Good morning, everybody. Thank you for joining us today for this presentation of this great lady that we have here, Dr. Jana Zimmerman. I don't think, I was thinking of how I could introduce her, but I really, there is nobody in this world of critical care who hasn't been touched by her work or knows about her, so I could go on all day, and I'm sure everybody in this room knows more about her work in research, education, field of critical care as a whole, and work that she represents as a woman in critical care, and I think I'm really very proud to announce Dr. Jana Zimmerman. I asked her to keep the intro short because it's just embarrassing sometimes, so. I chose the topic of women in critical care achievements and challenges because it was something I knew a little bit about in my over 30-year career, and I'm not telling you exact number of years, so you can't tell how old I am, but it's old. So what my objectives are with this talk is really to review the achievements of women in critical care and decreasing that gender disparity that we all know has existed for a long time, and I also want to highlight some of the ongoing challenges that women in critical care face. And also, there's not a lot of time, but I do have some suggestions about maybe some of the steps that need to happen to further advance women in critical care. And as you probably know, there's not a lot of data and evidence for some of the topics I'm going to talk about, so I have had to make some generalizations and also some extrapolations to kind of illustrate some of the points that I'd like to cover. So when we ask how far women have come in critical care, I want to touch on these topics. Money, financial compensation, professional and academic development, research and publication, how women fare in our organization and other organizations around the world, and also end a little bit with harassment. So this, I want to set the stage as kind of a general tone for where that gender gap is for women. This comes from the World Economic Forum, and they calculate this index every year and publish it for over 146 countries. And what they do is they take into account economic, social, health, and political empowerment factors to come up with this index. And if you live in Iceland, that's where they have the narrowest gap, only 9%. So the U.S., I put just a few selected countries there, in the U.S. we're at .75. What that means is that women in the United States have 25% less opportunities than men in the United States. And if you're interested, you can Google this and come up and find your country. Unfortunately, the U.S. went from 27th place down to 43rd place in 2023, so we're losing ground in the U.S. So let's talk money, right? Again, there's not a lot of specific data about critical care. When I looked for information on nursing, pharmacists, respiratory therapists, the only place I got some specific data was for the women physicians. But what I did is kind of use some generalizations from the data I found to show you the gap. Now in general, in professions where women predominate, such as nursing, the gap is smaller. And I think you can see that for nurses, it's only about a 9% gap, but that increases to 15% for pharmacists in general, and also to 20%. But when we come to intensivist physicians, women physicians, we make 26% less than our male colleagues. Now one of the problems with getting data on compensation is that it's kind of one of those dirty little secrets. You know, a lot of us sign contracts that say we will not divulge our salaries. So that's why it's, I think, unfortunate that we continue to have this ongoing gap. Now this is some data that is specific to critical care, and in this particular article, they looked at, they used the American Association of Medical Colleges data. So it's from academics, and I pulled out the critical care. So in blue is the gap for women with a starting salary, and in green is the gap that exists year 10 after you have started in your career. So for adult intensivists, starting salaries for women are about $39,000 less. The gap narrows just a little bit at 10 years to $35,000. Pediatrics does a little bit better at the beginning. The gap is smaller, $27,000, but it actually gets worse the farther along you go in your career up to $42,000. What this equates to is that women in critical care, women intensivists, make over a million dollars less over a 30-year career, and I'm sure a lot of you could find something to do with a million dollars. So this is an unfortunate reality that we face. Now many reasons have been proposed for the salary gap. A couple of these have been shot down really well. Women work less hours. Nah, that doesn't happen. Women are less productive. Nope, that's not true. What is true is that women do tend to undervalue their services, and they do not tend to negotiate salaries. So women are more likely to accept an initial offer than a man is. There's also no doubt that you have bias and discrimination, and you can't negotiate bias and discrimination. Some of that is implicit, and some of that is explicit as well. So I think the challenges for women in critical care in all the professions going forward is to say that that wage gap is just not acceptable. By the way, in the U.S., there's an Institute for Women's Policy Research that estimates the salary gap in the U.S. for women in general will not close until 2058. I'm hoping we can close it in critical care a lot sooner than that. But I do think the problem here is the system, and I will, again, emphasize system issues because there's a tendency to try to fix the women, and you can't really fix the women if the system is stacked against them. So we have to fix the system. And this means you have to have pay transparency. And there is two laws in Congress since last year, who knows how long they'll be there, for both pay equity and pay transparency. So we'll see if those go. And some states do have pay transparency laws that may be helpful. There should be pay audits every few years to make sure salaries are equitable. We have to eliminate the bias. And I think there is a role for some negotiation training for women so that if that gap is not there when you start, it won't be there 10 years into your career, hopefully. Let's talk about career development. And I used this image. I Googled Google images for career advancement. Do you know that 85 to 90 percent of the images feature a male figure? So Google is very biased as well. So your institution where you work, your hospital, your medical school, your health care institution is one of the primary gatekeepers for career advancement for men and women, again, regardless of your profession. So that's one of the major gatekeepers. And unfortunately, we don't have very good information, in fact, no information specific to critical care, whether it be for nurses or for physicians or respiratory therapists or pharmacists. This again comes from the World Economic Forum, and they looked at that leaky pipeline, if you will, for women. And I'll just call your attention to the lower one. That's for women in science, technology, engineering, and medicine. That's us. And again, they estimated about 30 percent of women enter those fields. But by the time you get to the highest levels of leadership, the executive level, we've lost over half the women as far as being represented. And that is probably no surprise to you. This comes from academic data in the U.S. in medical schools, and you can see at the instructor level, women outnumber men. But by the time you get to the full professor level, they have lost over 50 percent of the ground. And I don't doubt that this is true for critical care. And by the way, in academic pharmacy, that same type of loss of women occurs in that profession as well. But again, I couldn't get specific data for critical care. Well, not everybody's in academics, and this is a study that came from Argentina from my friend Alyssa Estensoro. They surveyed over 100 ICUs to see how women are represented in the different levels of leadership. And go from the top, this is their designations, residents down to assistant physicians and deputy medical directors. But the biggest drop is at the bottom, the ICU medical directors, where women are only about a little over 20 percent. And this kind of is similar to what data came out of Australia and New Zealand. It was published in 2016, but they found that only 10 percent of ICU directors in that country were women. And clearly, there's many more women in critical care than just 10 percent in Australia and New Zealand. There are some unique factors that affect women in their career development and career advancement. Again, I'm generalizing a little bit. Women tend to be a little more perfectionist, so that can hold you back a little bit. Imposter syndrome, where you think you're not qualified, you're not good enough, does affect women more than men, but it can affect men. Women are kind of indoctrinated socially not to boast or to brag, so we don't promote ourselves as well. Another thing that affects career advancement is the flexibility to move or travel. So one of the biggest bumps that you get often in both salary and career promotion is when you move to another institution. And women are often less likely to be able to move because of family issues. They also, again, negotiation skills play a role with career advancement, not just money, but also that promotion in that career ladder. We do know that in medicine, this has been studied, women do tend to be more interested in teaching and research. And the problem there is not that that's not a good thing. It is. It's just that teaching is often valued less for career advancement than research, and that priority obviously needs to shift as well. So I think some of the challenges that we have to face in critical care is that we need institutional promotion practices that are objective, that are very clearly written, and that are applied fairly, and recognizing that different professions have different contributions that they should be evaluated on. The cultural biases, we still have to work on those because women are expected to be in more service roles, self-nurturing roles. We need mentors and sponsors to help these women say you are good enough. You do need to put in your hat in the ring for that leadership promotion. Women need to be recognized for their contributions, and that doesn't happen enough in the academic field as well as even outside academics. How many of you are in hospitals where somebody's on the chair of the committee for 20 years? Right? So what does that mean? Less opportunity. And I bet that the majority of those chairs of those committees are men. It's kind of like you need term limits, and this is also to get new innovative ideas, but also to give women and other people a chance to assume those positions and learn skills along the way. And of course, women have a difficult time with work and family balance. I think men do as well, but I think it affects women in critical care a little bit more. So let's talk about research and publications. And I will just mention again, publications, medical journals, are another one of the main gatekeepers for career advancement, whether it's critical care or another field and specialty in medicine. But let's look first at research. We have no data for critical care. There is no Institute of Critical Care at NIH. What we do know is that institutions provide more startup support for men. Female surgeons receive fewer and smaller NIH grants. At NIH on the study sections, male reviewers greatly outnumber women. And when women are reviewers, they're more likely to be temporary members. And they're not on the institutes that have the most money and the most grants. So NIH has actually been working on this. They've recognized the problem. But this is kind of where we stand. And I think this is probably similar to what we face in critical care. This is an interesting study that came from Canada. And I don't know if Allison's around. There she is over there. But this, I thought, says a lot about the problems for women getting research funding. So in the Canadian Institutes of Health, they had kind of an experiment. They had these stages and foundation programs where in stage one, they focused on the caliber of the investigator. And that's often part of assessment for grant funding. That was called the foundation program. Stages two and three was called the project program. And in that phase, they focused on the quality of the research. And again, you can see in that stage one, that covers two funding years there. Women are in the light green, were much less successful than men in getting funding. But when they focused on the quality of the research, which is on your right, women were funded at an equal opportunity, so to speak. So this is a sign of implicit bias, explicit bias, systemic bias. And I think this is what is holding back. And remember, once you get a grant, it's kind of a self-fulfilling prophecy. So one grant means you're more likely to get the second grant. So if that woman doesn't get that grant, she's less likely to get the next funding opportunity as well. So it's a vicious cycle that we have to recognize is existing in research funding. Another way to look at research funding, and I thought this article was published last year, was to look at clinical trial leadership. And this was very interesting. They looked at almost 245,000 clinical trials. And they looked at how many had women as principal investigators. And they did break it down by specialties, but there was no critical care specialty. Overall, it was 32% women investigators. Pulmonary was 25%. Infectious disease, which might include some of our sepsis studies, was 30%. But also look, industry-funded trials, women much less represented. And women are much less represented in interventional trials and phase three trials, which are going to have a higher impact. So the good news was that they did find that there was an increase in women as trial leaders over time. So I guess that's the good news. It would be very interesting to maybe look at this for some of our critical care trials and see how we compare and separate us out from this study. So the challenges for research is we have to have an unbiased review process. And it has to focus on the quality of the studies. And I think that means gender balance on granting panels, whether it's NIH or foundations. I think SCCM does a good job with balance on their awards that they give out. And again, mentoring women, it's been shown that women in their funding proposals and also in their publications tend to use fewer positive words than men do. I found that very interesting. I think it comes back to not valuing our services and not wanting to boast. But we can do, hopefully men and women can help women and mentor them to improve that. But we do need to figure out what's going on in research and critical care so that we as an organization can figure out how we can get more specific solutions. Now I mentioned publications is another gatekeeper for career advancement. Publications have so much impact. It means you might be invited as a speaker. You might get a promotion. You need that for your scholarly productivity. It helps you get research funding if you've published. It might mean you get invited to be on the editorial board or on a task force or guideline committee. It just has a very pervasive impact in critical care and in other medical specialties. What we know from critical care, and Dr. Varonis published this, in 40 critical care publications they looked at women as first and senior authors and found that they were underrepresented. Women were about 30%, 31% of first authors but only about 19% of senior authors. They also noted that women in critical care tended to publish in lower impact journals. Guess what? You get fewer citations if you're in a lower impact journal. The other interesting thing that's been shown, not necessarily for critical care, is that when men are first authors, they have more citations than if a woman's the first author. Publishing in a high impact journal is really important, I think, particularly for women. What about in nursing? Nurses make up 85% to 90% of the profession. Again, I couldn't find anything specific to critical care, but this study took three leading journals and women as first authors wasn't too bad, it was 82%, but women as senior authors were only 72%, and they dominate the profession. Even in nursing, we don't know about critical care nursing, there is an underrepresentation of women in authorship. We have a very gendered publication system in critical care, and I want to take you through this because this is one of the things that we need to work on. This article looked at women editors-in-chief for the top 10 journals in the different specialties. Here we are for critical care, 10%. Surgery did better than us, 20%. Now, we can say we're better than anesthesia, 0%, but I would like it maybe to be somewhere between that 20% and that 70% of women editors-in-chief for primary care publications. We have predominantly male editors-in-chief. Editors-in-chief choose the editorial board, right? This is an older study that was published, which was kind of worrisome, and they took these five journals and they said, how many women are on the editorial boards? This was back in 2010 that they looked at it, and it looks pretty pathetic, right? As far as we're trying to think, women in critical care around the world at least represent 30%, at least 30%. Some countries like Brazil, it's 50%. When you see numbers like 1.4%, pretty bad. Has this improved? So, I've been kind of following this more recently, and this is the updated information, and it is improving. Now, it took the American Journal of Respiratory and Critical Care until 2023 to get a significant change. Critical care medicine, our journal, is up to 26%. Intensive care medicine is at 50%, and all of them have improved, so that's the good news. We're still not 30% or more, okay? So we still have a ways to go. Okay, well, the editorial board members choose reviewers, right, for those manuscripts. Reviewers determine or suggest the acceptance of manuscripts. Who are the reviewers? This was a very interesting article from Lancet, and they looked at reviewers. New England Journal, men, 82% of super reviewers over a six-month period. Over a 10-year period, men were 87% of the reviewers. Lancet, they looked at one year, men, 90% of reviewers. What about us? I only looked at critical care medicine, which I have access to, and I looked at one year in 2020, men, 77% of the reviewers, which means there's 23% women, but of those women physicians only make up 16%. I looked in 2022, which was the most recent I could find in the journal, men, 75%. Women physicians actually went down, non-physician women actually went up a little bit. So we have an issue there. Now, I will tell you, people will say, well, I've asked 10 women to be a section editor or to be a reviewer, and they said no. Well, when a woman turns down an opportunity, it's a sign of a bigger issue, the unseen barriers that impact women's decisions. Probably the most important one and the biggest one is those domestic inequities, if we want to say that, the disproportionate duties that they have at home, not only for children, but also caregiving to older family members. And at work, also, women have a lot of unrecognized jobs that they do. They're mentoring people, but it's called ghost advising, because they're not designated as a mentor. So those also take up their time, so they have less time for being a reviewer. There's also that problem with a lack of confidence and feeling that they don't have the skill to do it that probably play a role. So these barriers are often not verbalized, but certainly play a role when a woman turns down an opportunity. So our challenge, and again, I think every major journal is working on this, is that gender balance and editorial boards and reviewers. Whether that will make a difference in acceptance of manuscripts by women, we don't know. We do know that men and women reviewers, by at least one small study, do make some different decisions. We need to engage women in this process, help them with publications, get them started as reviewers, and I'm gonna make a plug for those of you in the room that are even thinking about being a reviewer, or thought about it and said, I don't wanna do it. Think about going to the reviewer academy, and this academy is this afternoon at 2.30, and, oh good, I had to put the plug in there. So this is where we have to start. This is gonna give people the skills, and it's not for just women, of course, it's for men and women, but this is where it starts. They will help you get the skills, show you how the process works, and I would really encourage women in the audience to try to attend that, or there's other, they'll probably have more down the road as well. Mentorship, men and women need to mentor women, and encourage them, help them be, say, go ahead and say yes to being a reviewer, I'll help you, I'll go over your comments with you. But more and more, we really need to start asking our membership, our women in the membership, what really are the barriers, not only to reviewing, but what are the barriers that you find in publishing, and we need to address that, perhaps, more specifically. Well, professional organizations are the other main gatekeeper for career advancement, because you can be a conference speaker on a task force, in a leadership position, and all those are very important for career development. So I wanna thank Diana Hughes for facilitating, getting me some information, and so I put together what the picture is for women in our society, and I'll tell you, it's very difficult, and the data has some limitations, because about 24% of you don't designate whether you're male or female when you do your profile. So what I did is I took those that did answer, and assumed that those that didn't answer are the same proportion, so you won't see this, these numbers anywhere in SCCM, I've extrapolated the data. But by extrapolation, about 47% of our membership is women, for physicians in the organization, about 35% women, and then as you would expect for nursing, and that includes nurse practitioners, by the way, in that category, 78%, pharmacists, almost 70% physician assistants, and the other includes our respiratory therapists, our physical therapists, our veterinarians, so if you'll kinda keep those data in mind as we go through some of the data specific to SCCM. Well, how are women doing in leadership in critical care organizations? So this, again, was published just recently, and they did a survey of 65 societies, but just note that the majority were in Europe and Asia. There was only four from North America, and it didn't include SCCM, and there were five from South America, but you, I think, can see in the green is the women on the board of directors or councils for these critical care organizations, and clearly underrepresented. The little bit that you see for those in North America, we did better, but how are we doing in SCCM? Well, we're actually doing pretty well, and these are just the women, this is the percent of women on SCCM elected council, so these are the people that you elect as your representatives, and since 2001, when it was about 27%, we've gone up and stayed close to 40 to 50% women on the elected SCCM council. Now, has that translated into women being president of critical care organizations? Not so much. I put together this interesting graph for you, and I have to acknowledge my women intensivist friends from around the world helped me do this, and I said, how long does it take to get a woman president for organizations? And this is not like ventilator-free days. The higher is not better, okay? So you'll see South Africa, 44 years, all the way down to Puerto Rico, their organization, their first president was a woman. SCCM is here, took us 29 years to get a woman. So really, and the other thing I wanna point out, there's some organizations that aren't on this graph, and I'll show you why. Now, the time to being, having a first president doesn't necessarily correlate with more women being president, so here's organizations in the percent of presidents who have been women. So some of the organizations not on that graph are here in the 0%. Now, this has been called the inexorable zero or near zero, and you should never see a zero when it comes to representation by women. In fact, in the US legal system, a 0% is taken as evidence of discrimination against whether it's women or another minority. So that zero or near zero needs to go away, and I have to say, Mexico's on there, but Mexico will have their first woman president next year, Dr. Susana Perez, and there she is, back in the back. And there's a near zero there for India, but as you all know, Sheila Miatra is the first woman president of India. And is Monica Meza here? She's at the meeting. She's the current president of the Peruvian Society, so I'm pleased to have so many women presidents from other organizations here. But as you can see, the numbers are low. Here's SCCM, we're at 19%. The Society of Turkish Intensivists is at the top of the list. I put them at the bottom, I should have reversed that, but they're at 43%. Neurocritical Care Society is at 25%. So let's look at this just a little bit closer, though, because we have to be careful about the numbers. The numbers look pretty bad. So in SCCM presidents, 19% have been women. Five of those were physicians, three nurses, two PharmDs. And I also thought, well, are we doing better more recently? So I took presidents since 2000, and 2000 was the landmark, because Dr. Carolyn Beckes became the first woman president of SCCM, and I said, how have we done between 2000 and to the current day today? And we've had 42% women presidents, 10 out of 24. Now that sounds really good, but I think you have to really look a little bit closer. We're a multi-professional society, and we need to make sure the women are being represented equitably, but that's not happening for all women's groups. So women are only making up 21, women physicians make up only 21% of presidents, but they're about 27% of membership. Compared to men presidents, men physician presidents, women make up only 26% of physician presidents, and we're 35% of the physicians. So women physicians are lagging behind men physicians in our organization. In reality, for every three physicians that are president, one of those should be a woman. So I hope that will change as we go forward. So we have a ways to go in leadership, and I think women in leadership are important. I think all the women in the room know that. First of all, we need to use those abilities and talents. We don't want to lose that. We also improved with diversity and this heterogeneity of ideas, it leads to innovation. Women are uniquely positioned to put forth their thoughts and experiences on women and families in the ICU. In the business world, having at least 30% of women on their boards leads to improved financial performance. Financial performance. You're probably stockholders in some organizations. Look at their board of directors. I did this when voting for my stock things for my financial counselor, and it's 30 to 40% for almost all the major business organizations. They also find in business that when they have more women on the board, they run into less legal trouble. So I don't know about that for our professional organizations, but the other reason I think it's important to have women in leadership is to recruit more women to our profession. They need to see those role models. They need to have mentors. The other thing women bring to the table in a professional organization also is the attention to gender equality and diversity. So that's a good thing for all organizations. Now, the other thing that happens in organization, of course, is women get assigned as speakers, maybe on a task force, guideline development. That's part of career development, and the one thing that really has irritated women in medicine is the presence of the mantles, and one of my good friends from Mexico gave me this one. The title here for this panel is Joining Efforts for Breastfeeding. Now, that was in 2018. Hopefully, that would never occur today, but we've only gotten rid of the mantles, really, in the last one to two years, and still, they pop up every now and then, so that's important to look at. So let's look at critical care speakers. Many of you are familiar with this data from Dr. Mehta, and they looked at women speakers in some of the major critical care conferences up between 2010 and 2016, and the CCF is Canada. Of course, SCCM is there, ESICM. ISICM is the Brussels meeting, as it's often known, and then the UK, and you can see over this time period, again, women not well-represented in many of the, in fact, in all of these conferences. The other thing they called attention to was women physicians, okay? So women physicians did much worse. They weren't, they didn't make up the majority of that 24% in Canada or 27% at SCCM. It was only 14% women speakers. So that's a concern, and again, it just illustrates where you need the right data to really determine if you have equitable representation. Well, has this improved? Well, Dr. Metoxa and Dr. Mehta graciously shared their data. They are updating that information, and this has been submitted, and this is the data from 2017 to 2021, and as you can see, it is improved. 37%, 38%, ESICM, 27%. On this year, this span of years, the Brussels meeting didn't do too much better, not surprising to some of us, but I just wanted to also note that women's physician speakers in some of these congresses have improved, not in SCCM, so it's something that really needs to be looked at. Here's the current data, which I wanted to put up there because I think it also says we're really getting there when it comes to representation in congresses. So Canada, 48%, SCCM, almost 45%. Even the Brussels meeting is 26%, but at the very bottom, I just want to note that that's the Emirates Critical Care Congress. There are still many congresses around the world in critical care that don't have adequate representation of women, so we need to help our colleagues around the world improve that statistic. Societies give out awards. They've given me the Lifetime Achievement Award, which I greatly appreciate. I looked at this in 2020, and I looked at awards that had at least a 10-year history. The only exception was Neurocritical Care Society. This is through 2019, and again, thinking that women are at least 30% of these organizations, you can see that women for awards are very much underrepresented. SCCM, it's 24%, but the top two awards, the Lifetime Achievement and the Distinguished Investigator, it's 9%. Neurocritical Care Society, it's 41%, which sounds good, but when they looked at their scientific awards, only 8% women. So I think this needs to change. We need to make a more conscious effort to recognize the women who are definitely qualified to receive many of these awards. So many organizations have diversity policies, and I think that's great, more need them, but a policy isn't gonna change anything unless you have a goal and you measure your progress toward that goal. So you need the metrics, and those metrics need to be transparent. They really need to be transparent to the membership. I think organizations are using conscious gender balance, and that's why we've come such a long way with representation as speakers in Congresses, and that's great, and we need to continue that mentorship and sponsorship, putting forward the names of qualified women to participate in these various activities. Last thing I wanna touch on is harassment, and I'm sorry I have to do this, but it really is important, because it's still occurring. Sexual harassment includes a lot of things. By definition, you'll see various definitions. It's gender harassment. That's you're harassed just because you're a woman, but there's also unwanted sexual attention or sexual coercion, and harassment happens to both men and women. It just happens more to women, and it's interesting that there's a higher prevalence of harassment in medicine than in other scientific fields, which is concerning and not very good, and these harassments often manifest as macroaggressions. We recognize those, so I think those have decreased, but what we still are left with is microaggressions, and some have said that maybe the term should be microinequities, and these are those verbal, nonverbal behavioral insults that I think hopefully most are unintentional. Some may be intentional, but basically there's a communication of some derogatory type of comment or hostile message that's sent, and these are some examples. Dr. Gloria Rodriguez Vega loves this one. How many of you have been in a meeting where a man has been asked to take the minutes? Nobody. Robert, okay, really? It was all men in the room? No? By asking a woman to do a mundane task, you are devaluing their talents and skills. That's a microaggression. A woman puts forth an idea, and it just gets, you know, on the side. The man says the same thing, and wonderful. If you're giving orders, as a woman, your orders may be questioned, but a man who's probably less experienced and qualified never gets his question, right? We know, this is published, that in meetings, women are interrupted more than men, and the women in the room can probably add about 100 to this list, but those microaggressions need to stop, and we need to do something about them. How bad is the problem? And I'd like to say this is old data. It's not. Most of this was published last year. Academic medicine, 72% of women faculty reported gender harassment. Internal medicine trainees, our residents, 25% reported some type of sexual harassment, and of those that reported, 61% said they never reported the most significant event. We do have some specific to critical care. French women intensivists, 37% reported harassment, and of those that reported harassment, over half of that was sexual harassment. ICU nurses in Australia and New Zealand, 57% bullying, 33% discrimination. Pretty sad. Through our international women intensivist group, we did a survey, and this is just part of it. We asked them, are they exposed to inappropriate comments or behaviors at work and in professional organizations? Because you're probably thinking, this is only at work. Well, it's not. It's happening in professional organizations. And then we asked them, what do you do about that? And we actually looked at this by generations to see if we saw any generational differences. So again, I'll just point out that overall, 50% of women either are silent or they just complain to their friend. Now, this is the saddest part, is our youngest generation, almost 60% did nothing or just complained to a colleague. Somehow, we have to get this changed, and I think by speaking up is probably the best way to stop this. So I think the challenge is with harassment. We all, in our institutions and organizations, have these zero-tolerance policies. Well, that ain't working well, okay? So we have to somehow facilitate reporting and support women and men who are harassed and make sure that there is no retaliation or repercussions for reporting. I think we all need education in recognizing these microaggressions and things that may be inappropriate to say or do that are derogatory to women. And we have to somehow educate women to speak up. We also need the bystanders to speak up. When you see something, it's kind of see something, say something. It's not for terrorism, but it's for, well, actually, I guess it could be. It's for harassment. So when you see something, somebody has to say something, and there are actually some very nice suggested ways of addressing these microaggressions in a variety of ways, in a very professional manner. And again, avoiding misunderstanding. And a lot of times, people don't realize that what they said or did was harmful to a woman. So I think by speaking up, we can also educate everybody on this. So again, just some common themes that you may have seen as we went through this. First of all, we need more data for our profession. We need accurate data. We need the right data. We don't wanna cover up something that's hiding under there, and it needs to be transparent. You've seen that conscious gender balance works, and that needs to be extended to all areas of career development for women. Mentorship and sponsorship is important for women, just as it is for men. And there's a few skills and tools that we can, I hope, give to women, such as negotiation skills that may help them. And we have to somehow get this harassment at work and in our organizations out of the picture, and hopefully nobody has to talk about it again, but I don't know how that will work. So have women come a long way in critical care? Well, we're better than we were, but we're not quite where we need to be in critical care. So I am hopeful that for you in the audience, all the members of professional organizations involved in critical care, that maybe you'll just roll up your sleeves and get the job done in the next couple of years, okay? I do have to, again, add my thanks for the people who have supported me. As I mentioned, Phil Dellinger and Rob Taylor got me started in critical care and worked me to death on SCCM projects, but it was fun. My World Federation supporters, Phil Taylor's in the audience, Edgar Jimenez and Chris Farmer are not here. I have to thank my critical care divas, my original group, Gloria Rodriguez, MJ Reid, and Marie Baldessari. We have moaned and groaned together for a long time. And I wanna acknowledge the International Women in Intensive and Critical Care. This is a new group, but they're an amazing group of women intensivists from around the world that celebrate each other. And I really appreciate the help when I've asked for information, they're so gracious in providing it. And again, to all of you, all of my friends, all of my colleagues, the SCCM staff that I've worked with, you've made this journey a lot more pleasant and a lot of fun along with all the hard work. And last but not least, this is my family. So thank you very much for being here today. Thank you.

women in critical care

gender pay gap

career advancement

leadership underrepresentation

systemic change

research barriers

harassment in workplace

equitable field