access_time published 12.05.2017
Challenging the “leaky pipeline” in faculties of medicine
Kathleen B. Digre
Challenging the “leaky pipeline” in faculties of medicine
Academic medicine is characterised by specific challenges with regard to time investment in clinical, research and teaching activities, as well as by a gendered image of the profession. As in the US and Europe, Swiss academic medicine has been modified through steps promoting women at the graduate level, but at the same time it suffers from a dramatic female drop-out at senior academic levels.
In this article, the authors address the issue of women’s underrepresentation in leading positions in academic medicine and describe the action plans implemented within the faculties of medicine of four Swiss Universities – Zurich, Lausanne, Geneva and Basel –in order to challenge the “leaky pipeline” and improve gender equality in academic medicine. Following a gender mainstreaming approach, these action plans aim at implementing equality aspects at all levels of the institution and at reaching a more balanced female representation in professorial positions by the end of 2016. They are part of the Swiss Federal Equal Opportunity at Universities Program, which ran from 2013 to 2016. Different measures, such as new career development programmes, talent screening, mentoring programmes, reform of recruitment procedures and scientific research on the structural barriers to women’s advancement are presented. Focusing on these innovative faculty-based actions, authors discuss the advantages of combining strategies that empower women as well as those that change institutions. For the latter, structural and cultural modifications are necessary that can best be achieved by national policies that create incentives for the universities to promote gender equality.
In the last few decades, the percentage of women graduating in medicine has increased gradually in North America and in Europe [1, 2]. With this process of “feminisation” of medicine, various aspects such as the clustering of female and male physicians in different specialties, salary inequalities, working hours preferences and implications for the practice of medicine and for patients were observed [3–5]. However, at the same time a “leaky pipeline” was identified within the academic track of medicine: the underrepresentation of women at higher professorial levels and leadership positions in medical faculties [1, 6]. Unlike the progress observed in other disciplines, such as humanities and social sciences, with a similar feminisation trend, in medicine advances have been described as “incomplete and inadequate” .
In 2013 to 2014 in the US, women represented almost half of all matriculants (47%) . However, at the faculty level finally only 38% were women with 21% full women professors . The contrast is even more striking in Switzerland: women made up 61% of students in 2014, but represented only 17% of professors [7, 8]. Within this highly gender unequal context, measures promoting female faculty seem particularly needed in Switzerland.
This article addresses efforts to combat women’s underrepresentation in leading academic medicine positions by describing and analysing the action plans implemented within the faculties of four of the largest Swiss universities: Basel, Geneva, Lausanne and Zurich. Geneva and Lausanne represent faculties of the French-speaking part of Switzerland, whereas Basel and Zurich are located in the German-speaking part.
After describing the obstacles to women’s advancement in leadership positions in medicine identified in the research literature, the article describes the main theoretical approaches adopted to counter these inequalities. We then present the case studies of the four Swiss faculties of medicine where action plans were implemented within the frame of the Swiss Federal Equal Opportunity at Universities Program, which ran from 2013 to 2016. Focusing on the innovative faculty-based actions undertaken, we discuss the advantages of combining strategies that empower women with those that change institutions by modifying their structure and culture to advance gender equality.
Slow advancement of women in academic medicine
Multiple factors identified
Multiple factors have been identified that contribute to women’s dramatic dropout on their pathway from graduation to leadership academic positions. The heavy workload in clinical, research and teaching activities combined with the lack of family-friendly structures and of life domain balance measures are often mentioned [9–12]. Medicine is also impregnated with gendered images and is characterised by a professional “ethos of permanent availability”, implying long and atypical working hours [3, 10]. Because this norm is based on a traditional family model, women – and mothers in particular – face more difficulties in conforming to it. This is particularly true in Switzerland, where deep-rooted gender role stereotypes have been identified as strong obstacles to women’s promotion in medicine [13–15]. Several studies have also highlighted the higher probability for women than men to be discriminated against during their academic career [10, 12, 16, 17]. Finally, the access to networking opportunities and to mentorship is also considered an important dimension for women’s career advancement [6, 13]. It is especially crucial in Switzerland, where medical training is less structured than in the US and in other European countries [18, 19]. To sum up, it has been argued that academic medicine does not manage “to create and sustain an environment where women feel fully accepted and supported to succeed” (p 201) . As a result of these interacting factors, women are less likely than men to pursue an academic career in both the US and Europe, including Switzerland [18, 20, 21].
Different approaches to challenge the leaky pipeline
In the research literature that aims to understand women’s underrepresentation in leadership positions, scholars often use a typology of the measures implemented to challenge the leaky pipeline [22–24]. In principle, there are two main approaches, which guide the actions undertaken by (medical) institutions in their efforts. The first aims at empowering women by educating them, supporting them in developing their skills, giving them career advice and finally offering them networking opportunities, as well as supportive mentors. These measures are meant to increase women’s self-confidence and assertiveness. The second is a gender mainstreaming approach that aims at modifying institutional structures and cultures in order to promote gender equality. It is usually based on the assumption that an increase in women’s representation among top management can most effectively be achieved by top-down measures that build on institutional leadership and accountability . Transforming structures and creating equal opportunities for women and men implies, for example, providing effective and affordable childcare services, scheduling important meetings between 9 a.m. and 5 p.m. to make sure that women (and men) with childcare responsibilities are not excluded from decision making, and offering job-sharing positions on a professorial level. Prevalent working cultures can be tackled by increasing gender awareness and removing unconscious bias from institutional practices with workshops organised for the faculty leaders. The first approach, “fixing the women”, was developed in the 1980s, whereas the second approach, ”fixing the structure”, has become popular since 1995 . Several successful programmes that combine both approaches have been established. The Executive Leadership Program in Academic Medicine (ELAM) in the US is an excellent programme for women in academic medicine, incorporating both aspects. Besides providing education at a high level, the programme is based on the belief “that a critical mass of successful women leaders will be able to effectively address those deeply entrenched aspects of organisational culture and climate that prevent women from advancement” (p. 138) . Therefore, the programme supports the sustained success of women by offering them the tools and training they need to move into and maintain positions as institutional leaders . About 50 senior women, nominated by their dean, are selected annually from medical and dental schools from all over the world to join this programme . In the class 2015–2016, two women faculty members from the University of Zurich, Switzerland were accepted as European fellows.
Presentation of four Swiss case studies
Academic medicine in Switzerland
The Swiss academic system is in some respects different from the one in the United States. In Switzerland, after six years, medical students graduate with a master’s degree. To pursue the academic track, a doctoral degree is mandatory (title: Dr. med. = MD), which takes another six months to one year. Alternatively, a PhD or MD-PhD degree is possible; however, the duration of these programmes is longer and may last up to three years. In the German-speaking part of Switzerland, the postdoctoral phase is completed by the so-called “habilitation”, which correlates to the degree of “private docent” (PD, lecturer). This “private lecturer” degree was adopted from the German and Austrian academic system. One can only apply to become a private lecturer after publishing a substantial number of original articles in peer-reviewed journals and gaining teaching experience. Finally, academics can be appointed to associate or full professorships. The model of assistant professorships has only recently been established in Switzerland, with a particular emphasis on tenure track positions (see table 1).
Table 1: Career paths in academic medicine in Switzerland. Table developed by N. Lerch-Pieper, University of Zurich, 2015.
Stages of the academic career
Standard length of academic stage
Private lecturer (= private docent)
Assistant professor (with or without tenure track)
6 years or unlimited
Senior consultant / head of a division
Until age 65
Head of department
Figure 1: Gender Monitoring University of Zurich 2014. Data collected from the Gender Monitoring Report, University of Zurich 2014, January 27 2016. * NB: In Switzerland, medical students graduate with a master’s degree. To pursue the academic track, a doctoral degree is mandatory (title: Dr. med. which is equivalent to MD, see heading “Academic Medicine in Switzerland” in this paper). The numbers refer to the medical and doctorate students counted together.
Figure 2: Gender Monitoring University Lausanne 2014. Data collected from the Statistical and Information System Service of the University of Lausanne – UNISIS, by the Equality Office of the University of Lausanne,, February 18 2016. * NB: In Switzerland, medical students graduate with a master’s degree. To pursue the academic track, a doctoral degree is mandatory (title: Dr. med. which is equivalent to MD, see heading “Academic Medicine in Switzerland” in this paper). The numbers refer to the medical and doctorate students counted together.
The leaky pipeline at Swiss faculties of medicine
As shown in table 2 and figures 1 and 2 (representing a university in the German-speaking [University of Zurich] and one in the French-speaking [University of Lausanne] part of Switzerland), there are over 50% women graduates, whereas on full professor level, the number drastically drops to 10%. To challenge this leaky pipeline, the faculties of medicine at the Universities of Basel, Geneva, Lausanne and Zurich developed four different action plans within the framework of the Swiss Federal Equal Opportunity at Universities Program 2013–2016. This federal programme provides funding for gender equality actions in Swiss universities to help counteract the leaky pipeline. The superordinate goal of the federal programme is to reach 25% women professors at Swiss universities (this includes all the different faculties from arts to medicine, economics and law to science) by the end of 2016. By the end of 2014, we reached 22% women professors university-wide, whereas the four faculties of medicine of the Universities of Basel, Geneva, Lausanne and Zurich include 17% women professors on average . The main aims and measures of each of the programmes for the faculties of medicine are described below.
Table 2: Gender monitoring University of Zurich and University of Lausanne 2014.
Faculty / University 2014
Faculty of Medicine University of Zurich
Women n (%)
Men n (%)
Faculty of Medicine University of Lausanne
Data collected from the Gender Monitoring Report, University of Zurich 2014, January 27 2016, and from the Statistical and Information System Service of the University of Lausanne – UNISIS, by the Equality Office of the University of Lausanne, February 18 2016.
* NB: In Switzerland, medical students graduate with a master’s degree. To pursue the academic track, a doctoral degree is mandatory (title: Dr. med. which is equivalent to MD, see heading “Academic Medicine in Switzerland” in this paper). The numbers refer to the medical and doctorate students counted together.
University of Zurich (UZH)
At the UZH faculty of medicine, incentives are needed to encourage women to stay on the academic track, particularly in the phase between doctorate and habilitation (see table 2 and fig. 1). With the new 2- to 3-year career development programme called “Filling the Gap”, the UZH faculty tried to establish attractive conditions for excellent women physician scientists to enable them to move forward with their academic career, particularly on a postdoctoral level. Filling the Gap is a three-pillar programme. Pillar 1 is based on the long-term planning of the academic career and research projects with the department chair. With pillar 2, a one-to-one mentoring programme (also previously available) supports the young academic in her career development. Besides this, career development and life domain balance workshops are organised within Filling the Gap. Pillar 3 provides paid protected research time of between 20 and 50% per year to allow the young academic talents to perform research, which is fundamental for an academic career. So far, 33 women have been funded for a total of 2.6 million Swiss francs or the equivalent of the same in US dollars. With this programme, we cannot reach the goal of having more women professors immediately. However, the initiative clearly aims at sustainability by providing support over a period of 2 to 3 years to promote research talents.
In addition, visiting professorships for internationally renowned women faculty with executive ability, gender know-how and experience in promoting young academics’ careers were founded. Furthermore, a project called “Search for Women Excellence” was launched to find at least 30% women candidates for new appointments at the level of assistant, associate or full professor. Based on references and reports in the literature, as well as good practice examples of other universities and medical faculties, and by using a “gender mainstreaming” approach, new guidelines were established on the composition of the appointment committee and the advertisement of the professorship [28–30]. The president of the committee is responsible for actively headhunting eligible women and reporting if and to what extent measures were taken. The project will be evaluated after 2 and 4 years.
University of Lausanne (UNIL)
The UNIL faculty of biology and medicine is the only faculty in Switzerland that combines medical and basic life sciences. There are 31% women at assistant professor level. However, the number of women holding a full professorship is approximately 12%, stunningly low, in both academic realms. To counteract this low number, an action plan has been developed, and financial support was provided by the dean of the faculty to ensure its implementation. The goal of the action plan “AGIR pour l’égalité” is to guarantee that by the end of 2016 25% of all newly appointed associate and full professors are women. To achieve this goal, four thematic strategies were identified:
- Améliorer (improve). Improve the reconciliation of work with family life (e.g., post-doctoral researchers can ask for paid support and protected time during parental leaves).
- Guider (guide). Guide women and men alike by mentoring, supervising and raising awareness concerning equal opportunities (e.g., a mentoring programme has been developed and funding is provided to organisers of events when they invite at least 40% of women key note speakers).
- Identifier (identify). Identify women with high potential and provide coaching for successful promotion (e.g., women can apply for specific post-doctoral research funding).
- Rechercher (search). Reform recruitment procedures and search proactively for women candidates for professorial positions (e.g., if there are not enough female candidates for an open position, the dean will postpone the deadline for candidates and ask the member of the recruitment committee to search for qualified women candidates in the field).
University of Geneva (UNIGE)
It is well known from the literature that female researchers often do not actively apply for promotions, particularly at the professor level. Also, talented women researchers might not put themselves forward or are overlooked by their department [31, 32]. Therefore, the dean of the faculty sent a letter to all department chairs of the faculty of medicine to screen their junior researchers for female talents who might be candidates for promotion. In parallel, a letter was sent to all female staff of the faculty of medicine with a potential research activity encouraging them to submit an application for potential promotion. A total of 100 applications in the first round and 17 in the second round were received. The evaluation of the research committee resulted in either promotion to the rank of professor or “Chargée de Cours”, a tenured appointment without professorial title. All young researchers who had applied, but were not selected, received a personalised letter with individualised advice from the equal opportunities committee on the advancement of their academic career.
Other activities within the action plan comprised the initiation of a Gender Prize for students, awarded for the best project that promotes gender equality within the faculty, a Gender Equality Week with poster exhibitions, taking place every year in March, and different social events such as the ‘Café Carrière’ to discuss guidelines for career steps. Since 2013, the proportion of women professors at the faculty of medicine has increased from 17 to 24% at the University of Geneva.
University of Basel
The efforts with regard to implementing and evaluating equal opportunity strategies at the faculty of medicine of the University of Basel comprised the establishment of a mentoring programme that has been running since 2004. In 2011, an exploratory cross-sectional survey was conducted in the north-western part of Switzerland to assess predictors for an academic career in a population of residents and senior consultants working full time or part time . Of the full-time working respondents, 71% of the women and 57% of the men favoured a work reduction to part-time 0.6 to 0.9. In this context, part-time working residents and senior consultants aiming at an academic career were invited by the Basel faculty of medicine to apply for participation in an individual 2-year support programme. This involved having regular meetings with the head of the clinical department, as well as with a member of the faculty of medicine’s gender equality commission. Of the seven recruited female physicians, six completed the entire programme. Over the duration of the programme, five of the participants achieved a higher position, published up to five papers and successfully applied for a grant. Nevertheless, three of the grantees decided not to further aspire towards promotion due to family reasons.
In addition, competitive career development programmes were launched to help women medical scientists to stay on the academic track after maternity leave and on their way to a professorship, and the faculty began to revise its appointment processes by focusing on equal opportunities due to the requirements of quality assurance.
The measures of all four medical faculties at the universities of Zurich, Lausanne, Geneva and Basel are summarised in table 3.
Table 3: Gender equality measures of the faculties of medicine at the Universities of Zurich, Lausanne, Geneva, and Basel, Switzerland. Table developed by I. Valarino, University of Lausanne, and N. Lerch-Pieper, University of Zurich, 2015.
“Fixing the women”
Workshops concerning career development and life domain balance
“Fixing the institution”
Actions to increase awareness for gender equality
Reform recruitment procedures
Career development programmes (protected time, stay on track, part-time support programmes)
Scientific research on the structural barriers to women’s advancement
Financial incentives for the promotion of gender equality
Table 3 shows that the combination of measures differs between the four faculties. This takes into account the specific constraints and opportunities in each faculty, and respects the autonomy and competence of the decision makers, which is particularly relevant in a small country like Switzerland, where different language regions reflect cultural differences. The different action plans also implement the specific situation and needs of young academics in their university with its cultural context. Different measures are needed to “break the glass ceiling” in the corresponding cultural and political contexts [27, 33].
Despite these heterogeneous approaches, table 3 shows that all four faculties combined measures that aim at supporting women and at the same time focus on transforming institutions and working cultures. Also Morahan et al. and Yedida et al. conclude that it is important to combine approaches on an individual as well as on a structural level that imply a strong commitment of decision makers and incentives promoting gender equality to successfully encounter the gender gap in medicine [22, 27, 32]. We therefore argue that it is important to empower women by providing measures such as career development workshops and mentoring programmes on one hand. On the other hand, it is crucial to combine this with measures that aim at modifying the structures of the institutions to create equal opportunity such as family friendly working conditions and the reform of recruitment procedures.
Summary and conclusion
We presented case studies of four Swiss faculties of medicine to promote women faculty. This work shows that all four faculties take into account the specific situation and the cultural contexts of each university and medical school. Furthermore, all four faculties have combined the two well-established approaches: the historically older approach to “fix the women” and the more recent approach to “fix the institutions”.
However, to fix the institutions, structural changes are needed, that can only be achieved by a cooperation of politics and policies with the universities. The Swiss Federal Equal Opportunity at Universities Program has made a difference in Switzerland. It assures that incentives are created for the universities to promote gender equality by indicating the goals on a national basis, and by providing gender expertise as well as financial support for faculty-based action plans that respect the different contexts and needs of each medical school. The importance of this leadership approach for structural change has been outlined recently in a comparative study of national policies and initiatives for gender equality .
The next steps will be to assess the effects after the ending of the programme period 2013-2016 and to make sure there is a follow-up on the measures and a continuity that ensures that improvements are maintained on a long-term basis to reach sustainability.
The Gender Action Plans are co-funded by the ‘Swiss Federal Equal Opportunity at Universities Program of Switzerland’ and the Universities of Zurich, Lausanne, Geneva, and Basel.
No potential conflict of interest relevant to this article was reported.
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S. Brander, M.A., is head of the Gender Equality Office of the University of Lausanne, Switzerland.
I. Valarino, PhD, holds a Swiss National Science Foundation research fellowship, University of Lausanne, Switzerland.
C. Zurbriggen, M.A., was project manager of the action plan “AGIR pour l’égalité”, Dean’s Office of the Faculty of Biology and Medicine, University of Lausanne
E. Maurer, PhD, is former head of the Gender Equality Office of the University of Zurich, Switzerland.
W. Herr, PhD, is professor for integrative genomics and former director of the School of Biology, University of Lausanne, Switzerland.
F. Müller, DMD, is professor of gerodontology and removable prosthodontics at the Faculty of Medicine and president of the Gender Equality Committee at the University of Geneva, Switzerland.
B. Mantilleri, Mag. art., is head of the Gender Equality Office of the University of Geneva, Switzerland.
S. Tschudin, MD, is private lecturer and head of the division of gynecological social medicine and psychosomatics at the University Hospital Basel and president of the Gender Equality Committee at the Faculty of Medicine of the University of Basel, Switzerland.
N. Kälin, lic. phil., is head of Equal Opportunities, University of Basel, Switzerland.
Kathleen B. Digre
K. B. Digre, MD, is professor of neurology, ophthalmology at the University of Utah, USA, and first Hedi Fritz-Niggli Visiting Professor, University of Zurich, Switzerland.
B. Beck Schimmer, MD, is professor of anesthesiology, academic project leader of the career development program “Filling the Gap” and head of the mentoring program at the Faculty of Medicine of the University of Zurich, Switzerland. She was ELAM fellow in the class of 2015/2016. She is member of the Presiding Board of the Research Council of the Swiss National Science Foundation (SNSF).