INTRODUCTION

As in almost every other field where gender inequity is present, academic medicine, too, continues to struggle. Disparities in salary 1, 2, grant funding 3, promotion 4, and retention 5 remain and there has been a failure to affect work culture in a way that fully addresses persistent barriers and ensures that women have the resources and support needed to reach their highest potential 6. This disparity is starkly evident in top leadership roles. Women remain stubbornly underrepresented in executive leadership positions such as medical school deans (19%) and department chairs (19%) and there has been little change over the past 10 years 7, 8. These leadership positions are especially important because they come with power, resources, and influence. Diversity in leadership has many benefits and having more women leaders may influence organizational culture in truly meaningful ways such as addressing sexual harassment in the workplace 9,10,11,12.

Multiple reasons for women’s continued lagging behind include poor or absent mentoring 13,14,15, lack of support (resources, space, funding) 16, work-life choices 17, 18, and overt and unconscious gender bias 19,20,21. Minority faculty face similar barriers and women of color are disproportionately impacted when it comes to academic advancement and attaining leadership positions 22. By training the next generation of clinicians and scientists, academic medicine has the potential to promote gender equity more broadly 23.

Many have looked beyond academic medicine for solutions and are shining a light on sponsorship as a path to leadership diversity 24,25,26,27,28,29,30,31. In business settings, sponsorship is a professional relationship that focuses on career advancement and rests on power 32, 33. In business, mentorship is viewed as necessary, but not sufficient for high advancement, especially for women 34, 35. Fortune 500 companies have developed structured sponsorship programs to advance women and minorities into leadership roles 35. Mentorship, traditionally the most important professional relationship in academic medicine, differs in substantive ways from sponsorship, as our prior work has shown 36. Sponsorship in contrast to mentorship is often an episodic, transactional relationship that is critical for high-level advancement. Mentors may serve as sponsors only when they have influential roles with access to resources and networks. However, if women in medicine experience the same mentoring pitfalls as in business (for example, by aligning themselves with mentors who have little organizational influence) 13, 14, 37, greater attention to sponsorship could prove fundamental to advancing women’s careers.

Although sponsorship has been promoted as a way to diversify leadership in academic medicine, little is known about how sponsorship works in this professional setting and how it influences advancement. The purpose of this qualitative study was to explore how sponsorship functions as a professional relationship in academic medicine and its relationship to gender.

METHODS

Study Design and Sample

We conducted semi-structured, one-on-one interviews with sponsors and protégés individually at Johns Hopkins University School of Medicine between March and November 2016. We defined sponsors as faculty in a position of influence and power who could promote the careers of junior faculty and defined protégés as junior faculty recognized for having leadership potential. Using a purposive sampling strategy based on these definitions, we targeted all clinical department chairs in the school of medicine (N = 19), and to identify protégés, we contacted a subset of faculty who had participated in the Johns Hopkins Medicine Dean’s Leadership Program between 2009 and 2014. The Johns Hopkins Medicine Dean’s Leadership Program is an internal executive leadership training program offered yearly. Participants are nominated by department chairs specifically for their leadership potential. We over-sampled for women and underrepresented in medicine (UIM) faculty participants in this program. Potential informants were sent an email inviting them to participate in a study about paths to leadership in academic medicine. No compensation was provided. A Johns Hopkins Medicine Institutional Review Board approved this study.

Data Collection

An interview guide was developed using literature on leadership and sponsorship 32, 33. We conducted four pilot interviews (two with sponsors and two with protégés) to gauge the length of the interview and to ensure clarity of questions and revised the interview guide accordingly. Interviews began by having the informant read a short vignette about sponsorship and definitions of the terms “sponsor” and “protégé.” The final interview guides varied slightly for sponsors and protégés (Table 1). Interviews, conducted by two research team members (MSA and RBL), lasted 30–40 min and were audiotaped, transcribed, and de-identified. To ensure confidentiality, we report limited demographic characteristics including gender, current rank, specialty (for protégés), and years as department chair (for sponsors). Informants provided written consent.

Table 1 Semi-structured interview question prompts
Full size table

Data Analysis

All transcripts were read by three researchers (MSA, KS, and RBL) using an “editing analysis style” to develop initial categories into a provisional coding template. With this method, the researcher reads the transcripts to identify meaningful segments of text that both stand on their own and are related to the purpose of the study 38. Each remaining member of the study team read five or six of the 23 transcripts using the provisional template to code categories from the transcripts. We then met as an entire study team to modify, add, and delete categories to create a final coding template. Next, the team organized the categories in the coding template into themes. After that stage, researchers MSA and RBL reread all transcripts to confirm the final coding template and the identified themes, and to select representative quotes for presentation. In a final stage, the entire team reviewed all themes and their descriptions and agreed upon the selected quotes. We attribute quotes to a sponsor or a protégé. Minor edits were made to quotes for readability. We shared the themes with study informants to make sure that we accurately captured their perspectives.

RESULTS

Informant Characteristics

Interviews were conducted with 12 sponsors and 11 protégés. All sponsors were full professor men. The mean number of years in the role of department chair was 9 with a range of 1–20. Of the protégés (55% women), current rank was four full professors (two women), five associate professors (two women), and two assistant professors (both women). One protégé had a PhD degree and the remainder had MD degrees. Protégé specialty included the following: anesthesia and critical care medicine (2), surgery (2), neurology (1), internal medicine (5), and behavioral science (1). Four of the 23 informants were UIM.

Themes

We identified three themes: (1) people (how and who): women seek out and receive sponsorship differently; (2) process (faster and further): sponsorship provides an extra boost, especially for women; and (3) politics and culture (playing favorites and paying it forward): sponsorship and fairness.

Theme 1: People (How and Who): Women Seek Out and Receive Sponsorship Differently

Sponsors and protégés noted differences in how sponsorship happens and stated that women were less likely to actively seek out or be identified for sponsorship. Informants alluded to gender stereotypes that might influence the specific attributes expected of potential leaders and the types of leadership roles that might be considered for a protégé.

Male protégés used language that suggested they felt much more comfortable proactively seeking out sponsorship. This protégé talked about being on faculty for several years, establishing his clinical practice and then wanting to move into more administrative and leadership roles and therefore specifically seeking out sponsorship.

…I go to my chair, and I say, hey, I really want this position in our association, and I’d like you to nominate me for it... (Man, protégé)

This protégé acknowledged how his gender and past experiences informed his willingness to take risks and viewed being a man as an advantage when it came to being identified as a protégé.

…as a person being sponsored, I think it’s easier for me to [take] a risk, to do this ‘thing’, because I have not been brought up short as many times in my life as someone else might have. And so taking risks may feel safer to me. (Man, protégé)

Protégés described how being a woman might present a disadvantage in being noticed as a protégé or in explicitly seeking out sponsorship.

I think in general, we tend to think that we can work hard, we tend to be more collaborative and not wanting to ever get credit for something… and therefore not really willing to put ourselves out there in the same way as many men do, and so I think that's to our detriment when it comes to sponsorship. (Woman, protégé)

And,

I think just being more aggressive in terms of seeking out sponsorship, letting people know what you're interested in doing, being very clear and consistent in your own set of goals and visions, that’s always been something I’ve struggled with too. (Woman, protégé)

Sponsors similarly recognized these issues when describing women and sponsorship.

There are obviously gender differences in terms of how women seek out opportunities and things. It’s a little different for men. (Sponsor)

This sponsor describes why some women may not be sponsored.

Unless they verbalize their interest in leadership or are outgoing enough, or have extraordinary leadership capabilities which are on display all the time, they often won’t get the opportunity or they won’t be asked or somebody won’t offer to be their sponsor. (Sponsor)

Sponsors and women protégés perceived that women were less likely to be beneficiaries of effective sponsorship.

And so the reason I say this is my husband is faculty, I was a professor as well, for him people will say, oh, you should apply for this, or we thought of you for these things, or they’re traveling to a meeting and somebody says, oh, did you do this leadership program or here’s an opportunity. And I don’t think that's as concrete for women. (Woman, protégé)

This sponsor describes another reason why women may not be sponsored and thus selected for leadership roles.

I think it’s a function of how we define the role and make it such a high bar that it’s near impossible to have all those attributes that would make you a candidate for the job. So we’re almost unconsciously selecting out anybody who could stretch to get to be eligible (Sponsor)

Here a protégé describes how women often are identified for specific types of roles.

So they’re always going to select the woman for some type of position…I call them the touchy feely jobs that are designed to make trainees or other faculty feel more comfortable. Then, I see primarily men get sponsored as replacement Principle Investigators. That’s where I see complete gender delineation. (Woman, protégé)

Theme 2: Process (Faster and Further): Sponsorship Provides an Extra Boost, Especially for Women

Both sponsors and protégés reported that sponsorship was critical to high-level advancement. Women and UIM faculty were believed to benefit specifically from the external credibility and access to networks and resources that sponsorship provides.

The following quotes highlight the importance of sponsorship for advancing to top leadership roles where competition is greater.

It seems really, really, really important in academics. I’m actually surprised at how much getting selected to be in leadership positions or to take advantage of opportunities has a lot to do with who’s willing to put you up… (Woman, protégé)

And,

I think that sponsorship plays a huge role as to whether someone will become a leader…. It also plays a huge role as to whether one will not become a leader. (Woman, protégé)

Women protégés and sponsors reported that women in particular benefited from the extra support that sponsorship provided. This protégé described difficulty accessing powerful networks without a sponsor.

…that networking thing, unless you’re great at doing it on your own, I think it really requires a lot of sponsorship…maybe I could have been promoted or moved up the ranks faster, but it seemed less important before and it’s getting to be really, really important now. Yeah, it feels to me like the higher up you go, the more you need it and the more you need to be good at seeking it out. (Woman, protégé)

Another protégé described how backing from her sponsor contributed to her success because it provided credibility. In this situation, her sponsor had advocated for her to go in his place and take a leadership role on an international project.

…I said, ‘No, we should go together because nobody would take me seriously if you don’t come with me to endorse me.’ We went, he endorsed me, and then subsequently I’ve gone on my own- he endorsed me- but then stepped aside and so I was able to do this… (Woman, protégé)

The same protégé spoke about the impact of her sponsor advocating for her, this time to receive an official title for work she was already doing and the backing this provided for her.

…we actually talked about this in our leadership development program asking, ‘Does a title matter?’ I don’t know but it probably does especially for certain groups of people, women I would say is one group, people of color is another group, you know it just validates you. (Woman, protégé)

This protégé clearly states the need for sponsorship specifically focused on women.

..we should just recognize that we should sponsor women…just having a clearly defined way in which women are sponsored so they actually can progress as quickly and as well as men. (Woman, protégé)

Similarly, these sponsors acknowledge that women require extra support to receive the same opportunities as men.

…there is the possibility that people are going to fly under the radar and not have someone promoting them and pushing them as a worthy candidate. I mean obviously we’re trying our best right now to do this for women faculty. (Sponsor)

And,

…we have to advocate for our women faculty members so that they can have the same opportunities that the men have had. (Sponsor)

Theme 3: Politics and Culture (Playing Favorites and Paying It Forward): Sponsorship and Fairness

Many informants viewed sponsorship as a way to “pay it forward” by supporting the career advancement of others. This was congruent with professional values such as collegiality, collaboration, and stewardship of the academic mission. However, informants also revealed concern about the potential for favoritism and bias in sponsorship as highlighted in the following quotes:

Well, I think it could be as simple as directors like some people more than others, and I don’t think that’s fair but that’s kind of human nature. (Man, protégé)

And,

…obviously it introduces all kinds of biases for people who are introverted, for women, and so on and so forth. But I also recognize that that’s most of how this works it seems to me. (Woman, protégé)

And,

I think it’s also really important for a sponsor to be aware of their own biases to make sure you’re not always sponsoring the same limited number of people who are closely in your network, you know that kind of thing (Woman, protégé)

And,

…whatever my own biases might be or my blinders that I reflected earlier, I might not think about someone who I should have. Again, in the role of a department chair in particular, that’s important. (Sponsor)

Others recognized the transactional nature and the lack of transparency of sponsorship as problematic as revealed in these quotes:

…sponsorship, in some ways, is a closed activity. (Sponsor)

And,

…for my colleagues who are in business, often [sponsorship] is done a little less altruistically; often, having this person that’s perhaps a good employee and a trusted person will help advance their own career, their own agenda. I think in academic medicine, because many of us perceive it to be—it may not be, but we perceive it to be more egalitarian and perhaps based on one’s real accomplishments. (Sponsor)

This sponsor recognizes the impact of sponsorship on the perception of fairness and equal access to opportunities in his sphere of influence.

Is there any perception of unfairness, why did I get this sponsor and somebody else got that other sponsor? Did I get the better one? So you do risk compromising lateral relationships in the name of fostering vertical relationships? (Sponsor)

DISCUSSION

Sponsorship is increasingly put forward as a method to promote leadership diversity in academic medicine 26, 31, 39, 40. We have previously described key similarities and differences between sponsorship and mentorship and briefly summarized challenges women have faced related to mentorship (such as aligning themselves with mentors with less power and influence) which may impact their experiences with sponsorship 36. Here we present a more in-depth exploration of gender and sponsorship in academic medicine. Informants agreed that sponsorship was particularly important for women by providing an extra and necessary boost for career advancement. As mentioned, business organizations have used sponsorship programs to successfully diversify leadership 32 and now report on the many benefits of diverse leadership including but not limited to improved financial performance 9. The comments of our informants share similarities with women’s experiences of sponsorship in business settings including some of the challenges related to being selected for sponsorship as well as actively seeking it out 32. Informants in our study also describe the disconnect between sponsorship and professional norms in academic medicine such as transparency, fairness, and merit-based advancement. Understanding how sponsorship functions in academic medicine, including its potential limitations, is a critical step in making individual and organizational decisions about using sponsorship as a deliberate approach to addressing leadership diversity.

Our findings reveal perceptions of gender difference and evidence of gender stereotypes that may influence the sponsorship relationship. Sponsors in our study, all of whom were men, acknowledged that women experience sponsorship differently than men. Both sponsors and women protégés shared a perception that women required additional support and reliance on sponsors for credibility. This finding is supported by research that shows that women who receive external validation and whose credentials are amplified by an influential source are more likely to have their input accepted 41. A sponsor by definition provides external validation and endorsement as was succinctly described by one of our informants.

Informants also noted that women may not be identified for sponsorship and were less likely to seek out sponsorship compared to men. Research validates these findings. Gender schemas in which women are stereotyped as more nurturing and less ambitious than men inform concepts such as role congruity 42. Role congruity results in women being viewed as less capable leaders than men and being judged more harshly when they exhibit behaviors that contradict those expected of them. Women may be less likely to be “seen” by potential sponsors as effective leaders because of role congruity. Women may also have greater concern about promoting themselves and seeking sponsorship out of concern for being viewed negatively 43.

Other studies on unconscious bias demonstrate that credentials may be “adjusted” based on gender wherein women may be expected to have a more illustrious set of credentials or the same credentials may be judged differently compared to men 44. This was explicitly described by one of our informants as “the high bar” and seen as a barrier for women. A woman’s accomplishments and potential may not be recognized and she may not be sponsored as often or as effectively as men. Structured sponsorship programs may address this issue. A program that uses a standard set of criteria to define “high-potential” protégés to proactively link women with effective sponsors may remove the need for women to overly self-promote themselves. Using defined criteria can diminish the chance for redefinition of credentials to occur.

The manner in which individuals are selected for sponsorship deserves further attention. It is important to emphasize that gender schemas are deeply ingrained in all of us and therefore can lead to unconscious bias. This has important repercussions 21. Studies demonstrate the impact of unconscious bias on hiring, performance evaluation, receipt of funding, promotion, and leadership appointment 45,46,47,48. In as much as sponsorship is interconnected to promotion and leadership appointment, it seems reasonable to view our findings as suggestion that unconscious gender bias influences sponsorship. Furthermore, sponsors in our study openly acknowledged the potential for bias to affect their actions. While our findings do not definitely associate unconscious bias and sponsorship, future studies modeled after research that demonstrates gender bias in hiring, performance evaluation, and leadership appointment could answer the question of whether protégé selection and level of support differs by gender. This will be incredibly important if sponsorship is expected to lead to leadership diversity in academic medicine. One way to guard against unconscious bias in sponsorship is to adopt methods that raise awareness of its existence and that also lead to meaningful behavior change. Carnes et al. have demonstrated that an intervention grounded in a behavior change model can address gender bias in hiring academic faculty 49, 50. Training sponsors around bias reduction may ensure that effective sponsorship is provided for all appropriate faculty.

Both protégés and sponsors expressed tension between sponsorship and academic values such as fairness, transparency, and merit. Thus, some aspects of sponsorship may be at odds with the professional identity and values of academic faculty. The importance of values alignment between faculty and their work culture should not be underestimated. Pololi and others linked intent to leave academia with faculty perceptions of disconnect between their own personal values and the institutional culture 51. This may have increased relevance for women and minority faculty 22, 52. In order to achieve the potential benefits of sponsorship in academia, it will be necessary to confront the issue of values alignment directly, in addition to addressing the potential for unconscious bias.

Our study has limitations. First, as with all qualitative research, the views of the researchers may influence the design, selection of data to be collected, analysis, and presentation of the findings. For example, our use of standard definitions may have triggered unconscious gender biases among our informants. On the other hand, some strengths of our qualitative methodology include the use of definitions with a specific example, purposive sampling, and validating our findings with informants. Second, this study was conducted at a single academic institution and therefore our findings may not be generalizable. However, research from our own institution demonstrates that we share issues related to gender and advancement that have been documented nationally 18, 53, 54. Third, all of our sponsors were men. While this reflects the reality of leadership at many academic medical centers, it limits our understanding of views of women sponsors. Lastly, we may have captured only views of successful sponsors and protégés although our informants described varying degrees of success and we specifically asked about the risks and limitations associated with sponsorship.

Our findings represent an in-depth exploration of sponsorship and gender in academic medicine and may inform the actions of individuals and organizations interested in achieving greater diversity in leadership. For example, the identified themes may provide an outline or guide specifically for individual women faculty who may wish to seek out and benefit from sponsorship. From an organizational perspective, structured sponsorship programs may help to address the leadership gap by specifically focusing on increasing the number of talented women faculty considered for advancement to the highest levels. Finally and perhaps most importantly, before we adopt and invest in sponsorship as an explicit intervention to address diversity in leadership in academic medicine, further understanding of the limitations of this method should be explored.