The Gendered Work/Role of Program Directors in International Graduate Medical Education

Abstract

Healthcare organizations offer numerous clinical and academic leadership pathways for physicians, among which the position of program director (PD) is considered to be a prominent educational leadership role. As PDs are instrumental in the recruitment and training of the next generations of physicians, PD gender distribution can affect the present and future of a medical specialty. This study offers a dialectical perspective in understanding how international PDs negotiate gendered understanding of their work/role by using the framework of Relational Dialectics Theory 2.0. Thirty-three interviews of PDs from Qatar, Singapore, and the United Arab Emirates were conducted and, using contrapuntal analysis, the competing discourses of meanings of gender in the PD work/role were examined. Competing discourses where structural, cultural, and professional meanings of gender were interrogated revealed inherent multiple meanings of how gender is understood in PD work/roles. In making sense of these meanings of gender, PDs express dilemmas of traditional gender binaries of masculine/feminine work/role meanings to explain the term in different ways in their everyday organizational and cultural struggles. The findings have implications for PD recruitment and retention in teaching hospitals.

Keywords

program director;gender;relational dialectics theory 2.0;graduate medical education

Introduction

Healthcare organizations offer numerous clinical and academic leadership pathways for physicians, among which the position of program director (PD) is considered to be a prominent educational leadership role. Program director are clinician educators charged with leadership and accountability in graduate medical education. Studies have documented that the PD work/role is complex, multidimensional, and tension ridden (Dutta, Ibrahim, et al., 2021; O’Connor et al., 2019). In addition to their patient care duties, PDs are responsible for trainee recruitment, teaching, supervision, program administration, and faculty development (ACGME, 2020). Often, the role of the PD extends beyond professional relationships with the trainees to include an emotional and advocacy component, as well as a longitudinal collegial bond that can persist even after training (Dutta, Stadler, et al., 2021). As PDs are instrumental in the selection and recruitment of new trainees and serve as role models for residents and medical students, PD gender distribution can affect the present and future of a medical specialty.

Although the enrollment of women in medical school has reached, or exceeded, gender parity in many countries, disparities remain in leadership roles, including residency and fellowship program directorship (AAMC, 2020; Long et al., 2011; Stadler et al., 2017; Woodward et al., 2017). The gender gap widens as women in medicine progress in their academic careers, with studies citing structural and cultural reasons, such as work–life imbalance and non-supportive organizational climates, as contributing factors (Alwazzan & Al-Angari, 2019). Women’s hesitancy to apply for, or accept, promotions has also been suggested as a contributor to the gender leadership disparity, with lower perceptions of self-efficacy and less flexibility in work cited as reasons (Liberatore et al., 2022). Research has also shown that the gender imbalance can differ depending on the medical specialty, with fewer women represented in procedural specialties (with the exception of obstetrics - gynecology) versus nonprocedural and primary care fields (Kennedy et al., 2021; Long et al., 2011; Woodward et al., 2017). While personal and professional choices have often been noted, implicit bias in the hiring and promotion processes for these positions is now well documented (Khan et al., 2021; Zhang et al., 2021).

To date, most studies document the presence and degree of gender disparity within specific fields or leadership roles. Recent studies have also highlighted the challenges and experiences of women in PD work/roles. Despite the studies on PD gender equity, there is a lack of research around what the gendered nature of the PD work/role means. Existing literature takes for granted the notion of gender as a simplistic, monolithic, homogenous, and stable construct, without exploring complexities around the understanding of gender in making sense of the PD work/role. In this study, we address this gap by using a lens of Relational Dialectic Theory (RDT) 2.0 (Baxter, 2011) to offer a nuanced exploration of gender and in-depth understanding of gender issues in the PD work/role.

Relational dialectic theory 2.0 extends philosopher Mikail Bakhtin’s (1981) work called dialogism and argues the prevalence or acceptance of one dominant thought over other views (Suter et al., 2014). The concept of dialogism points to the idea that sense is meaning making. RDT 2.0 forwards the theory by proposing that the discourses are often a collection of meaning around a concept. Discourses are then explained as a cluster of meanings that showcase the different meaning making exercises (Baxter & Braithwaite, 2008). Scholars have broadly applied RDT 2.0 to health studies, specifically physician-patient communication (Amati & Hannawa, 2014), including dialectical tensions in health care (Jones et al., 2019). Such studies offer dialectics or discourses as an essential lens to explore taken-for-granted assumptions in healthcare. As Scharp and Thomas (2021, p.195) explain “meaning is made in the competition of discourses.” As such, the theory provides us with an appropriate lens to support the meaning making of different discourses of the gendered nature of PD work/role and differs from the traditional tropes of gender presented in earlier studies. Furthermore, discourses are defined as “systems of meaning that are uttered whenever we make intelligible utterances aloud with others or in our heads when we hold internal conversation” (Baxter & Braithwaite, 2008, p. 349). The authors maintain that discourses are culturally organized systems of meaning commonly understood among members of a group. It is assumed that whenever we communicate, we solicit indirectly multiple systems of meaning. As a corollary, discourses are opposing and often competing (Baxter & Braithwaite, 2008). For instance, “the treatment is effective, but I am not sure if it will work here” is an example of a competing discourse.

In this study, we extend the theory of RDT 2.0 to the field of medical education to better understand how men and women who are PDs make sense of the gendered context of their work/role, within cultural and structural contexts and constraints. In doing so, we propose an alternative construct of gender as a complex, evolving, and non-binary entity or term, which requires a dialectal and dialogical approach to deeply understand how it operates in a particular space and role. The theory helps to explore potential new meanings of gender, departing from historical definitions of the term, which are presently used to highlight differences between men and women in certain roles. By using the context of Qatar, Singapore, and the United Arab Emirates (UAE), we aim to understand the different structural and cultural environments, which may depart from Western ideologies, but offer equally important meanings of what gender means in the context of PD work/role.

Relational dialectic theory 2.0 has been a useful construct to examine the various dialectical tensions pertaining to healthcare, as it critically opposes monologic interpretations of a phenomenon that often dominate other forms of understanding that phenomenon. Examples include maternal depression experiences (Scharp & Thomas, 2017), meanings of end-of-life care (Amati & Hannawa, 2014; Ohs et al., 2015), and physician tensions related to consent processes (Olufowote, 2011). Brown and Oetzel (2016) studied how male patients on a prostate biopsy waiting list negotiate their communicative tensions through networks. Olufowote and Wang’s (2017) work focused on the discourses of physician educators on assimilating students, and the phenomenon of dualism of biomedicine and bio-psychosocial issues. The dualism was considered as an antagonistic clash between the ideologies or thoughts.

Gender and the PD Work/Role

Studies have consistently suggested that women in academic medicine who are in leadership positions, including PDs, have been systematically and historically underrepresented. Many specialties and subspecialties, such as pain management (D’Souza et al., 2021), surgery (Filiberto et al., 2019), internal medicine (Willett et al., 2015), gastroenterology (Woodward et al., 2017), cardiology (Khan et al., 2019), plastic surgery (Zhang et al., 2020), neurosurgery (Odell et al., 2019), and radiology (Ahmadi et al., 2018), have less women PDs in their training programs. Research has shown that lack of diversity, specifically gender diversity, can dissuade women from joining specialties (Brotherton & Etzel, 2018; Sethi et al., 2022). This potentially leads to the systemic under-representation of women in the field of medicine, especially in leadership roles, such as the PD work/role.

For the purpose of our study, we have situated the data collection in the countries of Qatar, Singapore, and the UAE for several reasons. Societal and cultural gender inequity has been well documented in these settings (Afiouni, 2014; Dutta, 2018, 2019). In addition, the intersections of society, family and tradition offer challenges common to these countries, which uniquely affect women (Blaydes et al., 2021)^. There needs to be further investigation on making sense of how PDs make meaning of their work/roles in settings where work/roles are considered gendered in nature. How PDs experience the double bind of their work/role being gendered in a gendered structural and cultural context warrants further investigation. The inclusion of both male and female voices offers a rich perspective into the dialectical tensions they might experience enacting the PD work/role. Therefore, the research question that guides our study is what, if any, competing discourses of dominant discursive assumptions are prevalent with respect to the understanding of the PD work/role as gendered from the perspective of the PDs themselves?

Methods

Recruitment

Eligible participants included current or former PDs in international medical education. We chose PDs from Qatar, Singapore, and the UAE as our representative research pool. In 2010 (Singapore) and 2012 (Qatar and UAE), residency programs in these countries underwent transformation replacing apprenticeship models of training to that of competency based in the context of graduate medical education, adopting a United States-based training model with similar PD roles and responsibilities. This transition offers an alternative perspective into the development and socialization of the PD role, as not only most PDs were new to their role, but also the PD role itself was a new leadership position in the institutions. For our study, PDs were identified through institutional websites or through personal contacts. Additional participants were then recruited through snowballing methodology. PDs were first approached via phone or email. Individuals who agreed to participate were then sent an email invite for an interview. Interviews were conducted until data saturation was reached.

Data Collection

One of the investigators conducted all of the interviews in English, either by audio interviews via Skype or WhatsApp (30) or face-to-face (3), based on the interviewee’s preference and availability. The interviewer also briefly explained the purpose of the project at the outset of each interview. Interviews were audio recorded and hand transcribed. The duration of the interviews ranged from 30 to 60 min, with an average of 45 min. Pseudonyms were used to mask participant identity. Interview questions were open ended, semi-structured and probes were used wherever applicable. We sought to better understand (a) the role of gender in PD work, (b) gendered experiences in PD work/role, (c) how PD work/role is perceived by the participants, and (d) general opinion of gender in a cultural context.

Ethics Statement

This study was approved by the institutional review board in each study country; the institutional review boards of the National University of Singapore in Singapore (S-18-200E), Weill Cornell Medicine-Qatar in Qatar (Approval 18-00010), Tawam Human Research Ethics Committee in UAE (THREC-593), and the Johns Hopkins University School of Medicine in the United States (IRB 00223113). Participants signed written informed consent prior to the interview.

Data Analysis

The transcripts were checked against the recordings for accuracy and reviewed thoroughly to remove any remaining identifying information of the participants by one of the authors. To identify the interplay of opposing discourses that surround the topic of gendered PD work/role, the first author employed contrapuntal analysis—a specific methodological practice developed by Baxter (2011) to examine the interview transcripts. Contrapuntal analysis is a specific kind of discourse analysis or understanding the pattern of language in use by the participants to respond to a particular question. The term contrapuntal is derived from music and refers to contrasting notes. First, thematic analysis (Braun & Clarke, 2006) was initiated to identify the discourses around gender in PD work/role, which is the first step to contrapuntal analysis (Baxter, 2011). In the initial phase, the interview data was open coded to identify themes on the basis of general meanings of gender in the data alone (Braun & Clarke, 2006). Themes were then considered as discourse (Baxter, 2011). Another round of coding was conducted to examine the apparent meanings, if any, based on the elemental understanding of the discursive systems underpinning the responses. The initial codes were arranged into themes by comparing, arranging to position as discourses about the PD work/role with respect to gender (Baxter, 2011).

After identification of the discourses on gender, the competing discourses were drawn out by analyzing the discourses that aligned and those that were in tension with others. Unfolding, or placing utterances in a linear arrangement of preceding and following utterances in the broader discourses of gender in PD work/role, was conducted (Baxter, 2011). The authors categorized unfolding as an interplay of different discourses in constant states of struggling and negotiating. Each utterance was classified on the basis of its positionality to other discourses and the subsequent responses elicited on the basis of the utterance. Diachronic separation, synchronic interplay and interplay of polemic discourses of gender were noted through the stories of PDs, when discussing work/role issues. For example, the authors noted polemic interplays when participants offered instances of upholding gendered stereotypes of PD work/role, while simultaneously privileging observations opposing the normative discourses. During analysis, the authors observed diachronic separation in interactions where one discourse was dominant over another. Negating, countering, and digressing (Baxter, 2011) were the synchronic polemic highlights in the data that were identified and analyzed. The examples from the data, as well as polemic interplays, were discussed and debated in regular meetings with the research team. In-depth discussion with team members helped in refining the examples and data clips.

Results

Thirty-three PDs were interviewed. Participants included 16 (48%) women and 17 (52%) men, and were equally divided from the two regions, with 16 (48%) PDs from Singapore and 17 (52%) PDs from Abu Dhabi and Qatar interviewed. The majority of the PDs were from medical specialties (20, 61%), with 5 (15%) surgeons and 8 (24%) hospital-based specialties, such as radiology and pathology, represented.

From the contrapuntal data analysis, the 2 main discourses that emerged competed with each other in terms of how the participants’ discourses conformed or competed with the broader cultural and organizational discourses. The themes and examples are outlined below.

PD Work/Role Discourses Supporting Gendered Cultural Context

The discourse of gendered PD work/role brings into focus the culturally informed assumptions that uphold the nature and scope of PD work. These broader cultural assumptions are reflected upon the meaning making of the participants, as they discuss the role of gender in PD work/role. The themes elaborate upon the culturally relevant understanding of PD work/role and gender in the context of careers, healthcare organizations and society. These discourses put forth a gendered context to the participants’ utterances of PD work/role as both male dominated and upholding that “women are better.”

PD Work/Role as Gendered (PAG)

Program directorship is often considered through a gendered lens, sharing a similar understanding with the discourses of masculinity, thus examining how dominant discourses marginalize women in leadership roles. Women in these positions are often relegated to a secondary role, whose work is often deemed less important when viewed through a patriarchal lens. These dominant discourses are then circulated, often mirroring the cultural context to stereotypically reflect the fitness of work/roles to gender. Regarding the interview data, the theme of PD work/role as gendered emerged in three prominent subthemes, sometimes parsing out the roles and work separately as gendered, embedded in dominant cultural stereotypes.

Cultural Stereotyping of PD Work/Role

This subtheme explores the cultural attributes commonly associated with gendered work roles in the organization in particular, and in the society in general. Existing discourses on women’s roles as mothers and homemakers are linked to participants’ discourses of the expectations of women PDs. For instance, when asked about the advantages and disadvantages of being a woman PD, the participants referred to the work-home divide and responsibilities salient to the woman PD, which are culturally sanctioned and approved. For instance, one participant reflected his personal, as well as broader cultural, disposition towards what constitutes as women’s work in the domestic sphere, and how that translates into doing PD work.

I am thinking… would she have the chance to do the same thing [PD work] if she was a mom, had a husband and a kid? I’d say no, maybe not… I was telling you about my associate PDs… none of them are married and none of them have kids. And I wonder if they have kids, would they have the same amount of time to give to the program? Maybe not. So, just from that aspect, I do think there is a gender difference in [masked] and it is a big disadvantage… [PD#003]

Another participant agrees with the ideologies that reflect the masculine cultural and contextual meanings of what it means to have a woman in the PD role. She provides her own balancing act of caregiving and, thereby, acknowledges the existing gender disparities which are often cultural in nature.

Yes, work life balance - that’s always a problem for women. So there have been instances where I would bring my daughter to my office, settle her to do her work… while I solve my work. [PD#016]

In a paternalistic cultural environment, these participants’ discourses align with the broader societal discourses of the mother as the primary caregiver of her family, and the understanding that women negotiate work life balance more precariously than men in the cultural context of the countries studied.

Structural Masculine Stereotyping of PD Role

In this subtheme, we look at the structural constraints related to gender and PD work. Specifically, we analyze the organizational or structural discourses linked to the administrative role. The masculine nature of work established in earlier research is upheld in the stories narrated by the participants. This is expressed through their descriptions of institutional culture and articulations of gender difference. For example, one participant shared her experiences with the organization’s expectations around her role as a woman PD. She noted that:

I have sat in the PD meetings, and I wonder really that most of the PDs are male. It is not easy for me… To be in that [PD] role in meetings, you have to be vocal as well, to express your opinion… I think that is maybe challenging for certain females who are not so vocal [PD#020]

Issues of gender representation in the healthcare organization were brought into focus by another participant, who noted: “As a female physician, being a female [PD], there is this conscious undertone that you need to step up to be heard. There is this undertone already there.” [PD#032] The participants felt that gender disparities were built into the organization’s structure and that being a female physician and PD came with its challenges. Both narratives offer examples of women not being heard in a masculine domain.

PD Work/Role as Gender Neutral (PAN)

Program director work/role as gender neutral (PAN) offers counter discourses to the PD work/role as gendered (PAG) theme by challenging the culturally and structurally defined gender roles in medical education. The counter discourses are revealed in the participants’ discursive construction of PD work/role and are found to be gendered in two ways: confirmation of women’s competence for the PD role and the discussion around the representation of women in PD work/roles. Competence here is defined as the qualities associated with women PDs, which make them suitable for the role. Representation refers to the career trajectories and number of women working as PDs. Both subthemes offer compelling evidence to challenge the notion that PD work/role is masculine, as well as cultural/structural discourses that favor men in the work/role.

PD work/Role is About Competence

In this subtheme, we explore the capabilities and competencies of women in the work/role, hence, challenging the master discourses that women are not suited to the PD work/role. Participants acknowledge that gender plays a role but maintain their belief that women earn their respect through competence and performance. Being supportive and respected was considered to be a way to challenge gendered and dominant PD work/role discourses. As one of the PD participants mentioned: “the main thing is having somebody in Dr Y’s position. She was fantastic, very supportive, very keen and…coming with the weight” [PD#029]. Here, the participant observed that women PDs prove their competence and earn respect through their hard work.

PDs also acknowledged that the prestige of the role brought them respect within the organization. According to PD#032:

I think all of that package [PD work] gave me more respect. Because I noticed that as soon as I told people what I did in the hospital, they listened, and they looked at me otherwise… I must say that the female PDs were respected at our hospital.

A few participants explained that the PD work can be performed by both men and women. They felt that both genders are able to carry out the roles and responsibilities associated with the position. One participant summed it up by stating that: “I don’t think gender affects that. It is just that understanding people affects if you can be a leader or a good program director or not.” [PD#025]

The above discourse embraces the alternatives in the PD work/role, asserting that certain personal qualities take precedence over gender, and that a man or a woman can equally perform the role. By drawing attention to the qualities of an individual, the participant acknowledges the issue of broader discourses in gender but chooses to focus on the competencies of the individual in the PD role. She parallels the pros and cons of the role, thereby, maintaining that either gender can equally perform the PD work/role. This view was shared by PD#015, who claimed:

I don’t think it [gender] has any role… It’s not a disability or efficiency to being a program director. Being a female or male doesn’t matter. The competencies we need as a PD would be the same.

In this discursive move, the participant also offers the view that both men and women can perform the PD work/role, as individual competencies take precedence over gender.

If you are a person who enjoys being with young people and nurturing and teaching and mentoring them, even if you’re not the person who likes all the administrative stuff… you will be able to do a good job as a PD… doesn’t matter if you are a man or woman [PD#026]

Women PDs are Well Represented

The subtheme of representation holds a special significance with the study participants. They often mentioned that gender was not relevant to what they were doing as PDs and strongly felt that women can be equally represented in the role as men. One of the participants discusses the career trajectories of their residents, stating “the majority of my residents were females. And many of them became PDs.” [PD#001]

Another participant [PD#010] felt that gender representation was fair, as he shared his own experiences of interacting with women who were in PD work/role. His quote “I have met many female PDs who are strong and good” expresses his personal experiences of working with women PDs whom he found to be competent and effective.

Negating

In contrapuntal discourses, the speaker uses negating statements to supplant or reject a statement mentioned earlier in the discourse. In doing so, the earlier discourse is rejected in favor of the competing discourse. In this case, discourses of negating are observed when the participants refute or challenge a taken-for-granted or normalized assumption of the PD role/work (PAG) with a counter discourse (PAN). For example, when asked about the role of gender in PD work/role, one participant shared:

I think women make just as good a PD as men. So, I don’t think it’s an issue. My successor is a woman, and I think one should look at it as something not whether so much as one gender is intrinsically better [PD#024]

The participant negates the idea that men make better PDs than women. By drawing references to his female successor, he states that gender is not important to the PD work/role. Here, the participant refutes the traditional discourses around men being considered more competent PDs, compared to women. Therefore, the participant draws on the prevalent notions of PAG, where PD work is assumed to be gendered, and whereby men are more competent in the role, and deliberately negates the discourse.

Another participant observed:

I shouldn’t think that gender affects any role in performing your roles and responsibilities, because I have seen great PDs - both men and women who I actually had an opportunity to learn equally from both of them. I don’t actually think that gender plays any role. [PD#033]

The above quote from the male participant confirms the negating discourses of the role of gender in performing the roles and responsibilities of PD work. The participant discusses that, in his experience, both men and women can be capable PDs and that he has learned from both, whom he refers to as being “great” in their roles. This refutes the assumption of PAG as the PD then explicitly expresses that gender is not relevant to PD performance. Such sentiments were also reflected in PD#022’s observation, “I don’t think I was chosen based on my gender...so to me no.” Like the other participants, he negated the role of gender in PD work/role and disrupted the discourse that gender impacts success in the PD work/role.

Countering

Another disclaiming sentence is countering, in which a discursive position is dispelled or superseded by another or alternative discourse. To explain this further, the participants would state the mainstream discourse PAG, only to sideline this assertion by bringing in PAN. In countering, for example, PD#005 noted that “well, of course there is a massive gender issue, but it didn’t really affect the program, because it was understood that no male obstetrician would ever apply.” We note in this discourse, the participant admits that gender inequities play an important role when it comes to PD role/work, but then immediately counters the discourse by stating that in their specialty, it is challenging to find men candidates. In another example, the PD notes:

I met many PDs from different specialties… I think the majority of the PDs are male. I don’t know why. In my experience, women don’t like challenge and problems like males. We males can tolerate challenges more than women. We travel more than females. Maybe we have some kind of gender wall to tolerate stress more [laughs]. But I met many female PDs who are strong and good. [PD#010]

In the above discourse, the participant reiterates the dominant discourses of PAG to highlight that PDs are mostly men, thereby acknowledging the gendered context of academic medicine. The PD also reveals his personal belief about the culturally and structurally sanctioned dominant discourses around some gender stereotypes. These socially constructed roles attributed to gender are common to PAG discourses discussed earlier. After centering the centripetal discourses that inform PD work as unsuitable for women, he argues that even within those values, he is aware that women PDs can be equally competent.

In another example, there is an acknowledgment of the structural inequities that contribute to the decreased representation of women in leadership positions, including PD. But following this central discourse is a countering discourse that admits that women can also be equally effective in these roles. According to PD#023, “Yes, at the top as you go up, there are less females. So, there is some reflection there of the PDs. But it doesn’t mean that the female would be less of a PD.”

Entertaining

Baxter (2011) defines entertaining as a discursive position, which is one possibility among several discursive positions. Entertaining discourses offer both centripetal and centrifugal discourses an equal platform of expression, where both competing discourses can possibly exist together. Entertaining discourses were brought up by a few participants who discussed that PD work is something that can be done by both men and women, or both genders are able to carry out the roles and responsibilities associated with the position. One participant sums it up by stating:

Actually I was pleasantly surprised, people respected me. I was able to have a voice as a female physician…You can always say women are more nurturing and more caring and would make better PDs than what’s required… I don’t know. I think these are all stereotypes… I think what’s important is that PDs come on board with eyes open… They come onboard and have had the requisite training and preparation and that there is a support system behind them. [PD#030]

The above discourse embraces the alternatives in the PD work/role, indicating that certain qualities in a person take precedence over gender. By drawing attention to an individual’s qualities, the participant acknowledges the issue of broader discourses in gender, but chooses instead to focus on the competencies of the individual holding the PD role. She parallels the pros and cons of the role, hence adopting the stance that both genders can equally perform the PD work/role.

Digressing

The theme of digressing illustrates how articulations of the role of gender are not always addressed as is by the participants but offer moments of digression from the question to highlight opinions or discourses that are not connected to gender. Through the discursive move of eluding, the participants evade talking about the role of gender in PD work/role altogether. When asked about the role of gender in PD work/role, a few participants digressed to offer other discourses, which did not align with the question. Although they answered the question, there were no direct references to gender, but instead they focused on unrelated topics. For example, one of the respondents digressed to discuss work styles when specifically asked about gender.

I think it’s more about different work styles… I think depending on who you are… I think depending on the workstyle you have… I tend to be more like systematic in what I have to do, you know. Even if extra paperwork, I will do it… With paperwork, at least you know when it’s done. [PD#019]

In another interview, the participant eluded the question about gender to discuss the establishment and consolidation of the PD program. The question of gender was addressed with references to policies and professional development.

When it comes to writing the policies, when it comes to professional development, there are so many things to be considered in the beginning. But now, we have them established in our residency programs and those systems are actually running on the ground. [PD#009]

We propose that digressing is a discursive mechanism to elude questions on a particular topic and, instead, offer alternative narratives that have no connection to the topic.

Discussion

Existing literature on the role of gender in PD work/role focuses primarily on the perceptions of binaries in managing the responsibilities of the job. The present study extends this notion of our linear understanding of gender in the PD work/role to better conceptualize and bring into focus the complexities on the understanding of gender in the PD work/role. The following sections summarize our findings.

Using contrapuntal analysis (Baxter, 2011), we identified competing discourses on the role of gender in academic leadership. The discourses by the participants confirm the gendered nature of the PD work/role, via the theme of PD work/role as gendered (PAG). The PAG discourses reinforced the dominant cultural and structural worldviews that align with the understanding that men are better suited to perform certain work/roles. The findings are in agreement with previous studies, which reiterate the gendered nature of PD work/role (Ibrahim et al., 2018). Further, the findings confirm that culture and organizational structures, along with masculine ideologies, shape the understanding of how PD work/roles are viewed by the PD participants (Low, 2006; O’Sullivan, 2016). PAG discourses support that cultural, societal and structural discourses in Singapore, Qatar, and the UAE affirm that the PD work/role is gendered in nature, hence influencing the perception of this work in the organization. The primary way in which PAG was understood was manifested in the labeling of PD work/role as being “male-dominated,” “not supportive of work/home balance,” and “primary caregiver role in congruency with PD role.”

Program director work/role as gender neutral (PAN) discourses offer an alternative understanding to PAG discourses through alternative articulations, where competencies identified with PD identities aligned with what women have to offer. In this context, the PAN discourses explored the capabilities and competencies of women to be better suited to be PDs. In this theme, the focus was on the characteristics of the PD work/role, which were more suited to women. The prestige associated with the work/role then made it easier for women to gain respect. Another discourse central to PAN was that of representation, whereby women can be seen executing the PD work/role as a part of their career trajectory. The theme highlighted and centered the discourses that women are equally suited to the PD position, as the work/role demands competence and capabilities that women are equally capable of executing. The PD work/role itself is respected, and women who hold this role are also assumed to command respect. Overall, PAN discourses put a premium on the importance of work/role, rather than the gendered assumption of the same.

The study also offers interesting perspectives on the role of gender in PD work/role as not linear, immutable or traditional binaries. Instead, it offers a complex understanding of negotiated meaning making of what gender means in enacting the PD work/role. The participants continually repurposed the understanding of gender in PD work/role, thus placing different discourses to describe their experiences, understandings, or points of view, via the interplay of negating, countering and entertaining. The polemic interplays of negating and countering inform us how participants make sense of gender and the contradicting worldviews around PD work/role in academic medicine. It is salient to note that individual assumption, agency, cultural and societal context, work aspirations, stereotypes and anecdotes come together to create meaning, which transcend stable definitions around gendered work in PD work/role.

The themes also elucidate that the taken-for-granted assumptions of gendered roles in healthcare organizations are also not stable. Rather, these meanings of PD work/roles, with respect to gender, arrange in compelling and competing discourses to highlight newer meanings of “gender in PD work/roles.” During the interviews, participants continually refined and articulated the meaning of gender in PD work/roles, based upon their personal experiences and organizational culture, and aspirations around academic medicine. Participants, at times, struggled to place the role of gender in the PD work/role, and instead, use the rhetorical trope of hedging, metaphorically and materially, to sidestep the topic under discussion. The discursive moves of eluding and not addressing the question directly step away from contradictory and competing themes of negating, countering, and entertaining.

The concept of digressing is a theoretical contribution to RDT 2.0 framework, where we argue that avoiding, rearranging and eluding discourses are essential communicative moves, which help participants to convey certain meanings around topics asked. Thereby, digressing is a strategic discursive moment of interaction with the topic, even when the participant fully comprehends that the answers are irrelevant to the subject. The practical contribution of the study is the greater awareness of how the PD work/role is perceived through the lens of gender, addressing the concerns, and challenges around the issues discussed. The study also addressed the taken-for-granted assumptions about the perceptions of gender in PD work/role, which moves away from the traditional tropes and offers multiple understandings of what gender means in this context. Finally, including both men and women participants in the research provided us with a holistic understanding of the topic of gender in PD work/role.

Limitations and Future Directions

The study has several limitations to consider. Although the interviewees shared their views of gender in PD work/role, the meaning making cannot be generalized and should be considered solely in the particular context of the study. Also, the meanings of gender in organizational work/roles can vary from one organization to another. Further studies can be conducted to address these limitations and offer additional perspectives to our understanding of gender in PD work/role.

Footnotes

Acknowledgements

The authors wish to thank Thurayya Arayssi, MD, Weill Cornell Medicine-Qatar, Siok Ching Chia, BS, National University Hospital, and Amanda Bertram, MS, Johns Hopkins University School of Medicine for their assistance in executing the study. The authors also extend their gratitude to all the program directors who participated in the study for their valuable time and invaluable perspectives.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by Massey University Research Funds, College of Business, Massey University, New Zealand.

ORCID iD

Debalina Dutta

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