went to see her was the year she was creating ELAM. That was twenty-eight years ago. So, she really encouraged me and I was a rule follower -- I like to follow people's advice and direction -- so I did that and I became an ELAM fellow in 2009 and 2010 and my eyes opened up. It was transformative. All the opportunities there were to lead in a variety of creative ways, innovative ways I found very exciting. I learned about myself over time that if there was a big gap, I wanted to figure out how to fill that and make things better and influence the healthcare system and I could do that by helping others be the best possible at their job, whether it was in medicine clinically or in science. So, that excited me and I learned to love to lead, to be able to do that. 

Michael: Do you remember one of the things that opened your eyes about the opportunities and the innovation that was possible in leadership when you first were in the ELAM program? 

Dr. Spector: Yes, I do. I remember going to ELAM having had the experience the year before of being in my institution where there are a lot of things happening and everybody just sort of complaining all the time...not everybody, but many complaining -- and I know we tend to do that. But when I went to ELAM, I saw all these people flip it and say, "This is a problem, but what can we do to change to make things better? So it's just flipping that framework, and that I found exciting. I also found it eye-opening when a lot of very smart thoughtful people in charge of our accrediting bodies will decide there is a rule that has to be followed and if nobody's interested in leading, it just becomes a mess. So, I found I had a gift for stepping up and saying, "I'll tackle that. I'll take that on. But I will do it so that the intent is fulfilled. The goodness is fulfilled, and we'll move forward." Those lessons I did definitely learn at ELAM. 

Michael: So tell us more about the size and scope of the ELAM program and how exactly you go about trying to address this gap of female leadership in healthcare? 

Dr. Spector: We are in our twenty-seventh year. We have currently over 1,200 graduates of our program and those women hold leadership positions in approximately 400 institutions across the country, currently. 

Michael: Wow.

Dr. Spector: You mentioned a statistic of half the women deans are from ELAM. We have a new number, which is seventy-five percent of the women deans in the country in medicine are from ELAM. Eleven of our graduates were appointed as deans in this past year during the pandemic, which is remarkable. Having said that, our main mission is to create equity at every level of leadership in academic medicine and of all those women deans I just commented on women are only nineteen percent of the deans of medical schools in the country. So, to achieve equity we have quite a ways to go. 

Our mission is to bring people to the program -- we have seventy one fellows in the class this year -- they learn a variety of leadership skills, hard skills such as finance, negotiation, etc. They also learn a lot about their own professional development, and they are paired in groups of six women so that they can build their network within a small cadre of the class, but also across the class. 

When they graduate, they enter into the 1,200 other graduates in a network that is incredibly powerful. We hope the power of that network will help lift all women up -- not only the people who graduated from our program, but also all the other women in the country. One of the things we've added in our recent curriculum is to ensure people have the tools to go back to their own institutions to make big change. 

Michael: So, what are some of those tools?

Dr. Spector: Strategies to do culture change. We teach them a lot about organizational dynamics. We give them just concrete tools to help mentor others. We open their eyes to concepts around sponsorship and allyship and encourage them to build programs that will support sponsorship and allyship for all, but in particular women with intersectionality and women who are underrepresented in medicine. 

Michael: So, when you're making the case to people about why it's important that women are in leadership positions in medicine, what is it that you tell them? What is the particular strength or difference or impact that women make as leaders in healthcare?

Dr. Spector: Well, women add a diverse perspective. We know a lot from the business literature -- we are always sort of looking at the business world for strategies to improve diversity and things like sponsorship and mentorship programming -- women have a different perspective. We know that more diverse teams have better outcomes. Right now in our structures, most high-level leaders are men and many are white men, and so there isn't that diversity of perspective. Also, if we're thinking about the fact that 77 percent of the workforce are women, but they're being led by men, we find that that can be a bit challenging. The people at the table making the decisions are not the people who are on the front lines or the mid-levels. 

Women will help in sponsoring others. It's shown that women are more likely to sponsor others, particularly women, than men. So, we have a ways to go. There are challenges for women in leadership. When women are appointed into leadership positions, they're often the solo woman, so they're a little bit on their own. They are a little bit more vulnerable. If they make a mistake, it's very visible. Unfortunately, it's not always the case that women of high-level leadership will help other women in high-level leadership. There are a lot of structural things and issues that we have to work on to support women to advance. 

In terms of women in the workforce, there's a lot been that has been written recently about patients who are cared for by women having better outcomes. And so yeah, we do want to support women in all levels of our academic and healthcare structures.

Michael: As the son of a nurse, I will endorse that completely. My mother always said the same things. (laughs)

Dr. Spector: Great! (laughs) 

Michael: So talk about the program itself a little bit. Obviously this networking thing is very powerful once they are graduates of the ELAM, but when they're going through the program what are some of the core things that folks in this program will learn?

Dr. Spector: I should mention it's a year-long program and it's part-time. The cohort will come together to do in-person learning and then apply things in their homework places. There are four curricular threads. One is on finance and resource allocation, which is something we don't learn about in medical school or in any of our professional schools. But you need to know the business of medicine and in particular now we really need to know the business of medicine. So that is is a critical component of the fellowship. 

The second is the personal and professional leadership effectiveness work. There are a lot of components to that, and a lot of it is a reflection on yourself, receiving 360-degree feedback. Each fellow is paired with a professional coach that they work with to do improvement on their own leadership effectiveness and style.

A third area is organizational dynamics. To make all those changes in your institution, you need to be very facile at that. For those of us who are doctors, we know that we don't like change. We always say we want change, but it's challenging to change. 

Michael: (laughs)

Dr. Spector: And then, the fourth part is those communities of leadership practice...those little groups of six. Women, by the way, under-invest in social capital. So, women need sometimes extra help learning how to do networking effectively to help support not only their own growth and development as a leader, but also to support efforts that you need allies and colleagues to make the change happen. So, you need to learn how to do that well.

Every fellow does an Institutional Action Project as part of the year. That is a project that's not related to their typical scholarship or science, but it's a project that their Dean and other high-level leaders decide is going to be really important to move the school along in its strategic visioning. The fellow will apply all those skills as they work through that project and the project also helps raise their visibility in the institution as they do that project. So, they can apply skills and get more visibility and do something very impactful for their organization. 

Michael: That's great. Obviously, this has been a very difficult time for women in the workforce because of COVID. So, talk about that a little bit as it pertains to the leadership picture that you pay particular attention to, but just broadly, what's going on with women in health care because of COVID?

Dr. Spector: Yes. So, I was thinking about your mom who was a nurse. I mean, there's a challenging nursing crisis right now. Nurses are leaving the field. People are burned out. The staffing shortages are incredible, which puts stress and strain on the entire system. I just had a call with several leaders in our organization where many hospitals are on divert. Hospitals, again, are not doing non-emergent surgeries, etc. So, there's just the constant stress and strain. 

We are seeing women at mid-level career leaving the workforce, which is terrifying because that's our pipeline. Anecdotally, my colleagues who mentor many women of color, they're seeing a disproportionate number of women of color -- so, women with intersectionality -- leave the workforce which is extra, extra terrifying. We know that women are often the primary caretakers of young children at home or elder parents or others in their families as they're still trying to juggle everything that they're doing in their day-to-day.

Often, they're the ones also responsible for doing things at the front line, leading at the front line. There are a lot of challenges. So, that burnout and women leaving the field is very concerning and alarming and we're doing everything we can by working with others across other organizations to see how can we partner and get out of our silos to work together to support women. 

Michael: Do you have some thoughts about what might turn some of this around? I mean, there's a lot of talk about retention bonuses and some other tactics like that...

Dr. Spector: Yes. So, there are organizations that are looking very carefully at ways to support women. They're opening their eyes to the idea that women are overly burdened and at risk, and what can those institutions do? There are some funding agencies that have been providing awards to institutions that are innovative and creative and thinking about ways to have daycare backup for providers, for instance, or to do things to change the timeline for promotion, for instance. Many of our schools have tenure clocks and promotion track clocks that we're trying to figure out ways to change to support women. We are recognizing already that women are not writing and publishing at the same rate as they were, and disproportionately to men. So, being aware of that, and thinking about how to support women so that they can do their academic scholarship work and don't fall behind.

Michael: Because that can be a factor in holding them back from promotion, right? If they're not publishing...

Dr. Spector: Absolutely. Yeah, it's all linked. And then, that gets really discouraging and that adds to the burnout problem.

Michael: Staying with the burnout theme for a second, we've heard a lot about frontline provider burnout, obviously, but what about burnout at the leadership level? What are your thoughts on that?

Dr. Spector: Thank you for asking that. It's something I have been very worried about in the last four months, in particular. I remember feeling in the fall this shift of my colleagues just doing everything they could to do the leadership well, to pivot, pivot, pivot; support, support, support, and all of a sudden I started seeing the fatigue, the actual fatigue, on people's faces and the exhaustion. I think it's real. We have been in a command-and-control leadership mode for a long time over emergencies. We're in that place again with this most recent round of COVID, and that's exhausting.

It's also discouraging when you can't do more proactive leading. So, we're reacting, reacting, reacting, and that's exhausting and you don't feel like you're making a forward progress. You feel like you're surviving. So, I am very concerned about that and I'm seeing people leave leadership. On the one hand, that will give opportunity for succession planning and new leaders, but on the other hand, it's definitely alarming. And we don't like leadership changes. It causes uncertainty and stress in our organizations. It's better when it's planned and succession planning is organized in a very thoughtful way. 

Michael: Well, nobody is in a position where they know when this is going to end and when they will be past the crisis. So, you can't start figuring things out from that perspective.

Dr. Spector: Exactly. And every time we think it's getting better...we all collectively had a big sigh of relief and sort of excitement in the summer, and then that went away. Then we were starting to feel better again in December. I was surprised in the November-December time, people were starting to open up in-person meetings again, big conferences that are very energizing for us as professionals. I started getting invited to in-person events, and then all of a sudden now we're pivoting again and I don't know how that will go. And so, yeah, we're going to have to think of how we're going to sustain ourselves through these big waves of new uncertainty. It's challenging. 

Michael: We're coming up on time and want to make sure we leave time for one of our favorite questions on the program -- our guests seem to like providing the answers anyway -- which is, we have a lot of medical students and early career health professionals listening to this. What advice would you give to them about meeting the challenges of the moment -- everything we've been discussing and more -- and also about just more broadly approaching their career in healthcare?

Dr. Spector: I think it's still the best profession to be in despite all the challenges we just talked about. I have been energized by the excitement, ideas, and commitment of our medical students as we've gone through this time. They're not running away from helping. They want to help. They are creative in thinking about strategies in Diversity Equity and Inclusion efforts; strategies to do the immunization campaigns for COVID-19; they are ready to pitch in when we have staffing shortages.

Their enthusiasm and energy and commitment, I think, are helping those of us who are more senior to remind ourselves why we're doing this work. Thank goodness, we have so many young people coming into the field. I'm sure you've spoken about it with others...there's a phenomenon we called the Tony Fauci Phenomenon which is the number of applications to medical schools is like skyrocketing. The number for our school went from 14,000 for a class of 300 to 17,000. 

Michael: Oh my goodness. 

Dr. Spector: Yes, so very strong interest in going into medicine. I'm very excited about that. In terms of thinking about your own career, it's finding your passion area. That's what gives you joy. And it doesn't mean that every day, all day long, you're working where you have the most passion. But if you find that sweet spot -- either it's clinical care or some administrative piece or teaching or science -- it is not a job. It's just a joy to do what we do every day.

Michael: Spoken by someone who sounds like they found their sweet spot.

Dr. Spector: I did. (laughs) 

Michael: (laughs) Well, I'm glad to hear that. On that note, I want to thank you very much for being on the show with us today, Dr. Spector.

Dr. Spector: Thank you. Thanks so much for having me.

Michael: I'm Michael Carrese. Thanks for checking out today's show, and remember to do your part to flatten the curve and raise the line. We are all in this together.