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Wednesday, 5 December 2018

Men’s Fear of Mentoring in the #MeToo Era — What’s at Stake for Academic Medicine?

https://www.nejm.org/doi/full/10.1056/NEJMms1805743?query=TOC Medicine and Society Sophie Soklaridis, Ph.D., Catherine Zahn, M.D.C.M., Ayelet Kuper, M.D., D.Phil., Deborah Gillis, M.A., Valerie H. Taylor, M.D., Ph.D., and Cynthia Whitehead, M.D., Ph.D. Article Metrics 44 References “Me Too” as a slogan to increase awareness about sexual assault dates back about a dozen years, but it has really taken off in the past 2 years as the issue has garnered widespread media attention after dozens of women in the film industry publicly alleged that Hollywood director Harvey Weinstein had engaged in myriad acts of sexual misconduct. #MeToo went viral on social media, and celebrities rallied to launch the Time’s Up movement to fight sexual violence and harassment in the workplace. As accusations against other high-profile men surfaced, conversations about sexual harassment and assault shifted to the broader issue of institutionalized sexism and discrimination against women in other industries. The field of medicine is no exception. More women than ever are entering medical professions, but at all levels of training and practice, they continue to experience sexual harassment and gender discrimination.1,2 For decades, women in medicine have encountered unwelcoming and hostile learning environments that have made it difficult to report transgressions.3 The #MeToo and Time’s Up movements have created a platform for women to challenge inappropriate gender-related treatment in the workplace. In response, some men in positions of power now say they are afraid to participate in mentoring relationships with women. In a study focused on engaging men in gender-equity initiatives, 74% of male senior business managers cited fear as a barrier to men’s support for gender equity.4 A 2018 survey of nearly 3000 employed U.S. adults found that some men have stopped meeting alone with women, and others will not meet with women they do not know well or who are considered to be their subordinates.5 Men say they fear false allegations of sexual misconduct that could compromise their reputations and end their careers, even if they were found to be innocent.6,7 This response has serious consequences for women’s career advancement. Being denied mentorship relationships deprives young women of career-enhancing experiences during critical periods of their professional development.8,9 Women leaders have identified mentoring relationships with men as key to their success, and they encourage other women to seek such opportunities as they navigate a career in leadership.9 In medicine, where female leaders are few — women represent nearly half of medical school graduates yet only 16% of deans — denying women access to mentoring relationships will perpetuate this gender gap.10 Recognizing the crucial role of mentoring, we urge both men and women to reflect on what it means when men in positions of power are “afraid” to mentor women. We live in what sociologists call a “culture of fear.”11 We are afraid of the wrong things, and our fears are out of proportion to reality. In this case, fear as a social construct can be used to perpetuate misogynistic views of women and to normalize gender inequality. Such fear can play a damaging role in the field of medicine, in light of the legal and ethical constraints and obligations of clinical practice and training. Physicians cannot refuse to see patients of a particular gender; nor can academic physicians limit their interactions with trainees or colleagues to only one gender because they are worried about being accused of sexual misconduct. Academic physicians have a professional and moral obligation to mentor the next generation of medical professionals. Fear as a Social Construct Conversations about men, women, and mentorship in the #MeToo era illustrate the way we use fear to make sense of our experiences. There is an extensive sociological literature on the nature of fear and its consequences. For thousands of years, humans have responded to fear by creating scapegoats.12 Groups that are chosen for scapegoating usually lack power and the ability to fight back. Although the reasons for scapegoating vary, fear plays a prominent role. It is part of our everyday lives in an invisible or ambient way.13 We fear things that we perceive as unfamiliar, unexpected, and uncontrollable. This fear response tells us something about ourselves and about our interactions with other people.14 Men’s expressed fear of mentoring women is an unexamined reaction to the changing gender landscape of medicine. Women in academic medicine are not only underrepresented in leadership positions,15 they also make less money than their male counterparts even after analyses control for factors such as specialty, seniority, and number of work hours.16 They are less likely than men to have mentors who actively foster their careers.17 Women also leave academic medicine at a higher rate than men do, and they bear more family responsibilities.18 To redress these inequities, some departments of medicine are exploring ways of breaking down gender-based career obstacles.19 There is growing recognition that such obstacles are rooted in systemic issues and a workplace environment that does not sufficiently support women through career advancement.20 At the same time, the number of women in medical schools is growing. The Association of American Medical Colleges reports that in 2017, for the first time, more women than men enrolled in U.S. medical schools — accounting for 50.7% of incoming classes, as compared with 49.8% in 2016.21 Since 2015, the number of women entering medical school has increased by 9.6%.21 This increase is especially noteworthy “in a year when women’s voices in the workforce are gaining more attention.”22 Medical leaders and educators are examining what needs to change in medicine to make the field more inclusive of groups that have been underrepresented. They are advocating for greater diversity in the physician workforce as a key strategy for meeting public and community health needs. Increased and sustained attention to gender equity and diversity has prompted proposed changes to the system that would make academic medicine less of a “chilly climate” for women.23 Fear Reactions to Change Responses to the increasing focus on gender equity and diversity in medicine can be understood through the lens of change theory. We have long known that efforts to effect change are often met with resistance, even when the changes make intellectual sense.24,25 Many people in our culture are anxious about change and uncertainty. We tend to anticipate the worst possible outcome,26 seeing change as a risk to our safety. This view may help us make sense of men’s fear reactions to gender equity. When women started to outnumber men in Canadian medical schools, some leaders in the field raised concerns about the “feminization of medicine.”27 Some proposed affirmative action for men to close the gender gap in enrollment.28,29 And some men see the growing female enrollment and efforts to promote diversity and equity as a threat. At the heart of this reaction is the notion that men are somehow at risk, a belief that can turn every experience that men have with women into a hazard that needs to be managed.4,30 This perspective underlies men’s fear of mentoring women in the #MeToo era. Being at risk places a person or group in a passive, dependent role, a condition of vulnerability. This vulnerability informs their interpretation of the threats they face.14 The idea that men as mentors are vulnerable or at risk flies in the face of current and historical experiences of gender inequity. Indeed, the claims of privileged men that they are not privileged can themselves be acts of privilege in their appropriation of women’s voices and fears. In North America, white men have traditionally held high-status positions, and changes that challenge male dominance can trigger negative reactions from men.30 Although not all men, or all white men, will feel the same way, privileged groups inevitably resist changes in the distribution of power that threaten their advantaged position.31 It makes sense, then, that men’s fear of mentoring women has been described as a backlash to the #MeToo movement — a strong adverse reaction by a group of people who think that others have received undeserved benefits.32 Some men feel that gender equity puts them at a disadvantage, that women’s advancement could come only at their expense.4 They are afraid they will lose their privileged status and will have more difficulty advancing in their careers.33 When men say they are scared to mentor women, they may really be saying that they fear losing advantages in the workplace. As the sociologist David Altheide has argued, “Fear does not just happen; it is socially constructed and then manipulated by those who seek to benefit.”34 The most insidious effect — discussion and acceptance of men’s fear of mentoring women — is its perpetuation of both hostile and “benevolent” sexism that maintain gender inequity. The backlash against #MeToo is an example of hostile sexism: it punishes women by withdrawing mentorship opportunities from those who challenge the status quo. “Benevolent” sexism manifests in various and nuanced ways, one of which is gender stereotyping. Although gender differences and human behavior are not determined by biology alone, our society imposes different behavioral expectations on women and men that are based on presumed biologic differences.35,36 Women are stereotyped as communal beings — nurturing, interdependent, and considerate; men are stereotyped as individual agents — independent, ambitious, and competitive.37 Women who do not fit the traditional stereotype are punished38,39; they are considered socially unskilled and unlikable.40 In the #MeToo era, men’s fear of mentoring builds on the notion that women are not intelligent or perceptive enough to know the difference between a mentor’s good and bad intentions. It is on this foundation of misogyny that the claim that men fear mentoring women is built. Moving beyond Fear Focusing on men’s fear deflects attention from the issues that triggered this response in the first place. Being afraid to mentor women is not simply about fearing false accusations of sexual misconduct: it is about discrediting women who speak out against sexual assault and harassment.41 It also sidelines conversations about the serious consequences for women of limiting their mentorship opportunities, and it threatens to halt progress toward gender equity in leadership roles. Understanding this fear, where it resides in academic medicine, and why it is being experienced at this particular time requires self-reflection.42 Potential mentors can analyze their own fear reactions to assess what underlies them. They can think about what excluding women from mentorship opportunities would mean and about the many benefits these opportunities provide: they create inclusive communities, optimize talent, and advance organizations and the practice of medicine. Insights gained through such self-reflection may help men move beyond fear and allow them to become strong mentors to more women (see boxes for sample scenarios). The Old Boys’ Network The problem: Jim has headed up his clinical division for 5 years. He recently hired two excellent young female clinician-researchers — the first women he’s ever personally hired. In the past, he made a point of taking new hires out for a beer after work to discuss their new jobs, and he made sure they were invited to join the departmental squash ladder. He worries that if he doesn’t do the same for these women they won’t fit in as well and might not feel welcomed. He’s particularly worried about the beer — what if they got the wrong idea? What if somebody saw them together and it led to gossip? One recommended approach: Reach out to trusted women leaders to discuss your fears. They can share their experiences, put matters into perspective, and provide potential solutions. Jim brings up the beer and squash question with a female colleague, and she reminds him that when they started working here, their boss ignored her but took him out to play golf. They reflect on the effect that the old boys’ club had on women’s inclusion in the division. They discuss how things that are not said or not done can affect the culture of the work environment. She suggests that Jim give the women the option of the traditional one-on-one beer with the boss, both having a joint mentoring session over beer with him, or having a beer with the boss and another mentor of their choice. At his colleague’s suggestion, he also brings up the issue of potential inequitable mentorship for women and other underrepresented groups at their next divisional meeting; the group brainstorms about situations they’ve encountered, and two senior women give examples of approaches that seem to have worked (or not worked) for their mentees. Biased Mentoring The problem: Spencer is the new physician-in-chief at his hospital. Eating lunch in the food court, he overhears a woman telling colleagues that she was passed over for a leadership position because of gender bias. She can’t help but think that taking her mentor’s advice to wait until after her maternity leave before assuming a leadership role caused a lag in her promotion, given that her male colleagues are farther along in their careers. Spencer worries: “Am I perceived as sexist or having gender bias when I mentor women?” One recommended approach: If you’re worried about being perceived as sexist, address the fear head-on by initiating an authentic conversation about it with mentees. Spencer could tell a female mentee that being in a privileged position means that he might not be as sensitive to gender issues as he could be and that he wants to learn from her experiences. He can demonstrate positive intent by being honest and asking her to give him constructive feedback if he says something that might be gendered or seemingly unhelpful to her career. He can tell her that he worries that he might say the wrong thing or be misinterpreted, so in this mentoring relationship, they have to both assume that the other is acting with the best intentions. Spencer could also shift the power dynamic by characterizing mentorship as a bidirectional relationship. He can express interest in learning about his mentee’s current experiences and where she sees herself in the near and more distant future. He can take her lead by asking her to identify ways he can help with her career, while describing what worked for him. He can also ask her how he should give advice in situations where their views of her achievements or capabilities conflict, particularly when the feedback might be perceived as negative. And he can stress the need for patience and open-mindedness. Productivity Problems The problem: David is the cardiology department chair at an academic medical center. Sarah, an assistant professor in his department, was hired 4 years ago but still has no independent grant support and no published work. A male assistant professor hired at the same time has met these milestones. Sarah had a baby 2 years ago, took 2 months of maternity leave, and has steady day care coverage. David knows he needs to talk to Sarah about her lack of academic productivity, but he’s wary of coming off as sexist — and fears that Sarah sees her male colleague’s comparative success as the result of discrimination. One recommended approach: Consider whether expectations are explicit or whether men and women have unequal access to unwritten rules and to mentorship and supervision, then work to correct inequities. David could examine previous performance reviews to recall what guidance, advice, and mentorship he gave each junior colleague in the past. Was Sarah’s lack of productivity pointed out to her previously? Did she have the same mentorship and supervision as her male colleague to increase her chances of obtaining grants? Was she given formal feedback about academic expectations? Are there departmental guidelines outlining expected performance? If such assistance is in place and all things are equal, David can focus on productivity in his discussion with Sarah and convey that he wants to understand what might be preventing her from meeting expectations. He could assure her that he’s there to help her reach her potential, ask what support she needs, and set reasonable timelines moving forward. If no guidelines exist, then perhaps men are getting more targeted mentorship than women, gaining access to unwritten expectations or rules. People tend to mentor others who remind them of their younger selves, and most of the department leadership is male. David could bring these concerns to his executive committee, which could strategize about improving mentoring for women and create written guidelines on academic expectations. It could also implement a process for negotiating a clock reset for promotion evaluation to accommodate leaves of absence for any reason, such as maternity or elder care. Academic institutions and health care organizations can implement strategies to help men move beyond fear and create an environment that supports mentorship opportunities. Such efforts include creating a “safe space” where men and women can talk directly about concerns regarding mentoring. An American College of Physicians position paper about gender equity in medicine makes recommendations that can support change.43 Recommendations for improving gender equity include being transparent in compensation arrangements; supporting universal access to family and medical leave policies; offering leadership-development programs and implicit-bias training; encouraging mentorship and sponsorship programs; and providing flexibility in structuring career paths in academic medicine, with flexible promotions and advancement criteria that reflect the range of responsibilities and unique contributions of female physicians. Among these recommendations, professional guidance and support that encourage self-reflection and address implicit biases toward women are particularly important, because it can be difficult to admit to bias and accept feedback that does not align with our perceptions of our private and professional selves.43,44 Tension between our actual and idealized identities can elicit strong negative emotions that we need to understand, process, and integrate, lest they lead to the very fear reactions that strategies for creating gender equity are trying to prevent.44 If fear is the lens through which potential mentors respond to and make sense of the world, then what is at stake for them on an individual level is the critical thinking, self-reflection, and empathy that are core aspects of the physician’s professional identity. On a broader level, characterizing men’s mentorship relationships with women as dangerous deepens institutional discrimination. If leaders and educators in academic medicine can examine these expressions of fear and find ways to move beyond them, our community will ultimately better support women’s career advancement. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org. This article was published on October 3, 2018, at NEJM.org. We thank Hema Zbogar at the Centre for Addiction and Mental Health for her editorial support. Author Affiliations From the Centre for Addiction and Mental Health (S.S., C.Z., D.G.), the Departments of Psychiatry (S.S., C.Z., V.H.T.), Family and Community Medicine (S.S., C.W.), and Medicine (C.Z., A.K.), University of Toronto, the Wilson Centre for Research in Education (S.S., A.K., C.W.), Sunnybrook Health Sciences Centre (A.K.), Women’s College Hospital (V.H.T., C.W.), and University Health Network (C.W.), Toronto, and University of Calgary, Calgary, AB (V.H.T.) — all in Canada; and Catalyst, New York (D.G.). 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Sukhera J, Milne A, Teunissen PW, Lingard L, Watling C. The actual versus idealized self: exploring responses to feedback about implicit bias in health professionals. Acad Med 2018;93:623-629. Crossref Medline Google Scholar OpenURL UNIVERSITY OF BRITISH COLUMBIA Article More about Medical Practice, Training, and EducationMedical Ethics December 6, 2018 N Engl J Med 2018; 379:2270-2274 DOI: 10.1056/NEJMms1805743 Editors

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