His opportunity, her burden: A narrative critical review of why women decline academic opportunities

This paper stems from a desire to deepen our own understanding of why women might ‘say no’ when allies and sponsors offer or create opportunities for advancement, leadership or recognition. The resulting disparity between representation by men and women in leadership positions, invited keynote speakers and publication counts in academic medicine is a stubborn and wicked problem that requires a synthesis of knowledge across multidisciplinary literature. Acknowledging the complexity of this topic, we selected a narrative critical review methodology to explore reasons why one man's opportunity might be a woman's burden in academic medicine.


| INTRODUCTION
2][3][4] A PubMed search of the keywords 'gender gap medicine' results in over 3000 publications, over 2500 in the last 10 years alone.Gender-based disparities are gaining attention because they persist in the face of great change.8][29][30][31][32][33][34] Though they were coined nearly 20 years ago, the metaphors of the 'leaky pipeline' (i.e., the consistent and noticeable reduction in the proportion of women, compared to men, at each progressive step up in promotion towards senior leadership) and 'Matilda effect' (i.e., under recognition and denial of contributions from women, compared to men) remain very relevant today. 4,16,35Clearly, our attempts to close the gender gap have been insufficient.

| The problem with strategies to date
We examined the literature on gender equity and identified three popular strategies for improving gender equity: (1) encourage women to 'lean in' or 'step up' 36,37 ; (2) increase awareness of the importance of diversity 38 ; and (3) encourage allies to take action. 39Unfortunately, these strategies are all reliant on the actions of individuals.We propose that meaningful change is not possible without addressing the influence of systemic biases and ineffective leadership.
The strategy to 'lean in' has affected very little change and has received significant criticism already, because it implies that the gender gap's presence and persistence are caused by a lack of effort on the part of women, 4,36,37 while many advocates in many fields still support the assumption that increasing awareness of gender inequity is sufficient to safeguarding women's progress through the leadership pipeline, evidence to the contrary goes back to the 1980s. 38,40,413][44][45] In the context of social status, and equity, the term 'allies' refers to individuals from a privileged group who are willing to take action that extends their own privilege to individuals from underrepresented groups 46,47 ; through allyship, men can support women's advancement, sharing the goals and responsibilities involved in the fight for gender equity.Allyship is a particularly important strategy in achieving gender equity given that significant power remains in the hands of men, and, thus, male allies may often be in a better position to change systems and ensure equitable recognition. 42,48,49As an example, women and allies have targeted the 'manel' (a panel of presenters dominated by men) for extinction. 11,23,49,50Allies that are aware of the 'manel' problem can use their power to mindfully recruit speakers for conferences, considering inclusivity and equity. 51wever, there remain significant and complex psychological and structural issues that prevent women from participating 21,52,53 ; alone, actions that extend privilege are not sufficient (Figure 1).What all of these strategies have in common is a failure to recognise the cultures and systems that waylay women's efforts to succeed-scholars have suggested representation will automatically lead to equity, that awareness is sufficient to change practice or that more effort on the part of women is the only thing required for change. 54These strategies reinforce the belief that women need to find a way to work within the existing culture and systems, instead of requiring the culture and systems to change in ways that recognise the value of equity and diversity. 9,48Given the resilience of the gender gap despite these efforts, we may only exacerbate the problem by placing additional burdens on individuals to fix or adapt to the problem.

| Exploring meaningful allyship
Meaningful allyship requires alignment with equity seeking groups with explicit recognition and acceptance of the need for further progress in the journey towards equality, but this has mainly been researched from the perspective of individual allies. 11,42,46Engaging in allyship that generates meaningful change requires informed action, which must be facilitated by faculty development and institutional change. 46,47The anecdote in Box 1 highlights this reality and illustrates some of the complexities involved in the work of allyship.Even when allies take action to advocate for representation of women, and women might benefit from such recognition, there are often unseen systemic barriers that hamper progress.
Box 1 An example of a scenario where divergent views occur between the invited speaker and the conference organisers.
Paolo and Martina made their way towards Joshua and Sharon who were seated at a nearby table within the conference exhibit hall.As longtime friends and collaborators, it was nice to meet together at this most recent international medical education conference-the COVID-19 pandemic had really strained their team dynamic.After ordering appetisers, the four scientists began sharing their experiences at the conference.Paolo had noted that he had found several of the talks very interesting.'I particularly found your panel discussion about competency-based medical education quite fascinating, Joshua'.
To complicate things further, saying 'no' is not always as overt as it appears; women might say 'no' overtly when asked directly, as in the anecdote, but they might also choose to delay acceptance, saying 'I hope you'll consider me for future events' or decide not to go after speaking engagements and other opportunities that could be available to them.And these responses lead to similar results-'manels' and other examples of women's underrepresentation in spaces of recognition and power stubbornly persist despite the recruitment efforts of allies.
This paper stems from a desire to draw on and deepen our own understanding of why women 'say no' in situations like these and to use this wisdom to support the work of allies.The figure below is grounded in conversations that we had as an authorship team and those we had as we discussed this anecdote with other women in academic medicine.It depicts the ways in which saying 'no' is complicated-'opportunities' cannot be evaluated outside of their context.Some of the reasons in the thought bubbles represent subjective beliefs, and some represent practical constraints on material resources, such as finances and time.Although the ally's thoughts indicate a genuine desire to recognise her expertise, accompanied by acknowledgement of the need to sponsor women, he is not considering the significant material constraints that limit her ability to accept the invitation.In our own examination of reasons behind 'why women say no', we identified strongly with constraints on time.Recognising a need to illuminate these barriers and build capacity amongst allies, we looked to the literature to determine if there is evidence that, compared to men, women have less time for career advancement opportunities such as research and leadership.To deepen our understanding of this phenomenon, we then sought to explore why women might have less time for research and leadership, compared to men.
And particularly, in cultures where gender equality is the norm, how are gender disparities maintained?We offer practical guidance on how allies can effectively take informed action, going beyond extending more invitations to women to address the psychological and material barriers that undermine women's ability to say 'yes'.

| Reflexivity statement
Our team is comprised of three academics who identify as women and are active in medical education.We have worked and trained at different institutions in Canada, trained in different disciplines and hold different family statuses, racial identifications and career stages.
Dr. Monteiro is a mid-career researcher, trained in cognitive psychology-a perspective that greatly informed our discussions.She identifies as a person of colour and parent to young adults.Dr. Chan is a practising academic physician in emergency medicine.She is an active health professions' education researcher who identifies as being in her mid-career.She has held many leadership positions at her institution and at a national level.She identifies as a person of colour, and her observations and experiences during her climb through the ranks of leadership greatly impacted our conversations.Dr. Kahlke is an early career researcher with a young family.She holds a PhD in Education, and her sociocultural perspective helped to balance and 'Yes', nodded Martina.'But … I was surprised that there wasn't a single woman or non-binary person on that stage with you.I was actually going to say something to you about that, Josh, because we're friends and collaborators-it would have been nice to have a more equitable slate of experts on that conference dais.A "manel" is not what I expected from you'.Joshua sighed.He knew this would come up-Martina was always known for speaking her mind, and he actually agreed with her.However, she did not know the misery and drama that existed in that backstory.Picking up on Joshua's non-verbal cues, Sharon piped up: 'I'm sure Josh didn't mean for that panel to turn into a manel, Martina.Right Josh?' Josh went on to explain that he was well aware of the optics of the final selection of panellists.Though he did not receive any specific direction from the conference chair or coordinators, he was familiar with all of the recent criticisms of 'manels' (i.e., a male-centred or dominated panel of experts)-both in the literature and social media.He had worried that there would be criticisms levelled at the conference organisers (and himself), but he assured his friends that he was not oblivious to the optics.As the discussion continued, Paolo related his own experience on a different conference's organising committee.
'What if the women or non-binary individuals you invite decline the opportunity?What if only the men say yes?I'm constantly running into this problem.The number needed to ask is much higher I find …'.Paolo reflected.
Paolo described how the committee, when selecting the keynote for an international conference, was very mindful of the 'manel' problem and committed to inviting women and non-binary speakers.He thought it should have been an easy task because the front runners were all women, all of whom had successful academic careers and experts on the topic.However, when he reached out to invite the speakers, he was mystified by the similar refrain expressed by each woman: 'Thank you for the invitation, but I must decline'.
'Honestly, I would love any pro-tips you have for how to get more of the women in our field to say yes to opportunities we are trying to make for them', stated an exasperated Paolo.Josh nodded vigorously in agreement and added: 'Sharon and Martina, we know you're not representing all women-and neither of you identifies as non-binarybut do you have any suggestions for how we could improve our process?What are we doing wrong?' frame our focus on literatures from cognitive psychology.Spurred by an interest in the anecdote presented above, we began this review by consulting our own lived experience of the gender gap and discussed the reasons that women might say 'no' when faced with an opportunity that might be seen as beneficial to our career advancement.Differences in our intersectional identities were critical in generating robust discussions that resulted in identification of myriad reasons why different women might say no.Our different disciplinary perspectives also informed our understanding of the problem and the literatures we consulted.To enhance our own scholarly perspectives, we have aimed to add rigour to our analysis by conducting a critical narrative review of the literature in this area.

| Procedure
A critical narrative review is useful for really stubborn problems that may require a new approach. 55The important feature of a critical narrative review is the reviewer, who acts as the research instrument, using their perspective to interpret literature and offer a new approach. 55For the stubborn problem we describe above, we found this methodology useful to help us outline our approach to the literature related to this topic and thread together a work of scholarship that seeks to clarify and challenge the current state of work in this area.Our critical review draws on diverse literatures to seek out more nuanced explanations for why women say no, or, more specifically, why they cannot say yes, to opportunities for career advancement.
When conducting critical reviews, researchers do not seek a comprehensive accounting of everything that has been said on a topic; rather, they draw on expertise within the team and consult with experts outside the team to select perspectives that best inform their questions and that have the greatest potential to shift their field's thinking on their topic. 55e first author (SM) conducted the primary literature search using the following search terms in Google Scholar and PubMed: 'Women speakers conference'; 'Women leaders medicine'; 'Women leaders business'; 'Why aren't women in business'; 'What aren't women in medicine'; 'personal decision women in medicine'; 'why do women say no to advancement'; and 'gender gap medicine'.As we were interested in documenting classic theories and strategies, learning from modern theories and mapping recurring trends, we did not limit our search by year.Over 100 articles were screened by the first author, retaining those with high relevance to our objective and empirical studies that offered explanations of the gender gap or strategies to address it.This screening process, conducted in 2020, identified 36 articles from 1991 to 2020.The first author explored these articles for evidence that women have less time for these 'opportunities' because they have greater time demands in other areas.Findings from this literature were organised to offer insights on the gender gap, reasons women say yes, no or are not invited to various academic opportunities including sitting on committees, collaborating on research or speaking at a conference.These insights were shared with all authors who prioritised this question: Do women have less time for career advancement opportunities, such as speaking engagements, research and leadership?We drew on robust literatures from Psychology (cognitive, industrial and educational), Sociology, Health Professions Education and Business to confirm that competing pressures on women's time negatively impacts their decisions about career advancement opportunities.This evidence is described in detail in the first section of the results below.
We then turned to these same literatures in search of potential explanations for why this gendered imbalance in available time for career advancement has proved so persistent, asking 1.Why might women have less time for career advancement opportunities? 2. Why do women have less time for research and leadership? 3. How are these disparities maintained?Additional literature was added by all authors as we progressed through the critical review process.Finally, in effort to recommend novel and evidence-based solutions to remedy the gender gap in our field, we asked: How can allies help?
To address these questions, we engaged in an iterative cycle of refining the problem through group discussion, identifying new search directions and returning to these literatures.In this way, our searches and analyses were intertwined.For example, some search directions proved less relevant to our evolving research questions and were dropped from our analysis.In keeping with critical review methodologies, other perspectives were determined to be particularly fruitful, such as stereotype theory from cognitive psychology, which offered insight into the mechanisms that contribute to the persistence of the gender gap and cause women to say 'no'.Thus, stereotype literature forms the backbone of our findings related to these three questions.

| Results
Within our search, we found compelling literature that helped us to answer our three core questions.In the following sections, we have outlined our key findings, organised as responses to our questions.

| Why might women have less time for career advancement opportunities?
In addition to evidence that women receive less recognition for their research and fewer invitations to collaborate in research and engage in leadership activities, our analysis of the literature from psychology, sociology, business and medicine supports our argument that women say no to these opportunities because they disproportionately take on other tasks that are not as well recognised, specifically those related to caretaking in their personal lives or supporting others at work. 12,36,56Studies showing differences in well-compensated clinical hours between men and women are mirror images of studies showing differences between men and women in time spent on supporting others. 57,58For example, women are more likely to sacrifice work responsibilities to care for children/family; globally, 75% of unpaid work is done by women, including child and elder care. 4,59Women are more likely to spend their time acting as an academic mentor, 57 a pattern that extends even to 'ghost advising', or serving as an academic mentor without explicit recognition. 60These mentoring and caretaking activities are critical to the functioning of academia and society more broadly, but they come at great cost to women.The result of this imbalance in labour is clear-women are slower to advance their careers because they have less time to spend on well recognised and compensated research and self-promotion/tenure seeking activities. 57On average, women simply do not have the same amount of time to commit to applying for and acting in leadership positions, preparing for keynotes or engaging in other time-consuming but high profile academic activities.Without careful consideration for how to distribute these commitments and recognition of these contributions equitably, women are likely to continue to say no to the very opportunities that can close the gap.

| Why do women have less time for research and leadership?
Historically, women in most societies have been expected to play a nurturing family-and community-oriented role, while men develop identities outside the home through their career or talents. 4,40These expectations persist today; indeed, socialisation into these domestic roles continues to reinforce expectations that women of many cultures should commit their time and energy to the benefit of the community over individual career advancement. 61though gender roles have certainly evolved, with more women working outside the home in diverse careers, there remain powerful gender stereotypes rooted in these traditional expectations; the stereotype of women as nurturing and less suited for leadership positions (thought to require assertiveness) is even stronger today than it used to be. 38,51,62,63Stereotypes, which are learned from birth and entrenched as early as 6 years of age, form societal expectations and limitations around how men and women should or should not behave. 9,64For example, stereotypes characterise female academic clinicians as more nurturing, while men are characterised as brilliant assertive leaders. 9,65,66As a consequence, women are ushered into underrecognised supportive roles that are often disguised as opportunities but limit so not facilitate further advancement; these decisions are often reactions to the stereotype that men have the required characteristics for leadership. 9Conversely, women may avoid higher profile or highly competitive situations, such as vying for keynote speaker engagements or senior leadership positions, because of their self-perceived lack of assertiveness, a perception that may be confirmed by their mentors. 16

| HOW ARE THESE DISPARITIES MAINTAINED?
Our literature review identified possible mechanisms that maintain these disparities.It is crystal clear that the problem is not women's capability; studies consistently demonstrate equal cognitive capacity of men and women in all types of academic, managerial, mentorship and leadership activities. 4,38Indeed, several studies have highlighted benefits of including women in leadership. 67Instead, social consequences for breaking with firmly entrenched stereotypes can be perpetrated by others in a social environment (e.g., criticism) or through self-sabotage (e.g., self-doubt). 68,69Social consequences generally occur because women are rarely expected in high profile roles and they are burdened with a greater need to prove themselves and demonstrate their expertise. 70,71For example, colleagues and search committees cast doubt on women's qualifications when they apply for senior leadership positions because women do not 'look like leaders'. 51,64,72,73This puts women in positions taking on the extra labour of convincing search committees and co-workers that they are assertive enough, or 'male', enough. 69,70,74,75Conversely, women are expected to have better interpersonal skills compared to men and are held to a different standard: Whether rated as a teacher, clinician, scientist or leader, women are criticised more harshly if their interpersonal skills are perceived as weak, while men are not. 64,76Women are encouraged to step up and lean in, but there is little recognition for the risks they take and heightened barriers they face when doing so. 56ongside the external pressures and consequences involved in challenging stereotypes, there is a self-sabotaging phenomenon described in the psychology literature as stereotype threat. 77For example, a common stereotype of women (noted in published work since the 1990s but present in academic discourse for decades prior to that) is a belief that women are weaker at learning and mastering concepts in mathematics. 64,78,79When placed in a competitive context requiring math skills, women often perform poorly or choose not to compete at all. 79This phenomenon is not related to ability, as it occurs even for women with exceptional aptitude and knowledge of the domain. 64,78,79A more modern conceptualization of this issue is the imposter phenomenon. 80,81All individuals who identify with a negative stereotype are susceptible to the phenomenon of stereotype threat, explained by a sub-conscious drop in confidence and performance.The evidence suggests that knowledge and fear of being compared to a negative stereotype cause people to lose confidence and inadvertently confirm the stereotype.Decades of research on stereotype threat reveals its impact in domains such as sports, 82 leadership 83,84 and communication skills. 85For example, women, who are aware of the negative stereotype regarding women and athletic ability, may opt out of competitive sports activities altogether.Men are not immune 86 ; in one study, men were observed to perform in ways that were less empathetic, or caring, when primed with the stereotype that women are more nurturing than men, compared to men who were not primed with this stereotype. 87Even as women venture into non-traditional roles, the phenomenon of stereotype threat may serve to support harmful stereotypes. 88,89

| DISCUSSION
The gender gap remains visible in academic medicine, particularly within leadership and traditional metrics of academic productivity.
There is much work to be done to remedy gender discrimination; however, knowing what remedies will work is proving to be a daunting challenge.In this paper, we argue that many efforts aimed at supporting, advancing and promoting women are not met with success.
Not only do some of these efforts miss their intended target but some of them also perpetuate discrimination they seek to thwart.In our critical review, we provide evidence that women have less time to dedicate to research and self-promotion activities, creating a gap between men and women in academic medicine.Simultaneously, the gender gap is maintained because men spend less time than women on teaching and mentorship and more time on better recognised academic activities.The gender gap in academic leadership is widened as academic career metrics value research and self-promotion above teaching and mentorship.Additionally, we have offered insights into how stereotypes function to perpetuate the gender gap.Stereotypes are oversimplified, inaccurate and often harmful representations of large groups within society.Stereotypes compartmentalise unique individuals through categories that reduce their complexity to a few characteristics, mis-represent who they are, constrain their activities and prevent them from accessing fair compensation and the power to make change.While many are aware of the diverse roles that women take on, especially in relation to historical perspectives, a dominant stereotype of women as caring and nurturing greatly influences how they perceive leadership opportunities, how they are perceived as leaders and critically how they choose to, or are expected to, use their time in academic medicine.As a result, women may also decide not to put themselves forward for advancement opportunities because they do not 'see themselves' in these roles and contexts.
Our review of stereotypes cannot account for the complex and intersectional identities (and the power relations imbued in them) that individuals take up or are saddled with in different moments.We recognise that we have taken to task binary stereotypes that construct only 'woman' and 'man'.These binary stereotypes are harmful for others beyond those who identify as women and can undermine the very existence of those who identify as non-binary or trans; these stereotype categories also impact people differently when they are also subject to discrimination and stereotypes based on other aspects of their identity, such as race, sexuality or dis/ability (for example).The intersectional impacts of gender and other stereotypes deserve significant attention but have not been addressed in the literatures we examined.We believe that the advancement of women can only be just when we address all aspects of intersectional discrimination across equity-deserving groups.Some of this work involves taking to task binary stereotypes that impact women, and most of the literature we encountered focusses exclusively on these categories.Clearly, more work needs to be done to understand the impact of gender stereotypes on the advancement of those who do not conform to these binary categories and those who experience intersectional discrimination.
Thus, we urgently need to think beyond the reasons that 'women' say no to consider why this woman is saying no, how intersecting identities impact stereotypes and women's decisions and why others who are underrepresented in well-recognised spaces might say no.We need to understand the psychosocial context in which women make decisions about their careers, identifying the multitude of reasons 'why women say no' when they encounter opportunities for career advancement.Until we address these complexities, the goal of ending gender discrimination will be unattainable; we cannot afford such failure.

| RECOMMENDATIONS: HOW CAN ALLIES HELP?
Recommendations for addressing the impact of stereotypes and stereotype threat require specific and concrete actions not vague guidelines. 4,38Critically, allies need support to amplify and recognise the contributions and perspectives of women and underrepresented groups.To address the contributions of time constraints and stereotypes towards maintaining the gender gap in academic medicine, we make the following key recommendations (see Figure 2 for highlights): highlights the key recommendations for allies to support women and other underrepresented groups.[Color figure can be viewed at wileyonlinelibrary.com] 1. Reward women equitably for the gendered work they currently do.
3. Develop and support the people that are underrepresented.

| Reward women equitably for the gendered work they currently do
We can all work with our department or programme leaders to realign career merit systems to create a more equitable system that fairly values the work of teachers and mentors.There are often conflicting value statements regarding the importance of research activities, compared to clinical education, administration, along with a lack of acknowledgement for caregiving responsibilities that occur outside of the workplace.On one hand, education activities produce revenue and are highly valued in some discourses at the institutional level.On the other hand, grants, research awards and publications are prioritised in annual career reviews and promotion decisions.In a selfperpetuating manner, those with more research productivity gain local, national and international status, which makes them more likely to receive invitations to present or collaborate on further research.
People in positions of leadership, such as department chair, programme director or dean, can address the gender gap by changing the culture and reward systems of their group.First, faculty who contribute extensively to education can be celebrated on the institution website and rewarded with resources to manage their teaching responsibilities.Second, it is time to consider new approaches to defining merit and setting incentives. 90,91The current evaluation/merit system is biased against women who may be more likely to prioritise workplace responsibilities such as teaching and mentorship activities-these activities are not recognised or compensated comparably with academic publications and keynotes.
Career review and merit systems may not acknowledge the development hours required to produce courses or supervise trainees.However, these activities are critical to the mission of an academic institution.
There is also overwhelming evidence that the dominant clinical and academic culture typically benefits people with fewer responsibilities outside the workplace context; historically, those have been men.This translates into inequitable evaluations of many women who create a balanced academic and personal portfolio, compared to many men who may prioritise their own scholarship.If our institutions truly value gender diversity, then workplace expectations and merit systems must account for women's gendered labour that occurs both on the job and off the job.This could mean evaluating workplace activities relative to individuals' domestic labour responsibilities, the majority of which falls on women's shoulders.This approach is largely untried in academic medicine, to our knowledge.

| Diversify models of leadership
This critical review was inspired by the question 'why women say no' to opportunities, but by no means are we implying that 'women should always say yes' to opportunities.Indeed, we have argued that an opportunity for one person may be a burden to another.Not only because of competing demands but also because it does not fit their personal values.Effective leadership in academia can take many forms, including choosing not to participate or choosing to deviate from the norm.We all have stereotypes of 'strong' leadership, which encourage behaviours that can exclude women or demand conformity with masculine stereotypes.For example, societal pressure encourages women to wait their turn to speak or exhibit more polite behaviours. 4However, this can be interpreted as meek or representative of a lack of passion and innovation.Women can challenge this stereotype through their behaviours and acceptance of being more vocal.
Allies can take steps to amplify their female peers to ensure they are heard.This technique can allow women to be heard, since you can repeat what they say with an endorsement and acknowledgement; the women of the Obama administration used this tactic to ensure their peers were heard. 92Rather than leaning into opportunities, women and allies can lean in to changing the culture, change how we think about effective leadership and make it clear that microaggressions and toxic behaviours are not accepted.
Allies can create safe spaces for discussion about stereotypes and ways to challenge or change them.Critically, diverse role models have the most impact at changing stereotypes, 67,93 as stereotypes are based on limited exposure to diverse experiences and views, make efforts to showcase and celebrate the diversity in your programme.
As we do this, remember that stereotype threat and imposter syndrome have a strong influence on maintaining inequity 18,94 ; people of all genders will require coaching to help change the culture.For example, men may not feel comfortable or competent at mentorship activities and may not identify as an ally. 61,80,95A concrete strategy for involving all people, regardless of their affinity to allyship, is to encourage and coach men to take on more activities that are typically managed by women.Additionally, allies can help translate different philosophies into leadership styles, models and behaviours.Exploring how these translations fit into our organisation, department or programme can help everyone recognise the qualities that individuals from currently underrepresented groups might offer as leaders.

| Develop and support the people that are underrepresented, including but not limited to women
Differences in granting success within your research or education group can guide support for equity deserving groups to help right the scales.While new evidence is not required to confirm inequity, continuing to capture these data can highlight where the greatest need lies.In our literature review, we have indicated that in academic contexts, women are often ignored, assessed by different standards or their contributions attributed to men. 4,56,71Although our selected literature did not explicitly acknowledge this, we propose these same challenges are experienced by all underrepresented groups, including non-binary individuals and men with intersectional identities.Academic institutions can be proactive in plans to sustain good leadership by extending invitations to faculty from all underrepresented groups to apply to leadership positions.Institutions can also examine leadership job descriptions to eliminate language that favours stereotypically male leadership traits and instead emphasise different strengths (e.g., links between leadership and mentorship, and collaborative approaches to leadership).Unsurprisingly, women report increased cognitive effort and stress to be seen, stay competitive or even in the game, because of the need to also challenge stereotypes. 67Consider inviting feedback from women and other underrepresented identities to share their concerns over barriers and reasons they 'say no'.Work with your programme for faculty development to create curriculum for women and other underrepresented groups to develop the skills to showcase all their contributions in their curriculum vitae. 96,97Conversely, other forms of faculty development can help clarify the value of diverse talents, contributions and views.

| Consider creating systems level changes that support people in ways that account and adjust for inequities
We have highlighted the different ways that men and women use their time.For women, this can translate into additional financial burdens over and above standard professional expenses.For example, faculty members with childcare responsibilities (which are often disproportionately women but certainly will include others like single parents of any gender) must consider childcare expenses over and above the airfare, registration and hotel costs for a typical conference. 98However, these are not standard expenses in a professional development allowance. 99,100While we understand, these financial stipends alone are not sufficient to compensate for the disproportionate burden that female academics face; however, it does provide an opportunity to acknowledge that these challenges exist and work towards some systemic change that allows for improvement.
When calls for leadership roles or local grants are announced, consider nominating a woman or someone from an underrepresented group and openly acknowledge that stereotypes continue to influence our vision of a 'leader'. 73,95Consider the intersectionality of your peer group-are there hidden aspects of their identity that leads to differences in your experiences?Learn about and appreciate these differences.By seeking to educate yourself on the evidence, you can help reduce the burden placed on women and underrepresented groups to educate others when advocating for themselves.Ensure you are not simply replicating yourself, by only supporting trainees or junior faculty that are like you, but that you are fostering underrepresented talent.Consider recruiting the power of social media to intentionally promote your own and your colleagues' work. 101

| CONCLUSION
Women make up over 50% of matriculants to medical schools, but they hold less than 15% of leadership positions in medical schools.
Such inequity harms our medical education efforts and the women we train.Seemingly feminist axioms, like 'lean in', encouraged women to work harder to close the gap.Even objectively positive messaging around imposter syndrome, or the old adage 'fake it till you make it' have a darker side-suggesting that women only need to get out of their own way.These axioms ignore powerful systemic barriers and significant differences in personal values that shape these choices and opportunities.Allies must work harder alongside the women colleagues to create real and lasting change.We can-and must-do

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I G U R E 1 A cartoon illustrating the divergent thinking between the characters in the vignette featured in Box 1 of this paper.[Color figure can be viewed at wileyonlinelibrary.com] better. of Northern British Columbia), non-profit organisations (PSI Foundation) and governmental sources (Government of Ontario).RK discloses unrelated grants from the Social Sciences Humanities Research Council of Canada, University of Ottawa, the Royal College of Physicians and Surgeons of Canada and the Society of Directors of Research in Medical Education.