Thanks so much for this invitation and I'm happy actually to spend my morning with you guys. So I have a few disclosures. I do have funding from the NIH CDC for research and clinical trials networks I do lead. I do receive DSMB fees as well as fees for scientific advisory panel. And I do have an intellectual and personal conflict of interest in that I am a female director of a critical care organization at Montefiore Medical Center. I have to admit when I was asked to give this talk I was a little bit unclear about what I should be talking about because to some degree, you know, I don't know that there's any difference between a man and a woman and their role as a director of a critical care organization. We have the same responsibilities, the same pressures, the same obligations and the same barriers to the things that we need done and the same mission with regards to a critical care organization. But when I thought about it more, I thought actually this might be a good time for me to reflect a little bit about women in leadership roles in critical care and how that might actually relate to the mission of critical care organizations and what we women in these leadership positions may face. So I thought actually to start with, I should educate myself, which is that I actually didn't even know how many women there are that serves right now as directors of critical care organizations. So first I looked to the literature and the landmark article from our very own Steve Pistorius here as well as my predecessor, Vladimir Kvitin, which surveyed critical care organizations in North America and found actually that 96 percent of them were led by male directors at that time. Now this was in 2015. So I wanted to see actually what's more recent, whether we see a little more improvement. So I kind of looked up all of those organizations that was there as well as actually try to find organizations that have sprung up since then. Now it's not nearly as well done as what Steve did in his, and I can't verify that they truly met all of the criteria for a critical care organization. But from what I can find, 25 percent of them now have women as either the chief or directors, which is an improvement from 2015. But how does that compare in terms of actually women representation in critical care workforce? And there we still seem to lag behind. The numbers are actually still a little hard to get in terms of actually how many women are in critical care right now, but it ranges anywhere from about 26 percent to more likely actually 40-something percent now, and it depends a little bit on the country and whether you look at like senior women, trainees, and so forth. So there's still a bit of a lag between actually women serving in the critical care and directors of critical care organization. But how is that different than actually other leadership roles in critical care? Well when you look at actually speakers, and I'm fortunate here to be speaking with you, but when you look at actually how many women comprise speakers in professional societies in national and international conferences, female physicians only make up somewhere between 12 and 21 percent of the speakers, even as actually their membership that are attending those conferences are actually more than double that. It's a little bit better if you actually can count the allied professionals. What about actually editorship in terms of high-impact journals in the sub-specialties? Well it turns out actually critical care medicine ranks among the bottom of all of the sub-specialties in terms of female editors-in-chief of their journals. So what does that then mean and what are the implications are for the missions of the critical care organizations? That was so well elaborated by my colleagues here in this table and what that challenge might be to women in the roles of directors of critical care organization. So let's talk about one first thing here that was so elaborated by actually Craig, Jason, and others that have talked here. The mission to provide consistent high-quality critical care to improve outcomes. Well the way we have done this, and this was mentioned by Craig, is that we oftentimes will implement protocols, policies across the system based upon evidence-based medicine. Well these evidence-based medicine usually comes from critical care task force as well as clinical practice guidelines that are published. And these are extremely influential groups in the sense that actually they are considered the leaders in the field and they actually set up and has high impact on clinical practice itself. But when you look at actually female representation on these groups, only about 0 to 16 percent of the membership of these critical care task force are women. And in clinical practice guidelines, only about 20 percent of the members, the authors on these clinical practice guidelines are female physicians. A little higher if you want to count allied professionals like nurses and pharmacists. But critical care ranks among the very bottom of the sub-specialties in terms of female representation on clinical practice guidelines. Now this has implications for a critical care organization. So I've been fortunate to serve on a few critical care task force as well as clinical practice guidelines. And I see actually the benefit in a few ways. Being a director of a critical care organization, when I serve on these guidelines, I bring in different perspective. Not just the research that I did, the clinical trials that were published, but also actually the practical aspects about implementation and value to the institution across a system when we're talking about certain evidence-based practices and how it gets implemented. And as such, that kind of a voice lends a very important input into how actually these panels' recommendations are crafted and how the discussion is made. And the other way works too. When I go into my institution and now I'm implementing a practice that's across the entire institution, I come in from a sense of authority and heft, if you will, because I have worked and served on these panels. Jason had talked about actually the importance of the academic mission within the critical care organization. And that's extremely important with regards to membership on these panels, partly because it raises the visibility and the academic heft of the critical care organization within your institution, but it also raises your institution into the national, international environment in terms of actually the headways they're making with regards to critical care. Now the other reason we implement evidence-based practices and policies across the board is that it helps standardize this consistent delivery of high-quality care and reduces disparity. And that is because we still see disparities, and we do still see gender disparities in acute management of patients. Women have taken longer time to antibiotics and sepsis, and fewer women complete the sepsis bundle in the emergency department. And women are less likely to get mechanical circulatory devices, ECMO, dialysis, and other invasive interventions. But there's also actually evidence that it's not only just women patients getting less of these things, but that there may be differences in terms of actually care that's given and outcomes depending on whether the women is being treated by a male physician or a female physician. Female patients with heart attacks treated by female physicians have a greater survival than female patients treated by male physicians, but the same was not true when it was male patients treated by male physicians. And the same was also seen with regards to surgery. Outcomes were better when female patients were treated by female surgeons than when female patients were treated by male surgeons. And the same was not seen when it was male patients treated by male surgeons or actually male patients treated by female surgeons. Now that's not to say, actually, that we should, you know, eliminate one gender or another from physicians, but it does bring pause to think about, well, why is that? What's driving some of that? And there's a lot of different reasons that can go into that. But one of those reasons that's a little controversial, but that has been seen in multiple, multiple studies and reports, is the presence of implicit bias in medicine. Now implicit bias is something that is common. This is not specific to any one individual or race or gender. We see it across all races, and we see it in men and in women, okay? It is inadvertently acquired, not because of your beliefs or anything like that, but because of the culture, the environment, the education, and the experience that you come from. Okay? We're all a product of what we've been through and what we have experienced. And that comes through in how we actually regard evidence, how we look at data, how we interact with others. And there's increasing number of data that shows that implicit bias can affect clinical decision making. And unfortunately, diversity training has a limited utility in reducing that. So what has been found to be more useful? Well, it turns out that the most effective way to decrease some of these implicit bias and these disparities is by increasing the cognitive diversity of the group making decisions about care, about how a policy is run, about management, about leadership, all of it. And what does actually cognitive diversity do? I mean, what it is is that it brings in people with different perspectives, that brings in a different point of view so that it helps the rest of the group reframe how they think about things with regards to certain situations. And it's been shown that increasing the cognitive diversity, and the easiest way to do that is just increase the number of women and minorities, underrepresented, into the decision making pool. Increasing that diversity of thought can increase and improve performance, problem solving, decrease disparity, and avoid this group think that might come about when everybody in the group making decisions all think about the same thing and come from the same background. Now I have to say, this is not new to critical care organizations. We have always known that one of the benefits of a critical care organization is the multidisciplinary approach to the care management of our patients. So just think about this not so much in terms of a multidisciplinary approach from different types of providers, but also in terms of actually physicians, clinicians from different backgrounds and different perspectives. And then that leads to the next thing that was talked about by Jason. Well then how do we increase this diversity? And that leads to our mission to educate and train the next generation of intensivists and to promote the professional development of critical care providers, our academic mission. We now see actually, fortunately, that we have been seeing an increase in terms of women applying for critical care fellowship. So that it's comprised actually about a third to 38, 40% of applications to permanent critical care and critical care fellowship. This has improved, however, it still lags behind the pipelines of residencies in like medicine and like anesthesia that usually leads into critical care, where the percentage of women is closer to 50%. So why is it then that women are not necessarily going into critical care or electing for it? And there's been actually qualitative studies that have looked at perceived drivers of this gender inequity. And the most common themes that seems to come out from all of these interviews are a couple of things. One is a predominantly male leadership that perpetuates the recruitment, selection and promotion of men over women. And this feeling of a positive women in leadership and role modeling position that creates an impression of limited success. Now you can see the problem here, right? This is like this, just this, you know, roller coaster that doesn't end or just merry-go-round that go round and round. You don't, you know, the women don't see women as leaders, they only see men as leaders, they think the men won't promote the women and then they don't want to go into it, which then leads to a small pool from which that you can select to be able to have women to be leaders within their institution. So this actually means that the only way you can break this is by actually improving the diversity of representation in critical care. Now does it mean that just having a female chair or a female, you know, director increases representation? Did they solve the problem just by hiring me? It's not that simple. So this is a study that was done by Haley Gershengorn, where she looked at actually the association between the percentages of fellows and residents who are women and whether they correlate to whether or not the chair or the chief of the division is female. And what she found was that there wasn't a significant correlation. And that other things like, you know, where you are, the East Coast, for example, versus like the Midwest or the South, and a specialty like cardiology and critical care versus say, you know, infectious disease seems to matter more. But take a look at a couple of things. One is if you actually look at the estimate size, they're all in the right direction, meaning women chiefs tend to have more women fellows and residents. It just wasn't statistically significant. And if they had actually included more programs and gotten out of internal medicine, they may have actually seen a difference. In addition, when you think about it, like who does the residents and fellows interact with? They don't actually interact with the chief on a daily basis. They tend to interact with whoever they are seeing and working with at the bedside. So when they looked at actually female fellows and whether or not it influences the percentage of women in the residency of the same programs, they did see a significant correlation. The more women fellows there are in a program, they also tend to have more women residents in those programs. And then you take a little step up. Well, what about higher up in the leadership? It turns out that if you have a female chief, you're more likely to have female leaders in that division. More than half of the programs that have a female chair or a chief also have a female fellowship directors. And this was true regardless of the specialty and where they're located. And this sense of sponsorship and mentoring comes through in other things too. So in terms of authorship on critical care publications and manuscripts, if the senior author is female, there is a much higher likelihood of another female either being a middle author or being the first author. And this is important because female publications, you know, female authors on critical care publication has been increasing at an agonizingly slow rate. So it looks pretty flat in this picture, but it actually, it's just that it's slowly, slowly improving. And that is concerning in terms of applications for critical care organizations, right? In terms of the academic mission, in terms of our leadership in our field, you want to be able to actually publish, but publication is also important for promotion. And this means that actually there might be less women who will be promoted to professor, which means less opportunities to get leadership positions and less mentors that are women who can sponsor other mentors, other female mentees. Individually it can affect their personal sense of satisfaction professionally and effectiveness, which as many of you might know from the Malice Inventory Survey on burnout, it can actually lead to more burnout in your staff. And personally, I find actually that having women in research is really important to help eliminate some of this disparity in terms of research and critical illness. So here I'm going to share a little personal story. So I've been fortunate to have been in a number of clinical trials networks and lead certain initiatives and trials across the country and nationally. And I remember actually being in one meeting where we talked about the EOLIO trial, you know, this is the ECMO trial for severe ARDS. And I remember asking the investigators, like, how come 70% of the patients enrolled in the study were men? Like, where are the women? And they were kind of surprised by that question because it never occurred to them and they just said, well, we just don't see women developing ARDS. And I was like, really? Certainly it was not the case when I looked at it for my epidemiological study where I looked at actually the rate of progression from an at-risk condition to ARDS and I didn't see that women, this gender was a protective or a risk factor. And when you look at other kind of clinical trials, you see actually women representation is closer to the 50% mark. So I don't know that women are necessarily less likely to get ARDS, but I do know that they are much less likely to be enrolled in clinical trials and in clinical research. And this is true across all studies. And when you look at those green dots, it's especially bad for government-sponsored studies like NIH studies. And I do know women are less likely to get ECMO clinically. So now that's not to say that actually there was like just, you know, negligence or anything on the part of any of the investigators, but it's just to show you an example of actually having a different voice coming from a different perspective may raise a point that actually didn't get considered until then. So just to conclude, as women as directors of critical care organization, I think female leaders in critical care, including directorships, are still underrepresented. And this is reflected across all leadership positions. And this has implications for critical care organization, both in terms of its effectiveness, but also actually in terms of its stunted potential. If nearly 40% of your faculty is going to be female or, you know, the current workforce, you need to harness all of that strength and all of those talents. And this is going to be important then for critical care organization in terms of their responsibility to train, to recruit, and to promote and mentor women in critical care. So with that, I want to thank you for your attention.

women in leadership

underrepresentation

critical care organizations

diversity in decision-making

patient care

gender disparities