Proportionate to the numbers, few women manage break to through the glass ceiling in health care and end up having to both lead and manage from below. In the US, whilst almost half of medical school graduates are women, less one in five of these women have positions as full professors and permanent department chairs. In Canada, the first female dean of a faculty of medicine was appointed in 1999 and there is still just one female dean in the 17 faculties of medicine. In the UK, only two out of ten chief executives of the largest teaching hospitals are women and in international centres of excellence such as Oxford, the situation is exacerbated. Women are rarely appointed as leaders of large organisational units either in university or hospital environments. However, they are relatively well represented as the leaders of smaller organisational (lower-level management) units.

Changes are occurring, but they are slow and often peter out before the critical mass of women required for sustainable change is achieved. Also, as our health systems become more complex, the pathways to the top become more obfuscated.

Women lead and manage from below. Trapped in professional purgatory.

Why don’t more women get to job heaven? Firstly, there is the issue of selection. Women who apply for senior positions in health care perceive the recruitment process as unclear and not transparent. They question whether there is an unconscious gender bias in recruitment, which is precipitated through informal hiring strategies. Many women are hired through informal processes, such as having positions created by mentors or colleagues, usually to run a specific program in their research specialty.

Another part of the problem is that healthcare is a unique environment, where the boundaries between leadership and management often blurred; especially for women. Leaders create vision and strategy, communicate, motivate and make effective plans. Managers enable the leader’s vision. Management is the more practical arm and that is why it is often delegated to women. So, women end up having to both lead and manage from below; trapped in professional purgatory, often with vague titles that imply a leadership role but are really only involve management and are paid at a lesser rate.  Some women work this way for years; in acting positions. Finally, an “outsider”, usually a man is given the top job.

Then there is the mid career paradox. Flexibility, which is the hallmark of women who have reached middle management and aspire to greater things, is also their downfall. Successful juggling of jobs, families and households requires a lot of resourcefulness. However, divided loyalties can also suggest a lack of the excessive commitment to work which is supposed to make a good leader. There is no evidence that women are less committed.

Even for the most dedicated, it is difficult to follow a pathway without a map or a guide. Women in middle management need more of both.