Gender inequities in ENT: Insights from women speakers at American Head and Neck Society meetings

Gender inequity exists across national speakers at American Head and Neck Society (AHNS) conferences. This qualitative study explores potential causes of this disparity by surveying women invited to speak at AHNS between 2007 and 2019 and examining advice, resources, and meaningful actions from “those who made it.”

Conclusions: While encouraging more women to enter otolaryngology residencies, increasing the number female role models and establishing strong mentoring networks may help to mitigate challenges.Meaningful progress requires the efforts of both male and female allies within the specialty.Simple solutions, such as educating on implicit bias, removing demographics from applications, and eliminating hidden penalties for maternity leave, may help improve diversity and mitigate barriers to career progression for underrepresented groups within ENT.
barriers to career progression, disparity, diversity, gender equity, head and neck surgery, implicit bias, inclusion, sexism, women in medicine

| INTRODUCTION
Gender disparity in medicine, more specifically in surgical subspecialties, is a well-established concept.A recent PubMed search for "gender disparity" and "surgery" yielded 281 results, with over half of those published in the past 3 years.Fortunately, great strides have been made to value and prioritize diversity in medicine over the past decade.Now, women comprise over half (57%) of matriculating medical students. 1However, the scales remain tipped when examining matriculation into surgical specialties, such as ENT (37.8% female), orthopedics (16.6%), urology (28.1%), and general surgery (35.7%). 2 Moreover, despite improving resident recruitment, a bottle neck exists with wide gaps in practicing surgeons, leadership, and representation at national conferences. 3,45][6] Contrarians may argue that diversification of formal, compensated leadership roles is time dependent, since these roles are typically filled by mid-career practitioners.Yet, gaps persist in research funding, academic committees, and presence at national and international conferences-all of which should be less impacted by career stage. 3,5,7In 2021, Hernandez Brandi et al. examined female representation at the American Head and Neck Society (AHNS) annual meeting.While women's attendance and participation have both increased over the past 10 years, a gap remains with only 131 unique women invited for 2096 speaking roles. 7The objectives of this study are to examine the subjective experiences of women previously invited to speak at AHNS conferences in order to better understand potential causes of the gender disparity in national speaking opportunities and identify barriers to career advancement for women in ENT, more broadly.

| METHODS
Contact information for 73 of 131 female speakers at AHNS meetings from 2007 to 2019 was successfully obtained via internet search.An electronic survey was distributed.Surveys consisted of 36 multiple choice and free response questions (see Data S1, Supporting Information) addressing demographics, recruitment to ENT, barriers to promotion, mentorship for female head and neck (HN) surgeons, and ways to establish oneself on the national sphere.Respondents had 4 weeks to return their responses.Data was deidentified and coded using ATLAS.ti(ATLAS.tiv23 Scientific Software Development GmbH, Berlin, Germany) by two independent investigators (AZ and MM).Salient points from each transcript were categorized as follows.Coders identified common themes throughout survey responses, primarily regarding perceived gender biases within the field.Independent assessments were then reconciled into four primary themes.Mentorship, a concept that permeated multiple themes, was separately assessed using an online word map generator (https://www.freewordcloudgenerator. com/) to extract the most frequently used verbiage regarding mentorship in ENT.Finally, proposed solutions, which often complimented each discussion topic, were analyzed categorized into common themes by the same process.
The four most prominent themes extracted from responses are as follows: 1. Need to increase female recruitment to otolaryngology residencies.2. General barriers to career advancement.3. Importance of women and minorities establishing a national presence within the field.4. Call to shift culture through development of strong support networks and education.
Each theme is summarized below with prominent points describing why each is relevant to career progression in ENT.Additionally, Table 2 includes representative quotes selected from individual survey responses in order to share the respondents' voices without the bias of our own interpretations.

| Increasing female recruitment to otolaryngology
The most direct method of increasing diversity in otolaryngology is recruitment.Three respondents attended residency programs without any female faculty.One is the only female faculty in her current department.Mechanisms to increase the number of women entering otolaryngology residency programs include: • Provide opportunities for early otolaryngology exposure to female medical students, and connect them with mentors within the specialty.• Increase the number of female faculty and women in leadership positions.• Improve the longevity of mentored relationships to benefit the mid-career woman, not just aspiring young professionals.

| Inequity and general barriers to career advancement
Eighty-eight percent of participants felt that their gender had hindered their career advancement.Eight respondents were reportedly discouraged from pursuing a surgical specialty during medical school and six respondents were reportedly discouraged from pursuing fellowship.Three specific barriers to career advancement from participants' responses are: • Implicit biases regarding women's inherent leadership capabilities.• Persistence of "boys club" culture within ENT departments.• Imbalanced expectations regarding childcare and family-related responsibilities.

| Establishing a national presence
Participants consistently noted that high-quality research and active involvement at national or international meetings were necessary for women to establish a national presence.Respondents also commented on male predominance in meeting leadership as a barrier to having more women speak nationally.Primary themes for this topic include: • Limited diversity on selection committees contributes to inequities in professional opportunities.

Medical student recruitment
Early exposure "Connect female medical students with faculty who have rewarding and successful lives-personal and professional."(3) "Grassroots programs to encourage women to examine surgery as a career.Opportunities for internship, travel scholarships, mentorship."(13) "Strategic exposure of the MS1 class to otolaryngology early and link medical students up with resident mentors also."(16)   Increasing female faculty and leadership "Making sure GOOD women are visible in positions of poweraffirmative action type positions or choosing favorites are seen right through by all."(Participant 7) "This has to be a conscious effort by the program.Having women faculty is a big part of this.When I applied for residency, [program] had all male faculty and an all-male residency.I did not even rank that program because I figured residency would be hard enough without also having to navigate gender issues in a department with what I perceived to be a clear bias."(9)   Improving mentorship for mid-career women "Yes, it is easy as an early-to-mid career woman to feel invisible, if your mentor no longer thinks of you for opportunities.You have to remind people that you are engaged and interested.Men tend to be better at doing that."( 14) "I did not have many choices or opportunities since I was looking for protected research time and did not feel I had much leverage to negotiate.Later I found out a male colleague starting at the same time had negotiated higher pay."(14)   Barriers to career advancement Implicit bias "Gender-based assumptions about how women leaders are supposed to lead (e.g., what would be assertive in a male is called aggressive in a female)."(3) "This is very difficult-when women have the qualities that make men good leaders, they are seen as aggressive, single-minded, etc.These unconscious biases present a huge barrier."(9) "I have watched men around me, junior to me, be given opportunities that I am never given; they have titles and responsibilities bestowed upon them without an application process, and without evidence of their leadership capability.They are given things, as it was said in the book Lean In, because they show potential.Women are made leaders when they prove they can do it, but we are rarely given the chance to 'prove it.'I also see a lot of men being promoted much earlier than I was promoted in the academic ladder.This is a problem.I am not sure how to fix it.My female chairman held me back from promotion."(22) Boys' club mentality "Many paths to career advancement are still based on 'who you know,' and men tend to gravitate towards other men, while women tend to gravitate towards other women.For example, we had a male fellow who made our OR schedule when I was a senior resident.My male co-resident would go out for drinks with him routinely… Thus, my male colleague routinely got the first pick of cases while I had to fight for them."(6) "Male leaders cluster together, and it does not occur to them to reach outside their cluster to invite to leadership positions.Invitations to more junior physicians to ascend to leadership must be intentional, and need to be consciously fair and equitable."(15)   Childcare burden "Having kids…and trying to be mom who is present has hindered my ability to be productive outside of work; I had to change from a tenure track to a clinical track at work.But this has also made me (Continues) "In Head & Neck it still feels that men continue to invite their friends who are male.The pandemic has stalled improvement, and 'manels' persist because of the ease of sticking with old panelist-buddies and old topics in the transition to remote meetings.The remote presentation format eliminates any up-and-comer from being recognized in the audience."(15) "It's not complicated.Nominate women to be the speaker, to be the chair, to be the leader.

| Shifting the culture of head and neck surgeons
When asked how to best support women in HN surgery, multiple participants emphasized the importance of calling attention to disparities that exist, continuing education on matters related to diversity and inclusion, and having targeted goals to address inequities.Importantly, multiple respondents noted that honest buy-in and follow through from leadership is imperative for any sustainable cultural shift to be achieved.Pillars of achieving a cultural shift within ENT are: • Structured education about implicit biases.
• Bolstering support resources and mentorship for women and underrepresented minorities.• Standardization of processes related to promotion, committee selection, and allocation of resources.
Proposed solutions for these barriers are summarized in Table 3. Specifically, themes addressed in Table 3 include medical student recruitment, implicit bias, boy's club culture, unequal childcare burdens, establishing a national presence, and mentorship.Mentorship is an integral part of development for young professionals and contributes tremendously to the culture of a field.Notably, no participants in this study stated that good mentors to women must be women themselves.Figure 1 depicts the most common verbiaged used in describing an ideal mentor.Intentional mentorship across social and ethnic barriers is critical to achieving more diverse representation across the field and to women and minorities establishing a national presence within the field.

| DISCUSSION
Over the past decade, the proportion of women in ENT has increased, though representation of women and non-Asian minorities remains well below population averages. 3,8Awareness of gender disparity has also improved thanks to national organizations, such as Women in Otolaryngology, and efforts of proactive women in the field.Despite this, otolaryngology continues to have the largest gender-base wage gap of any medical specialty 9 and there is a dearth of women in local leadership (e.g., PD and chairs) 3 as well as on the national stage (i.e., speaking at conferences). 4,5,7In this study, recruitment of diverse residents and promoting women to leadership roles were identified as an integral components of promoting a more equitable environment in ENT.
Presently, more than half of medical students in the US are women, yet women are less likely to apply into surgical specialites. 10In this study, early exposure to surgical subspecialties was named as one method to augment recruitment to ENT.In a 2006 survey study examining deterrents to surgical specialties, Garguilo et al. found that men and women were equally deterred from surgical specialties based on the presumed lifestyle. 11This begs the question: if the surgical lifestyle is not just a women's issue, why aren't men and women deterred at equal rates?In our study, more than one third

Themes
Representative quotes "…keep educating the men in power about the optics of manels, the gender inequities that persist, the increasing number of women coming through medical school (and the impact on the future specialty) and hold them accountable.Ultimately, it boils down to equal treatment at the annual review, offering equal opportunities, and being sensitive to burdens of childcare and elder care."(7) "Actually discuss gender inequity openly as a faculty (people need to understand the problem).Discuss targeted goals and policies to help address inequity or potential concerns and make it easy for residents to bring up issues without fear of penalization or stigma."(18)   Current culture: Improving with room to grow "…the specialty still is reputed to be made up of 'really smart' and 'really nice' people.However, I am more cognizant that there are persistent numbers of gender biased male faculty and private practitioners, which, ironically, I did not perceive during my residency.I also believe now, after many years of experience and exposure, that the specialty is not as 'nice' as I naively thought."(15) "Still a culture of friendliness and not overtly sexist.We have problems, but they are more subtle than neurosurgery and orthopedics, for example.That almost makes it harder, but it is better."(23) of participants were specifically discouraged from pursuing a surgical specialty during their medical education.This may be attributable to implicit biases which suggest women care more than men about lifestyle or family.One participant supported this theory commenting: "those with the ability to promote women may 'assume' they are not interested due to family responsibilities" (Participant 11).Further, women face greater challenges establishing supportive mentorship in surgical fields.The concept of "Boys Club" culture was a pervasive theme in our study and echos much of the recent literature.It suggests, as one of our participants stated, "men tend to gravitate towards other men, while women tend to gravitate towards other women" (Participant 3).Taken at face value, this has a trifold effect.First, and most obviously, the paucity of female role models in ENT limits recruitment and promotion of women in the field.Second, this places an unfair expectation on the few female faculty to mentor the many prospective medical students-a responsibility that requires significant, uncompensated time and energy that their male colleagues do not have to sacrifice. 12Third, it further reinforces gender-based or racially-based silos within the field.In Garguilo's study, number of women in the field was not a significant deterrent to women considering surgery, but the male dominated culture/personality within surgical fields was. 11This should not undermine the value of diverse leadership, but rather should encourage us to critically examine what culture we are promoting as a field and which implicit biases we carry as individuals.
The majority noted their most influential mentors were men When asked what makes a good sponsor, answers included "someone who cared about my professional development as well as my wellbeing" (Participant 3), somebody responsive, approachable, with goals of providing tangible opportunities for career advancement (e.g., research support, leadership opportunities, etc.).Though representative leadership was consistently important to participants, responses to this specific question should empower physicians to search outside of their demographics to "identify the best and brightest and charm them with how challenging and rewarding an otolaryngology career can be" (Participant 19).Thus, while fair representation in leadership is important to the field as a whole, intentional and inclusive mentorship to women and underrepresented minorities is more important for recruitment.The Boys Club culture is not only an impediment to recruitment, but also has implications for women in the field.Though this phenomenon can result in exclusion of women, 13 it more often contributes to unintentional gender-based cohorts within a work environment.Thus, men in leadership more familiar with male junior faculty, providing men with a more direct line to leadership roles.One respondent comments, "Male leaders cluster together, and it does not occur to them to reach outside their cluster to invite to leadership positions" (Participant 15).Another notes, the "majority of national society leaders are men" (Participant 5).Without a clear advocate for diversity and inclusion, such initiatives may be overlooked by program selection committees.Standardization of selection/promotion processes can help facilitate a leveled playing field.However, sponsorship of junior faculty, either within a department or within national organizations, needs to be "consciously fair and equitable" (Participant 15).Moreover, those in power (i.e., senior and mid-career physicians) must lead this charge to break the cycle.
Further exacerbating sexism in ENT, there exists a double standard for women in high-powered jobs.Men are more likely to be offered promotion for their potential, whereas women have to earn and advocate for their promotions.It is well established that imposter syndrome tends to affect women more than men. 14,15As such, men tend to be more effective advocates for themselves in this regard.Multiple participants lamented that they did not develop negotiation skills, had not self-promoted, and struggled to ask for what they want in the past.Without the tools and encouragement to self-promote, the aforementioned barriers (i.e., inequity of opportunities, Boy's Club culture, and overt sexism) can be insurmountable to young career women.Participants revealed: When it was brought to the chair's attention that I was eligible for promotion he admitted he "hadn't thought of it."(Participant 15) Women are made leaders when they prove they can do it-but we are rarely given the chance to "prove it.I see a lot of men also being promoted much earlier than I was promoted in the academic ladder.This is a problem.I am not sure how to fix it."(Participant 23) I know the one woman faculty in ENT was isolated and eventually left.The Chair of the department was a hard core good ole boy.(Participant 24) These data provide several poignant examples of participant experiences, and demonstrate the harsh implications of male-dominated culture.
Just as good sponsors are found across both genders, microaggressions can be from both male and female colleagues.One participant described "…the 'queen bee' syndrome-where a successful woman thinks that because she has struggled to achieve leadership, she should not sponsor other women and make it easier for them (i.e., they should struggle as much as she did)" (Participant 14).Unfortunately, this, too, is well a described phenomenon.
Another double standard prevalent in medicine is that women tend to get judged as women first and as physicians/leaders second. 13,16For example, in society women are commended for being kind, accommodating, and maternal whereas surgeons are praised for assertiveness, direct communication, and a strong leadership style. 17The dissonance between these stereotypes often yields a negative perception of female surgeons."When women have the qualities that make men good leaders, they are seen as aggressive, single-minded, etc.These unconscious biases present a huge barrier" (Participant 9).
Due in part to the generalization that women have better so-called "soft skills," they are often invited to lead diversity and inclusion initiatives, recruitment, and mentorship roles.Such roles are not consistently valued equally to directorships or division chair positions.Thus, they do not receive fiscal compensation and do not have protected time for the associated clerical responsibilities.Faucett et al. calls for redistribution of these roles to avoid the undue burden that "tokenism" places on women and underrepresented minorities in medicine. 12n reality, our narrow view of admirable traits for different roles is outdated.While there is much literature demonstrating differences in the perception of women and male leadership, 18 there is limited data to suggest that one gender is less effective than the other in leadership styles.In some settings, it has been demonstrated that patients with female physicians have lower mortality rates and fewer readmissions than those managed by male physicians. 19Women's leadership styles are also more likely to be team-based than male archetypal leadership, 18 an approach that is increasingly favored in academic medicine.Yet, women continue to battle a rigid glass ceiling in seeking leadership opportunities.
Implicit biases regarding gender roles carry into childcare and family responsibilities, as well.In society, female surgeons are typically expected to prioritize such responsibilities above work, though there are limited resources or accommodations provided for maternity leave, childcare, or sick leave.While women in this study affirmed that family should be prioritized above work (for both men and women), the disproportionate expectations placed on women require emotional energy and time that detracts from work.Men typically do not have to balance these obligations.Paradoxically, when men do request time or accommodations to prioritize familial responsibilities they are met with shock and adoration. 17This is a stark contrast to women who face tremendous barriers for even minor accommodations, such as private space for lactation post-partum. 13amilial responsibilities can also impede greater professional opportunities as women struggle to take time away from family to attend conferences or participate in continuing education.As previously discussed, familiarity breeds opportunity.Thus, absence of a robust network of women at national meetings may further perpetuate the paucity of women invited to speak or participate on committees.Hernandez-Brandi et al. demonstrated that 131 women were represented in the 400 female speaking roles at AHNS between 2007 and 2019. 7It is possible that active participants are invited back in subsequent years rather than nominating new faces to contribute.While this theory applies to both men and women, it has a disproportionate effect on women.Multiple participants spoke to this point, identifying the following barriers to speaking nationally: "[the] same people making the programs year after year and inviting the same people to the podium" (Participant 7), "Too much 'who you know' to get on panels" F I G U R E 2 Shifting culture in head and neck surgery.
(Participant 11), and a "Lack of awareness of who are coming up in the rank" (Participant 7).Further, they suggest that "…the committees selecting speakers need to include more women, and need to be very intentional about selecting a diversity of speakers" (Participant 6).Familial obligations can also preclude women from attending conferences; multiple participants commented on the challenges of traveling for work with a family at home.To combat this, the most recent International Conference on Head and Neck Cancer offered on-site childcare for participants.Unfortunately, this program remains an exception to the rule.This raises an important call to action for seniors in the field not only to nominate diverse, young faculty to speaking roles and but also to provide opportunities for young professional such as travel grants, on-site childcare and other resources to facilitate junior faculty involvement.
A final message from participants is that, although women should not be solely responsible for shifting the culture within ENT, they must take initiative in rendering professional opportunities for themselves.Junior faculty should also be encouraged to take initiative, volunteer early and frequently, and to perform well when opportunities arise in order to mitigate preexisting hierarchical culture and promote a more inclusive environment at the national level.For those not able to join committees, attending meetings and networking is the first step to building professional relationships.Establishing a niche is another method that some participants set themselves apart on the national sphere.Otherwise, hard work and accountability were the pillars of developing a strong professional reputation and thus opening the door to new professional opportunities.
Despite some improvement in female/underrepresentative recruitment to ENT, 2,8 the field of otolaryngology continues to demonstrate objective inequity in pay 9 and representation 10 for these groups.Nominating underrepresented minorities for unpaid, time-consuming leadership roles is likely contributing to burnout in these groups, as well as painting a misleading picture of equity in a field that has much work to be done. 3,16One of the most critical components to female and underrepresented minority success in ENT is continued conversations about the preexisting barriers (Figure 2).We must be transparent in how promotions are delegated to ensure that vulnerable groups are not shouldering the burdens of diversity and inclusion initiatives.Additionally, we must sponsor diverse young professionals to seize leadership opportunities on both local and national scales.

| Limitations
This study is limited by the restraints of qualitative research.Participation bias may skew the results; those who responded may have been more heavily impacted by their experiences regarding the topic at hand, leading them to respond.Further, the cohort recruited for this survey was limited to women who have previously presented at AHNS meetings.The binary nature of male versus female does not account for other minority experiences in ENT.Finally, we only queried speakers from AHNS.Thus, these experiences may be biased towards HN surgeons and may not fairly represent the experiences of otolaryngologists as a whole.Future studies may include generalists and specialists across other subspecialties within ENT.

| CONCLUSIONS
In this qualitative study, female speakers from recent AHNS conferences were surveyed regarding their experiences as women in ENT and perceived barriers to career advancement.Common themes included need for more diverse medical student recruitment, increased female faculty and leadership and destruction of the "Boy's Club" culture.Respondents collectively call for standardization of education on inequities to mitigate implicit bias and improved infrastructure to support women in both career opportunities and in balancing the disproportional familial responsibilities that women often face.
ThemesRepresentative quotes more focused at work, and changing tracks helped me go up for promotion on time (from assistant to associate) and early (from associate to full).I limited travel to a few times per year (prepandemic) because it's harder for me to be away from my family, but this also means not accepting every invitation to speak.I know that I run the risk of fewer and fewer invitations, but my family is more important to me.One of mentors tells me that no matter how supportive a husband is, the mom is still the mom.My husband is incredibly supportive and a real partner, but this still rings very true." (9) "My focus on my family produced the typical delay in productivity and promotion seen in many women.I am a single mother which completely eliminated the spousal advantage many males enjoy.As a single mom surgeon I made job changes while my son was an infant/ toddler/child.I made sure I lived within 10 minutes of hospital and my son's elementary school was walking distance and arranged my schedule to walk him to school 2-3 mornings a week.I moved my aging parents in so my son could benefit from their parenting, then took care of them as they approached end-of-life.I hired the best nanny I could find, referred from prior physician parents.I accepted that my income/productivity/academic 'success' would be limited or delayed.I was able to raise an amazing young man.I actually have poorer work-life balance now that he is in college and I can concentrate on my 'career.'Iwouldn't change a thing prioritizing my family over my 'career,' but I know of NO male surgeon who has done the same."(15) "I have had a long record of research and publications, and service on multiple committees.I also went to every single national meeting for more than a decade and that's really how people get to see you and meet you.I sent abstracts to all of these meetings.Then, when your abstract is accepted or you are invited, you have to do a really good job.You have to keep showing up.You have to keep showing up and you cannot say no to service when you are junior if your goal is to be in the club."(7) "I was recruited by senior males-the one in Thoracic told me that they had never trained a woman-I replied, well, I'm your woman.Challenge the male leaders-have THEM set the goal and hold them to it.
The barrier is not being nominated.Men are the gate keepers, by and large.They have to change."(22)Seizeopportunities,ormakethem"Takeevery opportunity you are given, no matter how small, and do a great job!This applies to panels, presentations, and committees.Don't forget to speak up.It's the only way to get noticed."(4)"(17)Shiftingtheculture Education and commitment to change "Educate faculty and residents on issues related to gender inequity so they can increase awareness.Develop assessment tools that can show how much progress (or not) the department is doing to promote equity."(3) T A B L E 3 Proposed solutions.
F I G U R E 1 Word Map: What are qualities of a good mentor?(Created using freewordcloudgenerator.com).