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Investigating the personal and organizational factors influencing the departure of female physicians from healthcare leadership roles

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Investigating the personal and organizational factors influencing the departure of female physicians from healthcare leadership roles

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Content Investigating the Personal and Organizational Factors Influencing
the Departure of Female Physicians From Healthcare Leadership Roles
Natalie Whitlock
Rossier School of Education
University of Southern California
A dissertation submitted to the faculty
in partial fulfillment of the requirements for the degree of
Doctor of Education
December 2024

© Copyright by Natalie Whitlock 2024
All Rights Reserved

The Committee for Natalie Whitlock certifies the approval of this Dissertation
Courtney Malloy
Mary Washburn
Dennis Hocevar, Committee Chair
Rossier School of Education
University of Southern California
2024

iv
Abstract
There is a critical need for more female physicians in leadership positions in the healthcare
industry. The lack of women in leadership positions in healthcare diminishes women’s roles in
policy decisions, which impacts women’s health. Patients, employees, organizations, and women
all benefit from addressing the gender disparity in healthcare. Greater gender diversity in
leadership also enhances organizational performance, with positive effects reported for employee
engagement, satisfaction, and retention. This qualitative research study examines the reasons
female physicians leave leadership positions. Bandura’s social cognitive theory and concept of
self-efficacy was used as the conceptual framework. Ten female physicians working in a were
interviewed using a semi-structured interview protocol. Varied personal and organizational
factors contributed to the decision of female physicians to leave their leadership roles. Personal
factors included feelings of hopelessness or perceptions of inability to make a difference, not
feeling supported or valued, family responsibilities, physical and mental health needs, and
burnout. Organizational factors included a lack of support for female physician leaders by male
leaders, structures that did not support female physician leaders, lack of mentorship and
leadership development, and organizational or departmental culture. Five recommendations were
identified from the data: provide leadership development training, provide formal mentoring,
strengthen organizational structures, improve organizational and departmental culture, and
conduct exit interviews when female physician leaders step back from leadership.

v
Acknowledgments
It takes a village to earn a doctorate degree. I am often humbled by the many supportive
people in my life who lift me up and believe in me.
To my parents, Howard and Nancy, and my sister, Serena, who have always been my
biggest cheerleaders. I always want to make them proud and appreciate their unwavering
support.
My boyfriend Matt, known in this program as Milo, always believes in me and
encourages me. With his help, our group survived in the desert in EDUC 524. That is also the
class in which Team Schoftsea was born. I will never forget laughing hysterically with these
people.
To my friends who celebrate my successes with me and were understanding when I had
to pass on social events to focus on school work. You all encouraged me and helped keep me
sane.
Dr. Pam Honsberger, who passionately supports female physician leaders and supported
me in this journey from day one. She looks for ways to elevate me and this important work.
My dissertation committee is Dr. Dennis Hocevar, Dr. Courtney Malloy, and Dr. Mary
Washburn. I am so lucky to have a committee that gave me helpful feedback and was invested in
my success. The feedback from my Chair, Dr. Hocevar, helped me to build my confidence
throughout writing this dissertation. I was so fortunate that Dr. Mary Washburn, a friend and
colleague, was generous in supporting me as a committee member.
Cohort 22 is an absolutely amazing group of humans. I formed so many wonderful
connections that I hope will last a lifetime.

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And to the female physician leaders who participated in this study. I learned so much
from each one and am in awe of their grit and passion. I appreciated their honesty, vulnerability,
and willingness to tell their stories. Because of their bravery, we can change the experience for
future female physician leaders.

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Table of Contents
Abstract.......................................................................................................................................... iv
Acknowledgments............................................................................................................................v
List of Tables ................................................................................................................................. ix
List of Figures..................................................................................................................................x
Chapter One: Introduction to the Study...........................................................................................1
Context and Background of the Problem.............................................................................2
Purpose of the Project and Research Question ....................................................................3
Importance of the Study.......................................................................................................3
Overview of Theoretical Framework and Methodology .....................................................4
Organization of the Dissertation ..........................................................................................6
Chapter Two: Literature Review .....................................................................................................8
Women in Healthcare Leadership........................................................................................8
Reasons for Gender Disparities in Healthcare Leadership ..................................................9
The Case for More Women in Healthcare Leadership Positions.......................................15
Retention of Female Physicians Currently in Leadership Positions..................................17
Physician Burnout..............................................................................................................18
Moral Injury.......................................................................................................................24
Conceptual Framework......................................................................................................25
Chapter Summary ..............................................................................................................29
Chapter Three: Methodology.........................................................................................................30
Overview of Design ...........................................................................................................30
Research Setting.................................................................................................................31
The Researcher...................................................................................................................31
Data Source: Interviews.....................................................................................................32

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Validity and Reliability......................................................................................................36
Ethics..................................................................................................................................37
Chapter Four: Findings..................................................................................................................38
Factors Influencing the Retention of Female Physician Leaders.......................................38
Chapter Summary ..............................................................................................................55
Chapter Five: Recommendations...................................................................................................56
Discussion of Findings.......................................................................................................56
Recommendations for Practice ..........................................................................................59
Limitations and Delimitations............................................................................................64
Recommendations for Future Research.............................................................................65
Conclusion .........................................................................................................................66
References......................................................................................................................................67
Appendix A: Recruitment Email ...................................................................................................76
Study Details......................................................................................................................76
Benefits of Participation ....................................................................................................76
Appendix B: Interview Questions..................................................................................................78
Appendix C: USC IRB Approval ..................................................................................................80

ix
List of Tables
Table 1: Data Sources 30
Table 2: Participant Demographics (N = 10) 39
Appendix B: Interview Questions 78

x
List of Figures
Figure 1: Conceptual Model of Social Cognitive Theory 6
Figure 2: Revised Conceptual Model of Social Cognitive Theory 27
Figure 3: Word Cloud of Responses About Leadership Style 46
Appendix C: USC IRB Approval 80

1
Chapter One: Introduction to the Study
This study focuses on a critical problem of practice: the need for more women in
leadership positions in the healthcare industry. Patients, employees, organizations, and women
all benefit from addressing the gender disparity in healthcare. The lack of women in leadership
positions in healthcare diminishes women’s roles in policy decisions, which impacts women’s
health (Odei et al., 2021). Greater gender diversity in healthcare leadership is essential to
eliminating gendered healthcare disparities and improving the quality of care (Mousa et al.,
2023).
Greater gender diversity in leadership positions has also been found to enhance
organizational performance, with positive effects reported for employee engagement,
satisfaction, and retention (Hoss et al., 2011; Hunt et al., 2020). The advantages of incorporating
more women into healthcare leadership teams include more diverse thinking required for
innovation, a more collaborative leadership style typically associated with women leaders, and
better connections to the expertise of women caregivers necessary to engage patients in
improving health outcomes (McDonagh & Paris, 2013). Furthermore, increasing gender equity in
healthcare leadership helps in the retention of a valuable workforce and reducing attrition rates
following the global COVID-19 pandemic (Mousa et al., 2023).
Women represent a large majority (76%) of the healthcare workforce but are generally
underrepresented in leadership positions (Cheeseman Day & Christnacht, 2019). Women
comprise 50% or more of medical school graduates but (a) only 13% to 15% of department
chairs in the United States and Canada and (b) an even smaller percentage of medical directors
on the trust boards of the United Kingdom’s National Health System (Roth et al., 2016). A study
of health systems, health insurance companies, and the U.S. Department of Health and Human

2
Services found that just 15% of CEOs are female (Odei et al., 2021). The underrepresentation of
female physician leaders and the disproportionate rate of women leaving leadership roles is
rooted in the adverse working conditions and pervasive burnout in the healthcare industry; thus,
research on burnout for female physician leaders is critical to the future of healthcare.
Context and Background of the Problem
Gottenborg et al. (2021) found four challenges women face in leadership positions: lack
of support to acquire leadership training and exposure, bullying in the workplace, combating a
sense of sacrifice, and the need for internal and external validation. These researchers addressed
women leaders as a whole, including healthcare leaders; physicians’ experience may differ when
segmented from the demographic of women leaders.
Women in leadership positions in healthcare face multiple challenges, the most
prominent one being burnout. The Women in the Workplace Survey found that 43% of women
reported burnout out compared to 31% of men, controlling for seniority of leadership (LeanIn &
McKinsey, 2022). In a study of administrative healthcare leaders, roughly one-third had burnout
scores that fell in the high range; however, overall, leaders’ burnout and occupational distress
appeared lower than those reported by clinicians (Shanafelt et al., 2022).
The high prevalence of occupational burnout among physicians is well documented
(Shanafelt et al., 2022). However, in examining the experience of burnout in physicians, the
impact of burnout for female physicians is different compared to male physicians. For example, a
study conducted by Athenahealth found that female physicians experienced burnout more
frequently than male physicians; 51% of female physicians reporting feelings of burnout a few
times a month or more, compared to 43% of male physicians (Watson, 2021). Other studies have
found that women physicians have a 60% higher burnout rate than men, yet healthcare

3
workplace decision-makers overlook the role of gender as a predictor of burnout (Linzer et al.,
2014).
There are additional unique challenges in the context of the intersectionality of female
physicians in leadership roles. Specifically, studies of physician leaders at Stanford Medicine
demonstrated that the personal burnout, professional fulfillment, and sleep scores of work unit
leaders correlated with their independently assessed leadership behavior scores as evaluated by
members of their team (Shanafelt et al., 2022). In a study of female physician division heads, one
challenge identified was the pervasive sense of sacrifice in balancing household duties,
administrative duties, and clinical duties, which led to feelings of burnout and inadequacy
(Gottenborg et al., 2021). More research is needed on how burnout affects female physicians in
leadership positions.
Purpose of the Project and Research Question
This study aims to understand the factors related to a female physician leader’s decision
to leave her leadership position, affecting the retention of female physician leaders. A single
research questions guide this study: What factors (i.e., personal and organizational) influence the
retention of female physician leaders in healthcare?
Importance of the Study
The disparity in the number of women physician leaders in health care makes it
imperative to address factors that influence the retention of female physician leaders. One of the
coping strategies physician leaders use to reduce burnout is leaving leadership roles, as
leadership roles can contribute to feelings of burnout (Dillon et al., 2020). Women often bear
greater responsibility for caring for young children and may choose to reduce their work hours,

4
for which they may face additional discrimination, making it harder for them to re-enter
leadership positions in the future (Dillon et al., 2020).
Research on why female physicians leave leadership positions is sparse; healthcare
research needs to address this gap. There is well-documented evidence of physician burnout
rates, but the data is not specific to physicians in leadership roles. Furthermore, the research
literature does not address how burnout impacts physicians’ decisions to remain in or leave
leadership positions or what can be done to address this problem. More research is needed to
understand the specific experience of female physician leaders in the healthcare industry with the
aim of identifying strategies and tactics for retaining female physician leaders in a complex
workplace environment defined by pervasive burnout.
Overview of Theoretical Framework and Methodology
Social cognitive theory is an appropriate theoretical model that can guide this study.
Social cognitive theory asserts that people are products of their environments but also create their
environments, allowing them to influence events and shape their lives (Bandura, 2000). As seen
in Figure 1, determinants of internal personal factors, behavioral patterns, and environmental
events interact and influence one another bidirectionally (Bandura, 1999). When using this lens
to assess the problem of practice, the person, the environment, and behaviors all influence the
gender disparity for women in leadership and the retention of women currently in leadership
positions. Personal factors, described above, include combating a sense of sacrifice and the need
for internal and external validation (Gottenborg et al., 2021). The environment as a critical factor
requires more organizational support to enhance leadership training and exposure with more
robust programs and initiatives to promote physician well-being (Gottenborg et al., 2021;

5
Shanafelt et al., 2022). This study examines how personal and environmental factors influence
the behavior of female physicians leaving leadership.
Figure 1 shows that how social cognitive theory presents a model of reciprocal causality;
internal personal factors (i.e., cognitive, affective, and biological events), behavioral patterns,
and environmental events all operate as interacting determinants that influence one another
bidirectionally (Bandura, 1999). Social cognitive theory emphasizes that much of human
learning occurs in social environments (Schunk & Usher, 2019). In social cognitive theory,
people are neither driven by universal traits nor automatically shaped and controlled by the
environment (Bandura, 1999). Human agency is a critical concept in which individuals exert
significant control over their thoughts, feelings, and actions; people are affected and influenced
by their actions (Schunk & Usher, 2019). Thus, it can be beneficial to assess the personal,
environmental, and behavioral factors that impact the retention of female physician leaders and
how they influence these women leaders’ decisions to leave leadership.

6
Figure 1
Conceptual Model of Social Cognitive Theory
Note. Personal factors include cognition, beliefs, skills, and affect. From Social Cognitive Theory
and Motivation (p.3), by D.H. Schunk and E.L. Usher, 2019, Oxford: Oxford University Press.
Copyright 2018 by the Oxford University Press.
Organization of the Dissertation
The research study addresses personal and organizational factors influencing the
departure of female physicians from healthcare leadership roles. Chapter One introduced the
problem of practice and provided an overview of the study. Chapter Two explores women in
healthcare leadership, including women physicians in healthcare leadership, reasons for gender
disparities, and the case for more women in healthcare leadership positions. Chapter Two
addresses the retention of female physicians currently in leadership positions, with a focus on
burnout and moral injury. Chapter Two also explores the conceptual framework in detail.
Chapter Three presents the research design, methods for data collection, and data analysis
procedures; it also addresses researcher positionality and ethical considerations. Chapter Four
Behavioral
Factors
Social and
Environmental
Factors
Personal
Factors

7
presents the research findings. Chapter Five introduces recommendations informed by the
research findings in the context of the existing research literature.

8
Chapter Two: Literature Review
This chapter reviews topics including women in healthcare leadership, women physicians
in healthcare leadership, retention of women physician leaders, and physician burnout. It then
discusses the theoretical framework of social cognitive theory and how the elements of the
conceptual framework can be used to understand factors that impact the experiences of female
physician leaders.
Women in Healthcare Leadership
Women represent a large majority (76%) of the healthcare workforce but are generally
underrepresented in leadership positions (Cheeseman Day & Christnacht, 2019). Only 25% of
leaders in the healthcare sector are women (Hill et al., 2016). According to the World Health
Organization (WHO), women constitute 70% of the global health workforce but hold just 25% of
the senior level roles (2019). A cross-sectional study found that only 15% of the CEO roles in
health systems and 16% of the CEO positions in health insurance groups were held by women
(Odei et al., 2021). The data clearly show that while women deliver the majority of global health,
it is men lead it (WHO, 2019).
This gender disparity is consistent for female physicians in leadership roles. In a study
done in a large tertiary-care, multi-site Canadian healthcare system, only 13% of department and
division heads were women (Roth et al., 2016). Women comprise 50% or more of medical
school graduates but (a) only 13% to 15% of department chairs in the United States and Canada
and (b) an even smaller percentage of medical directors on the trust boards of the United
Kingdom’s National Health System (Roth et al., 2016).
Furthermore, a cross-sectional analysis found that women accounted for just 13% of
department leaders at the top 50 U.S. medical schools funded by the National Institutes of Health

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(Wehner et al., 2015). As few as one-third of academic emergency medicine physicians are
female, and these physicians face disparities in representation and academic rank by gender
(Bennett et al., 2019). In their quantitative study of an emergency medicine database, Bennett et
al. (2019) found that female emergency physicians were less likely to be associate or full
professors when compared to their male colleagues, even after adjusting for detailed factors that
vary across male and female physicians and that may be associated with academic advancement
(e.g., age, years since residency, publications, grants, medical school ranking, and clinical trials).
Work must be done to increase the number of women physicians in leadership positions.
Reasons for Gender Disparities in Healthcare Leadership
There are many reasons for the lack of women in leadership positions in the healthcare
sector. This section focuses on individual, behavioral, and structural or organizational factors
that influence the promotion and retention of female physician leaders.
Individual Factors
One individual factor that impacts women in leadership positions is women’s need for
more confidence (Haines & McKeown, 2023; Hoss et al., 2011). Women who believe in their
self-worth and strengths tend to have confidence, which impacts their successful ascent into
leadership positions (Haines & McKeown, 2023).
However, women may not consider pursuing leadership due to a belief that they lack the
skills or personality to lead (Chisholm-Burns et al., 2017). Women also may take fewer career
risks when compared to men (Chisholm-Burns et al., 2017). In a systematic review of nine
papers on the experience of women leaders in healthcare, Haines and McKeown (2023)
uncovered a theme of internalized feelings of inadequacy and doubt in relation to being female.
These studies showed gaps in women’s self-perceptions of capability for leadership and

10
reluctance to accept leadership positions (Haines & McKeown, 2023). A lack of confidence can
hinder a female from applying for a leadership role.
Another factor that impacts a woman’s decision to pursue a leadership position is the
struggle to create work-life balance. Women frequently take time away from work due to
caregiving responsibilities, which can impact their careers by delaying women from advancing
through the ranks (Chisholm-Burns et al., 2017). Some women feel forced to choose between
having a family or having a career (Chisholm-Burns et al., 2017). Women often report an
internal battle between motherhood and striving for advanced leadership (Haines & McKeown,
2023). In a qualitative study by Roth et al. (2016), female participants acknowledged that they
often took on a more significant proportion of family responsibilities than their male
counterparts, and these responsibilities interfered with their career aspirations.
Women often experience pressure to self-sacrifice to achieve a desired balance between
their personal and professional lives (Gottenborg et al., 2021). Women leaders also find it
challenging to balance domains within their profession (e.g., clinical and administrative duties)
which creates feelings of sacrifice. In the qualitative study by Roth et al. (2016), one participant
mentioned that the higher you go, the less you see patients. Women may also self-sacrifice
because they are cognizant of other women’s needs and may not want to step on toes by taking
an opportunity away from someone else (Roth et al., 2016). This sense of self-sacrifice can lead
to personal feelings of burnout and inadequacy (Gottenborg et al., 2021).
Women in leadership roles may need internal and external validation (Gottenborg et al.,
2021). External validation aims to prove to others the value of women’s contributions in their
leadership roles (Gottenborg et al., 2021). Internal validation addresses feelings of “imposter
syndrome,” where women doubt their own capacities (i.e., feel like an imposter) in spite of

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evidence that they are indeed competent and qualified (Gottenborg et al., 2021). Women may
also experience a fear of rejection in applying for leadership positions and often need the support
of others to encourage them to apply as well as to encourage them if they are rejected for the job
(Roth et al., 2016). Women may not seek out and apply for leadership positions if this support
and validation is absent.
Behavioral Factors
Stereotyping is a behavioral factor that impacts the number of women in leadership
positions. Gender stereotypes and norms are common in societies and drive occupational
segregation, sorting men and women into different kinds of jobs; the gender schema for women
often remains incompatible with professional management roles (McDonagh et al., 2014; WHO,
2019). One example of stereotyping is the common belief that women are preoccupied with
raising a family and do not intend to pursue leadership positions (Haines & McKeown, 2023).
The dominant stereotype in many cultures assigns men the role of breadwinner while women are
relegated to homemaking and childcare (WHO, 2019). This stereotype is the leading cause of
occupational segregation; it devalues women’s contributions to the labor force or limits their
workforce participation, leading to gendered inequities such as women’s lower salaries and
limited opportunities to exercise authority (WHO, 2019).
Another behavioral factor noted in the research literature is workplace discrimination,
including bullying and microaggressions (Haines & McKeown, 2023). These behaviors are often
rooted in unconscious bias and can lead to deeply rooted sexism in the workplace (Haines &
McKeown, 2023). A consequence of this unconscious sexism is that women adopt a negative
mindset about work and their career path (Haines & McKeown, 2023). Women may not be taken

12
seriously when aspiring to leadership positions, which may instill and perpetuate a belief that
women do not belong in these positions (Haines & McKeown, 2023).
Gottenborg et al. (2021) reported bullying in the workplace, which showed up in the form
of antagonistic behavior by both men and women; this bullying was perceived as
microaggressions and lack of support from other women. One of their study participants
mentioned that two junior male co-workers made it clear they were not happy with her as their
leader. Another participant explained that other women can bring each other down instead of
supporting one another (Gottenborg et al., 2021). Thus, discriminatory behavior can have a
detrimental effect on the experience in leadership.
Another behavioral issue that impedes women from seeking leadership positions is the
preference for a male leadership style or model (Hoss et al., 2011; Mousa et al., 2023). Typical
male leadership traits include competition, assertiveness, and decisive action; female traits
include modesty, cooperation, and emotiveness, which are viewed as incompatible with strong
leadership (Hoss et al., 2011). Chisholm-Burns et al. (2017) noted that typical male
characteristics are the default or standard expectations by which female leaders are hired,
promoted, or retained, whereas typical female characteristics are devalued.
In a qualitative study by Gottenborg et al. (2021), participants noted that they often felt
pressured to depart from their natural leadership style to adopt a more normative male leadership
model. Women feel the tension of trying to do the job like a man does while finding the unique
ways women can add value (Gottenborg et al., 2021). Mousa et al. (2023) found that social and
cultural cues around women’s interactions were influential in women’s career progression;
feelings about gender were articulated from traditional societal views that concentrated men into
agentic roles and women into communal roles and responsibilities (Mousa et al., 2023). The

13
feelings of having to yield to gender-congruent behaviors, avoid resistance, and fulfill the
expectations of others were perceived to compromise the effectiveness of women in leadership
positions (Mousa et al., 2023).
Lack of support also challenges women’s attainment of leadership positions and was one
of the most prominent barriers noted in the research literature (Haines & McKeown, 2023). This
lack of support can come from family and colleagues, a scarcity of role models, and inadequate
communication and transparency around leadership opportunities (Haines & McKeown, 2023).
Female mentors and role models are needed to inspire and encourage other women to seek
leadership positions (Haines & McKeown, 2023). Participants in a study by Roth et al. (2016)
identified a need for more transparency of available leadership positions and a need for
discussions around leadership strengths and weaknesses as part of the annual evaluation process
to help support the advancement of women into leadership positions. Participants needed both
male and female mentors (Roth et al., 2016). Increased support may encourage women to seek
out leadership opportunities.
Organizational Factors
As mentioned earlier, women often must balance work and life responsibilities. Policies
that support or do not support work-life balance can either help or hinder the advancement of
women into leadership positions (Chisholm-Burns et al., 2017). Women might be more inclined
to seek leadership positions if their organizations had a culture encouraging men and women to
prioritize family needs (Roth et al., 2016). Parental leave policies are one way to acknowledge
and support the importance of family responsibilities (Roth et al., 2016). Flexibility in schedules
and support of parental responsibilities may impact women in leadership roles. Workplace
culture to be more supportive of women by creating flexible schedules to allow more time to

14
balance work-life responsibilities (Hoss et al., 2011). Participants in one study described an
evolution of the culture of medicine by valuing diversity and flexibility (Gottenborg et al., 2021).
Leadership development opportunities and women-focused organizations also impact
women’s readiness to advance into leadership roles. Leadership development programs are
essential for preparing the next generation of leaders and strengthening teams of leaders to work
in a more collaborative environment; however, women are often not a focus of these essential
programs (McDonagh & Paris, 2013). Organizations that advocate for women are not new, but
several new groups have been created in the past few years (Glauser, 2019); for example, the
Canadian Women in Medicine and the GRIT conference as part of the Mayo Clinic. Such groups
can host conferences, participate in advocacy efforts, offer workshops, and provide mentorship
opportunities (Glauser, 2019). In a qualitative study by Lin et al. (2019), multiple participants
described leadership opportunities, awards, or experiences they either would not have achieved
or would have achieved later in their careers if not for the opportunities and relationships
cultivated in these woman-focused professional organizations. These pro-women groups allow
females to gain support in their leadership journey.
A supportive organizational culture that is open to change affects the advancement of
women into leadership roles. The lack of a supportive organizational culture perpetuates
inconsistent gender equity practices and undermines opportunities for women’s advancement and
promotion (Mousa et al., 2023). Healthcare leaders need to have a solid understanding of the
systemic barriers faced by women to implement appropriate interventions to address these
barriers (Mousa et al., 2023). In a study by Roth et al. (2016), participants found their
organizational culture resistant to change and lacking the desire to move from its autocratic style.
Traditional bureaucratic organizational structures stifled creative and collaborative relationships

15
and were not conducive to women’s transformational leadership styles (McDonagh & Paris,
2013). The pervasive culture in healthcare still embraces a male leadership model that does not
allow for the optimal inclusion of women (McDonagh & Paris, 2013).
The lack of mentors, role models, and sponsors also plays a role in inhibiting the
advancement of women into leadership positions (Chisholm-Burns et al., 2017). A lack of role
models feeds into a mentality that women are not meant for leadership positions (ChisholmBurns et al., 2017). Mentors and sponsors are vital in encouraging women to seek and apply for
leadership positions (Chisholm-Burns et al., 2017). Mentors act as advisors who offer career
guidance and help navigate organizations; sponsors take on the role of promoter as they market,
advocate, and advance the cause of others (Chisholm-Burns et al., 2017).
As an example, female emergency department physician study participants reported
benefiting from sponsorship, primarily in the form of senior members nominating junior
members for leadership positions (Lin et al., 2019). The ability to engage with and observe more
seasoned women gave junior physicians a sense of confidence that encouraged them to advance
(Lin et al., 2019).
The Case for More Women in Healthcare Leadership Positions
Across occupational sectors, including healthcare, organizations with a higher proportion
of women in leadership have been shown to outperform their peers in innovation, accountability,
and financial outcomes (Desvaux et al., 2010). Among the 279 companies studied by McKinsey
(Desvaux et al., 2010), those in the top quartile, as measured by women in leadership,
outperformed companies without women in leadership by 41% for average return-on-equity and
56% for operating results. A 2019 analysis by McKinsey (Hunt et al., 2020) found that
companies in the top quartile for gender diversity on executive teams were 25% more likely to

16
experience above-average profitability than peer companies in the lowest (i.e., fourth) quartile.
Women in leadership impact an organization’s bottom line.
Other studies have cited multiple advantages of including more women in healthcare
leadership positions, including but not limited to greater access to the thinking needed to drive
innovation, a more collaborative leadership style associated with women leaders, and access to
the expertise required to engage patients in improving health outcomes (McDonagh & Paris,
2013). Increasing gender diversity is a strategic imperative supported by data that demonstrates
that by adding more women, the overall effectiveness of a leadership team improves (McDonagh
& Paris, 2013). In a study by Roth et al. (2016), participants perceived that organizational culture
shifted from “autocratic” to more collaborative with women in leadership positions. Roth et al.
(2016) recommended that further change would be supported if organizations place females at all
leadership levels where they can continue to influence cultural shifts.
Many women utilize a more transformational leadership style characterized by values and
favoring higher-order needs (McDonagh et al., 2014). Transformational leadership closely aligns
with characteristics often attributed to women such as an interpersonally-oriented participatory
style (McDonagh et al., 2014). Moreover, transformational leaders are well-equipped to build the
cultures and systems required for the future of healthcare (McDonagh & Paris, 2013). The most
effective leadership styles for healthcare workplaces are transformational and collaborative
leadership, which rely on communication and are relationship-driven; these attributes are often
characteristic of female leadership styles (Haines & McKeown, 2023). More women in
leadership positions in healthcare will help transform workplace culture and improve outcomes
for patients and employees.

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Retention of Female Physicians Currently in Leadership Positions
Data from the research literature clearly demonstrate a disparity in the number of women
in leadership positions in healthcare, which includes female physicians. This disparity and the
barriers women face in achieving leadership positions make it critical to retain those female
physicians who are currently in leadership positions. One study found that almost 40% of women
work part-time or leave medicine within 6 years of completing their residencies (Paturel, 2019).
The emergence of this gap so early in physicians’ careers likely contributes to ensuing gender
inequities in compensation and advancement, which suggests the importance of expanding social
and institutional support for work-family balance (Frank et al., 2019).
For example, cardiology is a sub-specialty that has gender inequities in compensation,
career advancement opportunities, and other workforce factors due to perceived negative
characteristics such as competitive environment, excessive duration of training, lack of
supportive mentors, and limited opportunities for part-time schedules (Sharma et al., 2019).
Creating a workplace environment that provides equitable advancement opportunities and
prevents attrition of highly skilled cardiologists will benefit healthcare programs and the patients.
Workplaces should strive to ensure women are in leadership and mentorship positions without
placing excessive burdens on them (Sharma et al., 2019).
Women often do not advance to senior ranks compared to their male peers. A study of
emergency medicine found that males were more likely to hold an associate or full professor
status, whereas females were more likely to hold assistant professor status (Bennett et al., 2019).
The study concluded that it was unclear what proportion the lack of retention versus a lack of
advancement contributed to the lack of female faculty at higher ranks (Bennett et al., 2019).

18
In a second study of emergency medicine, a workgroup developed initiatives to assist
with the recruitment and retention of female emergency department physicians, including
advancement into leadership positions (Choo et al., 2016). Some of the initiatives included
family-oriented administrative policies, facilitating the development and advancement of female
physicians as well as supporting the health and wellness of women physicians. This study
emphasizes that initiatives encouraging and enabling women to advance into leadership positions
must be explored.
The use of exit interviews can help the healthcare industry to understand the reasons
employees leave positions, organizations can use feedback to enact changes that will benefit
employees still working in the organization. The strategic use of data from exit interviews can
enable organizations to retain key employees (Hossain et al., 2017). A study of an academic
medical center focused on multiple retention efforts, including conducting exit and transfer
interviews, to gather data to inform center leadership about changes that could be made to retain
employees (Daniels et al., 2013). Researchers created a questionnaire that focused on job
satisfaction, reasons for leaving, and opportunities for improvement (Daniels et al., 2013). This
provides a model for how exit interviews with female physician leaders who left their roles can
provide organizations with valuable insights on ways to reduce turnover.
Physician Burnout
Burnout is characterized by a loss of enthusiasm (i.e., emotional exhaustion) for work or
life, feelings of cynicism (i.e., depersonalization), and a low sense of personal accomplishment
(Maslach et al.,1996; Shanafelt et al., 2012). Burnout is conceptualized as a continuous variable,
ranging from low to moderate to high degrees of experienced feelings (Maslach et al., 1996).
Among physicians, emotional exhaustion includes feeling used up at the end of the workday and

19
having nothing else to offer patients from an emotional standpoint (West et al., 2018).
Depersonalization includes feelings of treating patients like objects rather than human beings and
becoming more callous toward patients (West et al., 2018). Lack of personal accomplishment
includes feelings of ineffectiveness in helping patients with their problems and lack of value in
work-related activities such as patient care or professional achievements (West et al., 2018).
Emotional exhaustion and depersonalization, defined as types of strain, are viewed as the core
components of burnout (Purvanova & Muros, 2010).
The experience of burnout is prevalent in the healthcare sector, and it takes a toll on
physicians when circumstances make it challenging to deliver the best possible care to patients
and fulfill their ethical commitments (Dzau et al., 2018). Researchers have found that burnout
begins early in medicine, with medical students and residents having higher rates of burnout than
peers pursuing non-medical careers (Dzau et al., 2018). A national study found that 50% of
physicians had symptoms of burnout (Shanafelt et al., 2012). A survey of America’s physicians
found that 60% of physicians in 2022 reported often having feelings of burnout compared to
40% in 2018, pre-pandemic (Physicians Foundation, 2022).
In addition to this alarming escalation of burnout, a study by Shanafelt et al. (2012)
highlighted three key findings around the prevalence of burnout. First, physicians in specialties
at the front line of care access (e.g., primary care and emergency medicine) were at the greatest
risk for burnout. Second, physicians who worked longer hours had greater struggles with worklife balance than other workers; Third, after adjusting for hours worked per week, higher levels
of education and professional degrees tended to reduce the experience of burnout in fields
outside of medicine, whereas a degree in medicine (i.e., a MD or DO) increased the risk of
burnout.

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Factors Contributing to Burnout
Many factors contribute to burnout, with work factors and work-related stressors causing
physician burnout (West et al., 2018). Among physicians, the degree of perceived control over
stressors at work is one of the most potent predictors of burnout (Patel et al., 2018). Work factors
attributed to burnout include but are not limited to administrative burdens, inefficient processes,
and computerized order entry (West et al., 2018). For example, Shanafelt et al. (2016) found that
physicians who used electronic health records and computerized physician order entry were less
satisfied with the amount of time spent on administrative tasks and were at a higher risk for
burnout.
Additionally, excessive workloads, work-home conflicts, lack of support from
colleagues, and deterioration of autonomy and meaning at work have all been associated with
physician burnout (West et al., 2018). Organizational culture factors also influence burnout, such
as negative leadership behaviors, lack of opportunities for advancement, limited collaboration,
and social support. Workloads and organizational stressors impact the experience of burnout.
Individual factors influencing physician burnout include gender, physician age, parenting
status and age of children, and spousal or partner occupation (West et al., 2018). Individual
characteristics such as personality and interpersonal skills may also influence how physicians
cope with stress (West et al., 2018). These personal characteristics associated with burnout
include being self-critical, engaging in unhelpful coping strategies, sleep deprivation, overcommitment, perfectionism, idealism, work-life imbalance, and inadequate support system
outside the work environment (Patel et al., 2018). These individual factors impact how a
physician feels and to what degree they may experience feelings of burnout.

21
Burnout in Female Physicians
The high prevalence of burnout is well documented in physicians, and studies show that
female physicians experience burnout at a higher rate than male physicians. Older research has
shown that women physicians had 60% greater likelihood of reporting burnout than male
physicians (McMurray et al., 2000). Using 2017–2018 data, Eden et al. (2020) found that female
family physicians, especially those under 40, experienced burnout at higher rates than males. In a
2020 study of physicians in private practice and academic medicine, 49% of female and 40% of
male physicians reported burnout (Marshall et al., 2020). Clearly, the experience of females is
different from that of males.
A meta-analysis conducted by Purvanova and Muros (2010) showed that women
experience burnout differently than men. Women were more likely to experience emotional
exhaustion than men, and men were more likely to experience depersonalization. A Norwegian
study found higher exhaustion levels among women, for whom burnout was notably linked with
work-home conflicts; higher disengagement levels were reported among men, for whom burnout
was most strongly predicted by workload (Langballe et al., 2011).
In a study of family physicians, Eden et al. (2020) found that female physicians were
significantly more likely to report emotional exhaustion than males in all age groups except those
over 60. In the same study, fewer family physicians reported callousness (i.e., depersonalization)
than emotional exhaustion. Additionally, gender differences were only significant for family
physicians under 40 years of age; these physicians reported higher rates of callousness.
For women, emotional exhaustion strongly influences depersonalization, which reduces
personal accomplishment (Houkes et al., 2011). Women who are burned out may be exhausted
and begin depersonalizing their patients; they may start feeling guilty and less sure about their

22
work and the quality of care they provide. In contrast, perceptions of personal accomplishment in
male general practitioners increased independent of feelings of depersonalization and emotional
exhaustion. These finding suggests that for men, reduced personal accomplishment is not a
dimension of burnout (Houkes et al., 2011).
Furthermore, patients have differing expectations of female and male physicians, which
may contribute to feelings of burnout (Linzer & Harwood, 2018). Female physicians often have
more female patients than male physicians and these patients have bring psychosocial
complexities; moreover, female patients tend to seek more empathic listening and lengthier
visits; however, female physicians are not allocated greater time to meet with female patients
(Linzer & Harwood, 2018). Similarly, female physicians tend to ask more psychosocial
questions, and appointment duration can be up to 10% longer for female primary care physicians
(Roter & Hall, 2004). These gendered expectations may have negative consequences and
disproportionally affect female physicians.
Consequences of Burnout
Physician burnout impacts patient care. Early studies suggested that burnout can lead to a
deterioration in the quality of care or service provided by staff (Maslach et al., 1996). In a crosssectional study of internal medicine residents, those experiencing burnout were significantly
more likely to self-report providing at least one type of sub-optimal patient care at least monthly
compared to residents not experiencing burnout (Shanafelt et al., 2002). Depersonalization was
the only dimension of burnout significantly associated with self-reported practices of suboptimal patient care (Shanafelt et al., 2002).
Similarly, Christensen et al. (1992) found a bi-directional dose-response relationship
between burnout syndrome scores and medical errors, where medical errors lead to stress and

23
stress leads to medical errors. For example, in a large national study of surgeons, approximately
9% of participating surgeons reported they had made a major medical error in the last 3 months,
with a strong relationship between surgeon distress and perceived medical errors (Shanafelt et
al., 2010). This study found that each one-point increase in depersonalization, emotional
exhaustion, and quality of life score was associated with a 5% to 11% higher likelihood of
reporting a recent major medical error. Only 15% of the surgeons reporting a recent significant
error in the study attributed the error to a system issue, while more than 70% attributed the error
to an individual factor such as fatigue, lapse in judgment, or stress/burnout (Shanafelt et al.,
2010).
The quality of patient care and the prevalence of medical errors not only has an impact on
the patient but the physician as well. Physicians experiencing burnout often report feeling tired,
fatigued, exhausted, inattentive, and irritable (Patel et al., 2018). The presence of any or all of
these symptoms can severely impact a physician’s well-being, disrupting their personal life and
decreasing professional efficiency (Patel et al., 2018).
Burnout takes a toll on physician mental health. Rates of self-reported major depression
and positive screening results for depression were significantly increased among residents who
met the criteria for burnout; unsurprisingly, career satisfaction showed a strong inverse
relationship to burnout (Shanafelt et al., 2002). In a cross-sectional analysis, surgeons who were
burned out and depressed were more likely to have alcohol abuse or dependence (Oreskovich et
al., 2012). Moreover, emotional exhaustion and depersonalization domains of burnout were
strongly associated with alcohol abuse or dependence.
Burnout also impacts the healthcare system. A physician suffering from burnout is less
productive and may even quit at some point, negatively affecting the healthcare system

24
economically by increasing costs (Patel et al., 2018). A 2022 survey conducted by the American
Medical Association reported that one in five physicians were likely to leave their current
practice within two years, and nearly one in three said they intended to reduce their work hours
(Butcher, 2023).
The exodus of female physicians from practice and academic positions is a critical issue
endangering the future of the American healthcare system (Kim et al., 2019). This issue is
exacerbated by burnout, which disproportionately affects female physicians. Interviews with
frontline physicians indicated that physicians cope with burnout by reducing clinical work hours,
leaving leadership roles, switching departments, changing jobs, or retiring (Dillon et al., 2020).
With fewer female physicians in leadership positions than males and female physicians
disproportionately deciding to leave leadership roles due to burnout, the lack of female physician
leadership can be expected to continue and escalate.
Moral Injury
Moral injury contributes to a physician’s experience and is distinct from burnout. Moral
injury is present when there has been a betrayal of “what’s right,” either by a person in a
legitimate authority or in a high-stakes situation (Shay, 2012). The term was first developed to
describe the experiences of war veterans (Shay, 2012). Moral injury is an irreparable trauma that
goes against one’s personal ethical standards (Sheikhbahaei et al., 2023). In medicine, the two
main causes of moral injury are (a) a divergence of purpose between the physician and the
institution and (b) a compulsive bureaucracy where a divergence of purpose or imposing
doctrines and ideologies contradicts the beliefs of caregivers (Sheikhbahaei et al., 2023).
The effects of moral injury can be substantial. Consequences include a loss of
institutional loyalty and detachment from noble ideas that attracted the person to medicine in the

25
first place (Sheikhbahaei et al., 2023). The difference between moral injury and burnout is that
moral injury can be irreversible. Interventions that help reduce burnout may not be effective in
addressing moral injury, as moral injury can be considered “soul wounds that leave permanent
scars” (Sheikhbahaei et al., 2023, p. 1). Moral injury may have a more devasting effect on
physician leaders than burnout.
Conceptual Framework
Social cognitive theory is an ideal theoretical model to guide this study as it asserts that
people are products of their environments but also create their environments, allowing them to
influence events and shape their lives (Bandura, 2000). This theory of human behavior
emphasizes that learning comes from the social environment (Schunk & Usher, 2019). Here,
internal personal factors, behavioral patterns, and environmental events operate as interacting
determinants that influence one another bidirectionally (Bandura, 1999). The theory argues that
people use various vicarious, symbolic, and self-regulatory processes as they strive to develop a
sense of agency in their lives (Schunk & Usher, 2019). When using this lens to assess the
problem of practice—a lack of women physicians in leadership roles in healthcare—factors
related to the person, the environment, and behaviors clearly influence this disparity as well as
the retention of women physicians currently in leadership positions.
Multiple examples of individual factors have been identified influencing the challenges
women face in leadership roles. Examples of individual factors include interpersonal skills, the
ability to manage stress, being self-critical, perfectionism, work-life imbalance, and inadequate
support systems outside of the work environment (Patel et al., 2018; West et al., 2018). People’s
thoughts, beliefs, and feelings affect their behavior (Bandura, 1999). A physician lacking a
support system may experience emotional exhaustion and become callous toward patients.

26
Behaviors impacting women in leadership include symptoms of burnout, which can affect
leadership behaviors and cause women to leave their leadership positions as a way of combating
burnout (Dillon et al., 2020; Gottenborg et al., 2021; Shanafelt et al., 2022). People are motivated
to act following their beliefs about their capabilities and the expected outcomes of their actions
(Schunk & Usher, 2019). The individual feelings or attributes a female physician leader holds
regarding their ability as a leader will impact how they behave. The reciprocal relationship
between personal feelings and behavior can be seen in women who are burned out, exhausted,
and beginning depersonalizing their patients; they may start feeling guilty and less sure about
their work and the quality of care they provide (Houkes et al., 2011). These behaviors, in turn,
have an impact on the environment. For example, a physician who is burned out may reduce
their hours or leave health care, which impacts the environment by contributing to the shortage
of physicians and increasing economic costs (Patel et al., 2018).
The environment also plays a role, shaping the need for more organizational support to
acquire leadership training and exposure as well as robust programs and initiatives to promote
physician well-being to address burnout (Gottenborg et al., 2021; Shanafelt et al.,
2022). Organizational culture is often influenced by behaviors that lead to burnout, including
negative leadership behaviors, limited collaboration, and lack of social support (West et al.,
2018). Reciprocally, people are affected and are influenced by these behaviors and the
environment (Schunk & Usher, 2019). Most environmental events exert their influence through
cognitive processing rather than directly; there are cognitive factors that determine what
environmental factors are observed and what impact they have (Bandura, 1999).
Figure 2 shows the social cognitive theory as a model of reciprocal causality; internal
personal factors in the form of cognitive, affective, and biological events, behavioral patterns,

27
and environmental events all operate as interacting determinants that influence one another
bidirectionally (Bandura, 1999). Human agency is a critical concept in which individuals exert
significant control over their thoughts, feelings, and actions, and people are affected and
influenced by their actions (Schunk & Usher, 2019). It can be beneficial to assess the personal,
environmental, and behavioral factors that impact female physician leaders and how they
influence the decision to leave leadership.
Figure 2
Revised Conceptual Model of Social Cognitive Theory
Note. Personal factors include cognition, beliefs, skills, and affect. From Social Cognitive Theory
and Motivation (p.3), by D.H. Schunk and E.L. Usher, 2019, Oxford: Oxford University Press.
Copyright 2018 by the Oxford University Press.
Behavioral Factors
=> Leaving Leadership
Social/Environmental Factors
=> Organizational Culture
Personal Factors
=> Self-efficacy

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Specifically, this entails looking at how individual factors (i.e., self-efficacy) and
organizational factors influence the decision to leave a leadership role (i.e., behavior).
Perceptions of self-efficacy address people’s beliefs in their capabilities to perform in ways that
give them some control over events that affect their lives (Bandura, 1999). It pertains to the
beliefs one holds about one’s ability to succeed in a leadership position; leader developmental
efficacy focuses on one’s beliefs about their ability to change and develop leadership skills
(Murphy & Johnson, 2016). Self-efficacy will determine how a female feels about herself as a
leader. Understanding how self-efficacy, as part of social cognitive theory, can help women
physician leaders is essential as healthcare systems look for ways to retain women currently in
leadership roles while addressing their feelings of burnout.
Self-efficacy beliefs are constructed from four sources of information (Bandura, 1999).
The first source is through mastery experiences, which are achieved by tackling problems in
successive attainable steps such that these successes build a belief in one’s efficacy (Bandura,
1999). If a physician leader can overcome feelings of burnout and show perseverance, it can
improve their perceptions of efficacy.
The second source of creating efficacy is through vicarious experiences (Bandura, 1999).
If female physician leaders see other females in leadership positions managing burnout, they may
believe they can do the same. Conversely, observing failures in others instills doubts in one’s
abilities to master similar activities (Bandura, 1999).
The third source of strengthening a person’s beliefs in their efficacy is through social
persuasion, which is hearing from others that they have what it takes to succeed (Bandura, 1999).
This persuasion helps people to exert more effort and persevere through challenges, helping to
decrease the impact of harboring self-doubts and dwelling on perceived deficiencies (Bandura,

29
1999). This can influence female physicians as they to try to achieve leadership positions and
help them overcome feelings of burnout.
The fourth and final piece of information that affects self-efficacy comes from a person’s
physical and emotional states as they judge their capabilities (Bandura, 1999). A way to alter
efficacy beliefs is to reduce negative emotional states (i.e., burnout). All four sources of
information influence self-efficacy and can be used to examine the level of burnout experienced
by female physician leaders and seek ways to improve self-efficacy, reducing feelings of
burnout.
Self-efficacy can be improved through mastery experience, vicarious learning, and social
persuasion, which can be achieved through leadership development training (Bandura, 2000;
Murphy & Johnson, 2016). Mentorship programs and role modeling are forms of vicarious
learning and can allow new leaders to develop their leadership skills and improve their selfefficacy (Taylor et al., 2014). It is essential to understand how self-efficacy impacts the
experience of burnout for female physician leaders and their decision to remain in or leave a
leadership position.
Chapter Summary
The literature review provides a case for why more women, specifically female
physicians, need to be in leadership positions in healthcare. Gender influences women in
healthcare disproportionately, especially with respect to burnout, which strongly influences
women physician leaders’ decisions to leave leadership. There is a critical need to explore
further the individual, behavioral, and organizational factors that influence female physician
leaders and how that relates to their decisions to leave leadership positions. This is the gap filled
by the current research study.

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Chapter Three: Methodology
This study aims to understand the factors considered in a female physician leader’s
decision to leave their leadership position, affecting female leaders’ retention. A single research
questions frame this study: What factors (i.e., personal and organizational) influence the
retention of female physician leaders in healthcare? This chapter outlines the instrumentation and
data collection and analysis procedures, as well as issues of validity and reliability and ethical
considerations.
Overview of Design
This study used a qualitative research methodology focused on semi-structured
interviews and narrative inquiry utilizing stories as data (Merriam & Tisdell, 2016). Interviews
were conducted with female physicians who had left their leadership positions. The methodology
also used a phenomenological approach as the research method, using narratives that constituted
stories of lived experiences (Merriam & Tisdell, 2016).
First-person accounts of lived experiences framed this approach’s narrative “text”
(Merriam & Tisdell, 2016). Interviews were one way of gathering narratives, which were used in
this study; the text was analyzed for the meaning as identified by the researcher (Merriam &
Tisdell, 2016). Table 1 shows the alignment of research questions and data method.
Table 1
Data Sources
Research question Data method
RQ1: What factors (i.e., personal and organizational) influence
the retention of female physician leaders in healthcare? Semi-structured interview

31
Research Setting
Female physicians were invited to participate in this study. Participants ranged from
working in large health systems to academic medical systems. Most participants came from one
health system with the pseudonym of American Quality Healthcare (AQH). In 2023, American
Quality Healthcare had nearly 250,000 employees, including more than 70,000 nurses and more
than 20,000 physicians. The organization has a reputation for high-quality, affordable care,
promoting racial equity, and innovation in its use of technology for health records. The
organization has been active in educating medical students and residents since its inception
nearly 8 decades ago.
The Researcher
As the researcher, I must be aware of my positionality and the biases that may impact the
study design or interpretation of results. I am the Physician Development, Support, and Wellness
Director for AQH in a large California county (AQH-CC). I oversee various physician programs,
including physician leadership development (PLD) programs. I manage a consultant who helps
coordinate our PLD and work closely with a physician leader who develops the content and
facilitates training sessions for our physician leaders as part of the PLD program. I do not
supervise the physician leader or other physicians in the organization.
I am very familiar with the experiences of women in leadership roles within AQH-CC, as
I have access to the results of our physician wellness surveys given my role as the administrative
leader of Women in Medicine, a group of female physicians that address the gender disparities in
physician experiences within the organization. I have been exposed to physician burnout. I hear
it expressed in meetings and see it manifested in our physician wellness survey scores. I have
opinions and assumptions about burnout, so I must be mindful to keep those from coming across

32
in the interviews. Given this history, I may hold preconceived notions about what is needed or
where the problems we face originate.
This study involved interviewing past female physician leaders. Many potential
participants were physicians I knew and worked with in the context of my existing role within
the organization. This created both positive and negative implications. The positive implications
were that the participants knew me and we had built trusting relationships. The negative
implications were that because they knew me and continued to see me after the study, they may
not have wanted to share deeply personal feelings or experiences. During the study, I continued
to stress confidentiality and using pseudonyms to encourage potential participants to feel
comfortable enough to participate.
Researchers who conduct research in their organizations can become compromised in
their ability to disclose information and raise issues of an imbalance of power between the
inquirer and the participants (Creswell & Creswell, 2018). To mitigate this, I showed how the
data would not be compromised and how such information would not place the participants or
the researcher at risk (Creswell & Creswell, 2018).
Data Source: Interviews
This study used semi-structured interviews conducted with female physician leaders.
Participants were identified through purposeful and snowball sampling, as described below.
Participants
This study used purposeful sampling to identify potential participants who met the
specific characteristics needed to learn the most (Merriam & Tisdell, 2016). Snowball sampling
was used to find additional potential research participants, including referrals from those
interviewed (Merriam & Tisdell, 2016).

33
The names of female physicians who had left their leadership roles were obtained
through contacts within and outside the organization. No formal list was maintained with this
information, so potential participants were identified based on information known by the
physician leader overseeing PLD for AQH-CC or from recruitment via social media or word of
mouth.
An email was sent to identified individuals outlining the study and inviting them to
participate (see Appendix X). Snowball sampling entailed asking these identified prospective
participants to forward the information to additional qualified participants. The goal was to find
10 qualified participants, female physicians who voluntarily chose to leave a leadership role.
Instrumentation
Interviews were conducted using a semi-structured interview protocol, common in
qualitative research and including a mix of structured and less structured questions (Merriam &
Tisdell, 2016). The questions in a semi-structured interview can use probes to ask for more
information or allow the participant to draw upon specific examples. A semi-structured format
made sense as it provided an opportunity to add to the questions or ask for more details as
information was provided during the interview. It was important that the participants felt
comfortable, and having a less formal interview was anticipated to feel more like a discussion,
encouraging the participants open up and share.
The interview protocol included 14 questions exploring about factors influencing the
female physician’s decision to leave leadership (see Appendix B). The questions mostly asked
the participant to draw on examples of lived experiences.
Patton’s (1987) six questions were considered in developing these questions to ensure
valuable information would be gathered from the participants. Patton’s (1987) six types of

34
questions provide a framework for shaping a research protocol: (a) behavior or experience
questions that explore actions and experiences; (b) opinion or belief questions that examine
beliefs, attitudes, and opinions; (c) feeling questions that address emotional aspects of lived
experience; (d) knowledge questions that investigate understanding and awareness of the
problem of practice; (e) sensory questions that probe how perceptions and interactions with the
participant’s environment; and (f) background or demographic questions that describe personal
characteristics and life histories. Interpretive questions can also help check the participants’
understanding of a topic (Merriam &Tisdell, 2016).
Physicians are busy, so this research was designed to ensure the interviews were a
reasonable length of time so people would want to participate. It was anticipated that each
interview would take between 30 and 45 minutes.
Data Collection Procedures
After meeting the research qualifications and agreeing to participate, each participant
received information about the study’s purpose and we established a mutually convenient time
for the interview. Interviews were conducted via Zoom and recorded with the participant’s
permission. The Zoom platform provided flexibility and convenience to participants; Zoom’s
high-quality recordings facilitated ease and accuracy of transcription.
The purpose of the study was explained at the beginning of the interviews, including a
statement on how the use of pseudonyms would protect the participant’s identity. This was
particularly important to ensure the participants’ comfort so that they would feel safe to share
openly and honestly.

35
All data, including the list of participant names and pseudonyms, recordings,
transcriptions, and other materials were stored on the researcher’s password protected laptop. No
other individual had access to this information.
Data Analysis
This study used a qualitative research method to explore and understand the meaning
individuals or groups ascribe to a social or human problem (Creswell & Creswell, 2018). In
qualitative research, data analysis inductively builds from specifics to general themes (Creswell
& Creswell, 2018). This research approach aligns with the purpose of this study because it dives
deeper into the numerous factors that influence a female physician’s decision to leave leadership.
The researcher transcribed the interviews using Otter.ai, a secure cloud-based software
platform. While the audio recording played, each transcript was reviewed and updated for
accuracy, and the researcher read it multiple times to get a sense of the data.
The researcher then highlighted words and phrases in the transcriptions using a priori
coding and documented codes in a codebook in Excel. The a priori coding identified key terms
from the literature that the researcher used to begin to understand the research data. The a priori
coding was expanded to include open coding that arose spontaneously from the interview data.
The codebook included terms like burnout, stress, moral injury, bias, bullying, barriers,
opportunities, culture, mentor, sponsor, advocate, work-life balance, family, cooperation,
collaboration, administrative tasks, toxic environment, confidence, personality, inadequate,
sacrifice, respect, leadership style, exit interviews, emotion, culture, effectiveness, support,
flexibility.

36
After coding the data, the researcher condensed the keywords into themes. This was a
subjective analysis of the data, connecting terms and phrases from the interview data into larger
units of meaning.
Validity and Reliability
To reduce potential bias rooted in my background and positionality, I engaged in
reflexivity by acknowledging past experiences and how past experiences shape interpretations
(Creswell & Creswell, 2018). I also need multiple validation strategies to demonstrate the
accuracy of the information (Creswell & Creswell, 2018).
One strategy I used was to establish credibility using respondent validation (i.e., member
checking), which involves the researcher soliciting feedback on preliminary findings from some
of the people interviewed (Merriam & Tisdell, 2016). This helped ensure I captured and
interpreted participants’ responses accurately. Repeating back pieces of the interview or
summarizing the themes were tactics that I used to ensure the participants’ insights were
captured with fidelity.
The other strategy I used was peer review, conducted with a colleague familiar with the
research or one new to the topic (Merriam & Tisdell, 2016). Peer review for this study involved a
physician leader familiar with burnout and females in leadership; this peer reviewed the findings
to ensure they were plausible, given the data. The physician was responsible for overseeing
AQH-CC’s PLD program and was well-versed in burnout and the experience of female leaders.
My doctoral committee chair and members, as well as colleagues in my doctoral cohort, also
served in the role of peer reviewers.

37
Ethics
Ethics must be taken into consideration when doing qualitative research. Before
beginning this study, approval was sought and received from the University of Southern
California Institutional Review Board and the AQH-CC Internal Review Board. The University
of Southern California Institutional Review Board deemed the study exempt and not deemed to
be a human subjects research study; therefore, a review by the IRB was not necessary (see
Appendix C). The AQH-CC permission is not reproduced as that would compromise
confidentiality. Verbal consent was obtained from each participant before each interview began.
The researcher also completed the CITI certification process.
One ethical practice is explaining the purpose and methods to participants and
addressing reciprocity, or what is in it for the interviewee (Merriam & Tisdell, 2016). The
researcher must also obtain informed consent and ensure the participants understand that the
study is voluntary (Merriam & Tisdell, 2016). Email communication about the study described
these issues to potential participants upfront. Informed consent was obtained from participants at
the beginning of the interview. Participants were also told that they could discontinue their
participation in the study at any time without repercussions.
It was essential to protect the confidentiality of the participants. To do this, participants
were assigned a number, and the researcher did not ask for the participant’s name during the
interview. All participants were asked for permission to record the session, and the purpose of
the recording was explained to them. The participants were free to decline recording if they
chose to do so.

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Chapter Four: Findings
The interviews focused on uncovering the personal and organizational factors
contributing to female physicians leaving their leadership roles. Questions focused on each
participant’s experiences and allowed them to reflect on what could have been done differently
to retain them in their leadership roles. This information is anticipated to be critical for
healthcare organizations trying to retain female physician leaders.
Numerous factors were discussed during the interviews that influenced the female
physician’s decision to leave their leadership roles. Multiple factors were discussed in each
interview, and participants never cited a single factor as the sole deciding factor in leaving. The
aim of the research was to uncover these various factors related to retention so that organizations
could better understand the needs of female physicians and develop strategies to retain female
physicians in leadership positions.
Ten female physicians participated in the interviews and held multiple leadership roles
for differing amounts of time, ranging from 2 to 12 years. Nine of the 10 participants had minor
children at home while serving in leadership positions. Table 2 presents the age, ethnicity, and
position data for the 10 participants.
Factors Influencing the Retention of Female Physician Leaders
Factors influencing the retention of female physician leaders fell into two categories. The
first category, personal factors, included four factors: family beliefs, mental and physical health
concerns, burnout, and leadership style. The second category, organizational factors, included
two factors: mentoring and leadership development.

39
Table 2
Participant Demographics (N = 10)
Demographic category Number
Age
41 to 50 6 (60%)
51 to 60 3 (30%)
61 to 70 1 (10%)
Ethnicity
White 7 (70%)
Native American 1 (10%)
Asian Indian 1 (10%)
Middle Eastern 1 (10%)
Specialty
Family medicine 2 (20%)
OB/GYN 2 (20%)
Internal medicine 2 (20%)
Ophthalmology 1 (10%)
Orthopedics 1 (10%)
Emergency medicine 1 (10%)
Pediatric neurosurgery 1 (10%)
Personal Factors
The first collection of factors related to personal factors, such as beliefs or feelings, that
led the participants to leave their leadership role. Multiple participants expressed feelings of
hopelessness attributed to not being able to make a difference. One participant described this as
“learned helplessness” because she felt useless and could only tell colleagues to report things to
human resources because she had no voice or ability to make changes within her department.
One participant verbalized her leadership experience as being “hazed and harassed for 7 years.”

40
One participant described an issue around wanting to compromise on work schedules to
better support working mothers, but the leaders above her were not willing to address the
concern. This was the point at which she felt she was no longer able to make a difference.
Another participant spoke of not feeling valued or having “much of a voice.” This
participant asked, “Why am I going to do something I do not want to do?” She mentioned that,
with women, there might be a sense of loyalty or a feeling that they should “hang in there
longer.” Another participant noted that she did not feel appreciated or respected.
Family Beliefs
For a few participants, the decision to leave leadership was based on a desire to focus
time and energy on family. Nine of the 10 participants had children at home during their time in
their leadership roles. Two participants also mentioned needing to care for aging or ill parents.
Participants wanted quality time spent with their family and friends.
One participant realized she was not as emotionally available for her teenage daughter as
she should have been before stepping into leadership. Another noted that she barely gave her
high school daughter “any attention at all” and worried she would regret that one day. A
participant described having two small children, an ill elderly parent, a cancer diagnosis, and a
spouse who was also a physician starting their own business during her time in leadership. She
stated
I think any one of those things is incredibly difficult, but also in trying to be a clinician
and have this leadership role and have any kind of mental space and bandwidth has been
incredibly negatively impactful . . . it all became a lot, and that is why I am stepping
away.
In reflecting about her health issues, she argued

41
Leadership is really important work. It is vital for the organization and the physicians, but
I don’t have the bandwidth for it and take care of everything at home. I think women are
incredibly capable of leadership; we need to have women in leadership for diversity of
thought . . . but, at the same time, society is not set up to support us; we’re still the default
parents and the default caregivers for our parents.
Being a physician and a physician in leadership takes up a great deal of time, and the
participants talked of long days and constantly needing to be available to meet department needs.
One participant described not being able to be home with her sick child because she was the only
one in the department willing to cover for another physician who was out ill. Another participant
said she did not feel she was attending enough to her children and the parents she was caring for.
One participant was undergoing fertility treatments during her time in her leadership role, and
there was a lack of understanding from her male colleagues as to what it was like to have to deal
with that. She explained, “I went through fertility treatment, and that can be quite challenging.
And I find that most men don’t seem to understand unless they’ve had spouses or partners who
have gone through it.” She added, “I found very much a lack of understanding in the department
for what it’s like to go through that.”
When the environment was not set up in a way that brought satisfaction to participant’s
time in leadership, they began to question where to put their energy. One participant admitted
So many things were going on with me personally, and just feeling like I am not
attending to those in a way that was great for my kids or my parents. And I just wasn’t
deriving the same satisfaction out of it. I don’t feel like I need the title; that’s not where I
get my satisfaction. My satisfaction is in personal relationships.

42
Another participant shared about her experience in leadership, “I just got to the point
where I felt like I was speaking to a wall. There was nothing to do to fix it. And it was just
getting more toxic.” In response, the felt she “had to prioritize what was important to me. And at
that stage, especially after the first wave of COVID, you realize that it’s really family more than
anything.”
A third participant shared an experience of needing to take some time to focus on her
mental health. She realized this was not going to be possible to do while in a leadership role, so
she took some time off work. She discussed a realization she had during her medical leave
My 12-year-old daughter came home from school, and she is a very stoic, brilliant little
thing. She walked in and came over to me and sat on the couch and leaned her whole
body, like all her body weight onto me, and just started talking about school. All the stuff
that had been bothering her that day and all the stuff that had happened at school. And
she had never done that before. And I realized it was because I had never been present.
No, not never, but I was often not present in those moments . . . in that leadership role,
you are sort of accessible all the time . . . there was so much chaos . . . I was constantly
thinking about work, even when I was home. And that was the moment of like, “Oh this
is what actually matters. I need to change. I need to change work.”
A fourth participant shared her frustrations with her incompetent leader. She explained,
“My frustration came from the leader I worked with who had competency gaps. It was my job to
make him look good; it got frustrating and exhausting. I was the one who made a lot of things
happen, but those above me took credit.” Many of the participants spoke of similar frustrations
with feeling the pressure of the job without any credit or acknowledgement.

43
Mental and Physical Health Concerns
Being in a leadership role also took a toll on participants’ mental and physical health.
One participant battled cancer during her time in her leadership role. She realized that stepping
down from leadership would help her take care of her own health, which was important to her.
Another participant discussed how exhaustion from the job would cause her to come
home and drink more than usual; she eventually gained weight and became pre-diabetic. She
noted that “the pressure of the job was affecting my health.” A third participant described how
she was “slowly dwindling away” and she “did not know who [she] was anymore.” She would
wake up in the middle of the night, unable to go back to sleep. Another participant indicated she
lost weight due to the stress of the job. Two participants noted that they began to withdraw, just
going to work and then going home.
A fourth participant needed to focus on her mental health and took time off to attend to
those needs. Another noted feeling “distraught and emotional,” deciding to step back and put her
energy into her family. One participant admitted that if she did not have kids, a husband who
also worked full-time, and an elderly parent to care for, she might have had more energy to
invest in leadership. The emotional toll prompted some participants to begin seeing a therapist.
Moral injury was raised by two of the participants. One of them described this as the
experience of having to make decisions that did not feel right. An example was providing a new
research program for orthopedics at the expense of providing the housekeeping staff with pay
increases. Constantly making those types of decisions became frustrating and took a toll,
contributing to the decision to leave leadership. The other participant brought up moral injury
when asked about burnout. She thought moral injury was a more appropriate description because

44
the experience involved knowing what was needed and being unable to do it. The moral injuries
had become more profound throughout her time in leadership.
Burnout
All 10 participants discussed burnout. Nine out of 10 participants indicated they
experienced burnout while in their leadership positions. The physician who did not experience
burnout indicated that she experienced moral injury. She felt that the term burnout implied a lack
of resilience.
Participants who experienced burnout noted that it did not impact the care they delivered
to their patients; they mostly expressed feeling emotionally exhausted. One participant said,
“Burnout mostly impacted how I showed up for myself and my family, not my patients.”
Participants described feeling “overwhelmed,” “disengaged from work,” “withdrawn,” and
“isolated.” This burnout and the mental and physical impact described above affected the
participants’ experiences. Some cited the cause of burnout as their leadership role, and one
participant felt “no matter how much I do, it will never be enough.” One participant indicated
that being treated differently as a woman by her peers and superiors contributed to her feelings of
burnout.
One participant described burnout as coming from working off hours, having early
morning meetings, or meeting during lunchtime. One contributing factor was not being provided
administrative time for their leadership role. Since physician leaders still see patients, they must
balance their leadership responsibilities with their clinical duties. Two participants explained that
they were not provided with dedicated time for their leadership role and did a lot of their
leadership work on their own time. This is an example of how the environment, or the system,
contributes to burnout.

45
Participants also emphasized that the pandemic contributed to their feelings of burnout.
For example, the emergency department had been overwhelmed since the pandemic began, and
there was a strong push to maintain metrics despite the pandemic. Even though her department
did not have the same resources, she kept pushing people for improvement. She felt that as a
woman, she needed to prove herself, always strive to do better, and prove she was capable. This
contributed to burnout. Some described their whole time in leadership as a “burnout situation.”
One participant explained that you can handle the long days during residency because you know
there is an end in sight. In her time in leadership, she felt like the dysfunction would never end,
which became defeating.
Leadership Style
Additionally, increased awareness of female leadership styles supports the retention of
female physicians. Organizations and their leadership should work to understand and value
diverse leadership styles; they should appreciate the styles of many female physician leaders, and
they can benefit the organization. One participant noted
I think making sure you have adequate representation from every standpoint in diversity,
equity, and inclusion, not just women, at a local level and regional level. I just had a
meeting with the entire regional team [for my department] and they don’t have a single
female on their entire team.
When asked to describe their leadership style, participants used words and phrases such
as “collaborative,” “relationship-based,” “approachable,” and “servant leader.” One participant
also expressed the importance of being “aware that women are doing the unpopular work, getting
it done, and not complaining.” She argued, “Pay attention and be more intuitive.” Appreciating
how females lead and acknowledging that they are most likely doing more than people realize

46
can help improve the retention of female physical leaders by helping them feel seen, respected,
and appreciated. Figure 3 shows a word cloud with the answers to questions asked of participants
about their leadership style.
Figure 3
Word Cloud of Responses About Leadership Style

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Organizational Factors
The primary organizational factor that contributed to the participants’ decisions to leave
leadership was a toxic and unsupportive culture from those in leadership above them. Often,
support was needed to handle the bad behavior of physicians in the department or within the
organization. When this type of support was not there, it led to feelings of hopelessness or a loss
of agency. Multiple examples were provided of senior leadership failing to address concerning
behavior.
For example, a board member physically assaulted a physician and nothing was done to
the board member until the media and the community became involved. When one of the
participants served in a leadership role while she was pregnant with her third child, she was
ignored for promotion because a male leader thought “she had too much on her plate;” this was
voiced in a meeting in front of her colleagues. She had never expressed feeling that she had too
much on her plate, and she never complained, but she was passed up for the position anyway.
Nothing was done about it when it was brought up to human resources. The fact that a healthy
pregnancy was used against her if pursuing a promotion caused much anger. The effects of a
toxic culture can be long-lasting.
Another participant described how leaders, in addressing the destructive behaviors of a
male physician, moved him from the day shift to the night shift; this participant was the lead, and
she was not consulted. The leaders were well aware of the issues and did not intervene. This
allowed the toxic culture to propagate as her chief ignored problems and allowed negative
behavior to continue; consequently, she began to withdraw and became emotionally exhausted.
An organizational factor brought up by two participants was the use of sexist language.
Female directors were told during meetings to “not become hysterical.” Concerns brought up by

48
females were dismissed and labeled as “complaining.” Additionally, women leaders would bring
up ideas and be told they would not work, only for the same idea to be later raised by a male and
subsequently implemented. Another participant spoke about being called a “princess” and shared
seeing another colleague ridiculed of because she was pumping breast milk in the office.
Another participant described an experience during her annual review, “During my
annual review, which is something we all have and is supposed to be about our
performance as doctors, they blindsided me and had two other doctors present . . . and
they asked me if I was having marital problems because I seemed upset at work. That
was the straw that broke the camel’s back.
This type of language and treatment contributed to a toxic environment, and leadership allowed
the behavior to occur without repercussions.
Another toxic behavior was being left out of meetings that the participants indicated they
were always a part of; then, the meeting invitations suddenly disappeared. Secrecy around how
decisions were made and being excluded contributed to female physicians’ decisions to leave
leadership. One participant described her emails and meeting requests being ignored.
Additionally, the healthcare sector’s organizational structure does not help female
physician leaders become successful. For example, many female physician leaders in this study
had children at home and were often the primary caregivers. Some participants pointed out that
women were still the minority in their specialty (e.g., emergency medicine and pediatric
neurosurgery) and in leadership positions. One participant described the challenges when leaders
were all men and lacked an understanding of the lived experiences of primary caregivers or
managing challenges such as infertility struggles. One participant was even told she should not
expect to have children because of her chosen specialty.

49
One of the participants noted that the men in leadership positions in her department had
wives who did not work, so they were leading the department from the perspective and
experience of having few responsibilities at home, which did not align with the lived experiences
of many women in the department. More than one participant spoke of scheduling inequities and
the impact of early morning meetings and lunch meetings on activities such as school drop-offs
and pick-ups. Another participant gave an example of how calling out of work happens more
frequently for females because they are often the ones to take care of children when they get
sick, so punitive policies primarily affect women more than men. In contrast, the sole participant
with no children was expected to work during the holidays because she did not have children.
A lack of understanding of how the environment and structure impacted female physician
leaders related to retention. Two participants spoke about the old-fashioned approach to
leadership, feeling that male physician leaders still held on to how things were done 40 or 50
years ago. One participant said organizations should “be willing to question the assumptions
about what it means to be a doctor that we have held for 40 to 50 years. To be a leader should not
mean you are going to work twice as many hours.” She stated that organizations should ask their
leaders, “How can we make this sustainable for you?” instead of saying, “Sacrifice everything
for this.” To retain female physicians, organizations should consider how to create a more
inclusive environment for women so they feel like they can achieve a leadership position without
sacrificing their personal and home lives.
One participant mentioned that new residents came into the organization and saw how
more senior physicians did things, ending up following these outdated patterns. There was little
turnover in leadership, which did not allow for newer perspectives. A lack of checks and
balances perpetuates a dysfunctional or ineffective culture. More opportunities for women to

50
attain leadership positions were clearly necessary. However, one participant pointed out that
“women should get positions because they deserve it and are qualified. It sets the women up for
failure if not done that way.” Promoting women into leadership roles is important, but only when
they are ready for the role and qualified. Mentorship and leadership development programs can
help prepare more women for leadership roles and help them feel more confident.
Supportive and Non-Supportive Behaviors
Participants cited specific behaviors from leaders that showed support for female
physician leaders. One participant spoke about how the PLD program showed that she was
supported in her role. Having regular one-to-one check-ins with her leader was also influential in
helping her feel supported.
Some participants spoke about how support came from informal partnerships with
colleagues focused on getting work done. One participant got support from other physicians with
similar roles who were outside of her department; this was important given the lack of support
from the board of directors and CEO. Another participant spoke about relying on informal
partnerships to get work done as those within her department were not receptive to making
changes or providing resources.
Some participants were in assistant chief roles and worked with other assistant chiefs,
who provided support. These partnerships helped the participants by providing someone else in
their same role and the same department to discuss issues and ideas with. This was especially
helpful when there was no support from the department chief.
One of the most significant factors mentioned by the participants that impacted retention
was feeling supported. Participants spoke highly of their leaders and how they felt valued, heard,

51
and respected. But for many participants, when leadership changed, support changed.
Participants spoke about support from both male and female colleagues.
Participants spoke highly of working for leaders who were tough but fair, had open
communication, and were considerate. One participant said that the initial male leader she
worked for ensured she had a hospital locker. Lockers were mostly provided for male physicians
in her specialty since the department was primarily comprised of male physicians, so the fact that
her leader thought to get her a locker meant a lot to her. She spoke highly of another male leader
who was also her mentor; he would send articles or stories of other successful female physicians
in her specialty and communicate his confidence in her. She ultimately chose her specialty
because of that encouragement. Another participant argued, “If you truly value them [female
leaders], invest in them. They sacrifice a lot; try to see what they need and support them.”
Feeling heard was integral to feeling supported. One participant described making tough
decisions in her department; one of her colleagues emailed the area medical director to complain
about her. The area medical director (who was female) shared the comments with the participant,
telling her she had the director’s full support in her decisions and asking if she needed anything
from the leader. This communicated to the participant that she was supported and her leader
trusted her. An example of not feeling heard was described by a participant
What wasn’t helpful was that in many of the spaces I was in, I was the only woman there.
And I would often find that my ideas were dismissed, or they would kind of just say,
“Oh, we can’t do that, that’s pie in the sky type thinking.” And I would say it and say it.
And, then, 2 years later, a male in that same space would say the same thing. And they
would say, “Yeah that’s a great idea. Let’s get on it, let’s do it right away.” And I’m like,
“I have been screaming that for like 2 or 3 years.”

52
Feeling heard was important to participants, but it was also important that they were not
only heard, but that action was also taken. One participant described
I was incredibly outspoken at every level about the frustrations I was feeling and the
disparity of resources experienced by different physicians and, therefore, different
patients. The needle kept moving further and further away from what I felt was good
care. So, the organization listened, but nothing changed. And I saw retaliation happening
from the organization to different physicians who were outspoken [and this affected] their
patients.
Participants described some challenges working with other female physicians while in
leadership. One participant explained, “Your greatest critics are your own female colleagues. My
greatest advocates were my male colleagues . . . I think the females in my department forgot that
I was a wife and a mom. Females give a lot more and get taken advantage of.” Another
participant argued that
More is asked of women when it comes to being empathetic. I was expected to be more
empathetic towards other women. Females in the department expected that a female chief
would be more empathetic towards their needs and side with them regarding time off for
kids and things. But I cannot discriminate; men also want to spend time with their
families; I cannot show preference.
Mentoring
Female physicians’ experiences in leadership role were also influenced by having a
mentor. Six of the participants indicated that they had informal or formal mentors, which they
described as helpful. Mentors were able to provide advice and guidance, helping participants
ensure they were on the right track with decision-making or how they were managing

53
challenging situations. One participant admitted that “it gets very lonely” in leadership, so
having a mentor was extremely helpful for her. Another participant had multiple mentors and
found it most beneficial to learn how they were “effective in getting difficult things done with
grace.”
Mentors were willing to meet with the participants and listen to their concerns, which
was another way they felt supported. One of the participants clarified that she had informal
mentors, not formal mentorship relationships. She believed it was helpful, but she also felt it
would have been more helpful to have a more formal mentor because the informal mentors she
sought out were sometimes involved in the same chaos within the department.
One participant who did have a mentor expressed that it was helpful, but even with a
mentor, she applied to positions and was passed over for a male with less experience. She felt
that having a sponsor who could advocate for her in getting positions or assisting in seeking
positions would have been helpful when applying.
Four participants reported they did not have a mentor. When asked if they thought that
having a mentor would have been helpful, they all answered yes. One participant thought it
would have been helpful to have a mentor farther along in their leadership career to best share
wisdom and insights. Another participant without a mentor said she “would break down so much
on my own.” She would talk to her husband and daughter about things, but they would get tired
of listening, which caused her to feel isolated. She believed a mentor would have been beneficial.
A third participant got a mentor after leaving her leadership role and recognized that it would
have been beneficial to have one while in her leadership role; she began trying to mentor other
female physicians in her department.

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Leadership Development
Providing leadership training to new leaders was also seen as important. Seven
participants indicated they were provided some form of leadership development training. Forms
of leadership development training included one-to-one coaching, conferences, and group
training addressing leadership skills. Most participants felt the various training they received was
helpful. Two participants felt the training offered was not robust enough to help with the issues
they faced while in leadership, such as harassment concerns or drug and alcohol use within the
department.
Other participants appreciated the skills they learned, as it was helpful to identify
dysfunctional behaviors occurring in their departments. One participant did not find the
leadership training she received helpful, describing it as fundamental and focused on skills she
had already learned during her medical training. She felt higher level leadership training would
have been helpful, and she asked to be sponsored to attend such training but was denied access.
Two participants worked with a professional coach, which they found valuable.
One criticism of leadership development programs is that the focus is often on shifting
mindsets instead of addressing systemic issues. One participant explained that the training she
received was beneficial, particularly in providing feedback. She mentioned that when she tried to
use what she had learned and gave feedback to a leader, she was then excluded from meetings.
Three of the participants were not provided with any leadership development training.
One participant explained that while resources and support were promised in her application to
the PLD program, nothing was provided. This participant went from a front-line physician to a
regional leadership position. Typically, a chief or assistant chief would be promoted into a
regional role where they would already have participated in a leadership development program.

55
This participant’s lack of leadership development training contributed to her not feeling
supported.
The other participants stated they were not provided leadership development training
opportunities. One of them expressed that physicians were not given leadership training during
their time in medical school and that it might not be a natural skill for many, so training for both
men and women should be provided.
Physician leaders in this research had different experiences because they were not only in
leadership positions but are also involved in direct patient care. Balancing these roles and giving
enough time to both patients and their leadership role was challenging. Furthermore, AQH-CC
did not help to make this experience more equitable between males and females. Some
participants said they were not provided dedicated time, or enough time, to successfully manage
their leadership roles, which caused them to do much of the work on their own time. This was
not sustainable for many participants or their peers, especially female physician leaders who
often had additional childcare duties or were caregivers to an aging parent or family member.
Chapter Summary
In summary, varied personal and organizational factors contribute to the decision of
female physicians to leave their leadership roles. Personal factors related to leaving leadership
include feelings of hopelessness or perceptions of inability to make a difference, not feeling
supported or valued, family responsibilities, physical and mental health needs, and burnout.
Organizational factors included a lack of support for female physician leaders by male leaders,
structures that did not support female physician leaders, lack of mentorship and leadership
development, and organizational or departmental culture. The implications of these findings are
discussed in Chapter Five.

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Chapter Five: Recommendations
In this study, the research served the women physician leaders and can also serve
healthcare organizations. The goal was to understand better the factors contributing to female
physicians leaving their leadership roles. Lower turnover and the retention of influential women
leaders would benefit the organization. A better understanding of the need for flexibility,
support, and the unique experiences of female physician leaders would support retention. These
factors should be considered if organizations want to retain female physician leaders. Chapter
Five discusses the study’s findings, provides recommendations for practice and future research,
and reviews limitations and delimitations.
Discussion of Findings
The findings from this study support the research literature regarding factors related to
the retention of female physician leaders. The conceptual framework used was social cognitive
theory, a model of reciprocal causality; internal personal factors in the form of cognitive,
affective, and biological events, behavioral patterns, and environmental events all operated as
interacting determinants that influenced one another bidirectionally (Bandura, 1999).
This study explored how individual and organizational factors affected a female
physician leader’s decision to leave leadership, which constituted the behavior being explored in
the model. Personal factors such as not feeling valued and feeling hopeless, experiencing burnout
and moral injury, and challenges to mental and physical health were explored in the context of
participants’ decisions to leave a leadership role. Regarding environmental or organizational
factors, most participants attributed the decision to leave leadership to toxic culture, lack of
mentorship and leadership development training, and lack of support from leaders. The decision

57
to leave leadership was not impacted by a single factor but a complex constellation of
experiences with numerous variables.
Some of the personal factors that study participants discussed were cited in the research
literature. The literature noted a strong need for work-life balance for female leaders, which was
brought up as a challenge by all participants (Chisholm-Burns et al., 2017). This caused the
participants to make decisions on where to spend their time and emotional energy. The literature
also noted that there is often a lack of confidence or feelings of inadequacy among female
leaders (Haines & McKeown, 2023; Hoss et al., 2011). Some participants discussed feeling
defeated because they felt they could no longer make a difference within their departments or the
organization as a whole. Some spoke about feeling like they were letting their colleagues down.
Participants did not express feeling a lack of confidence, but one participant did discuss how not
having leadership development training made her feel like her leadership style was “not great;”
she admitted that she could have used some training.
Being bullied or experiencing microaggressions was also reviewed in the literature
(Haines & McKeown, 2023). The participants discussed examples of times discriminatory
behaviors or language were used against them, such as being passed up for a promotion because
of being pregnant. One participant also discussed how the females in her department turned
against her because she did not give them preferential treatment. This type of treatment was
difficult for participants to handle and became very defeating.
The literature discussed how females often feel they need to change their leadership style
to align with more of a “male style” (Hoss et al., 2011; Mousa et al., 2023). Many participants
described their style as collaborative or relationship-based, and two participants talked about
how it served them well in their positions. Two other participants noted that they were expected

58
to be quiet or not to voice opposition. One participant indicated that it was challenging because if
she was too hard on people, she would be criticized for being too tough, but if she was not as
hard, she would be criticized for being too soft. She felt she would not have received those same
criticisms if she were a man. Also, this participant noted that women are expected to be more
empathetic, especially towards other women. This was likely not the same expectation set for
male leaders.
The literature noted the importance of a supportive organizational culture for female
leaders to thrive (Mousa et al., 2023). All participants spoke about how a toxic or dysfunctional,
non-supportive culture negatively impacted their experience as leaders; this was specified as the
reason many of them left their leadership positions. A non-supportive culture emerged as one of
the most critical reasons female physicians left their leadership positions.
The other organizational piece noted in the literature was a structure that would support
females in leadership positions (Chisholm-Burns et al., 2017). According to many of the study
participants, this supportive structure was lacking. Inflexible schedules and meeting times were
two examples of elements that did not support female physicians with children at home.
The literature also highlighted the importance of leadership development training in
preparing women for leadership roles and helping them feel confident (McDonagh & Paris,
2013). The participants spoke about whether or not they received training. Those who did found
it helpful in their role; those who did not get the training felt it would have been helpful if it was
provided to them. Another factor in feeling supported was having a mentor. The literature noted
the importance of having a mentor or sponsor in feeling supported in a leadership role and when
seeking a promotion (Chisholm-Burns, et al., 2017). One of the participants spoke about how a
mentor was helpful, but a sponsor would have been more beneficial when seeking new positions.

59
The problem of practice for this research study was the need for more female physicians
in leadership positions in the healthcare industry. Because of the gender disparity, there is a need
to retain the women currently in leadership positions and to adapt the workplace to encourage
leadership by female physicians. This study explored the personal and organizational factors
influencing a female physician’s decision to leave a leadership role. If healthcare leaders can
gain a better understanding of what contributes to a female physician leader’s decision to leave,
they can develop strategies to address those factors to retain those female physician leaders.
Recommendations for Practice
Based on this study’s findings, multiple recommendations for practice are made. Based
on learnings from research participants, the first two recommendations are the most critical in
retaining female physician leaders. These recommendations would be most helpful for healthcare
administrators and physician leaders, especially those hiring and selecting physician leaders.
These recommendations would positively impact the experience of female physician leaders and
could improve retention.
Recommendation 1: Change Organizational Structures
One of the most critical aspects of retaining female physician leaders is ensuring
supportive structures are in place. If there are no structures in place that support women in
leadership, it does not matter how many female physicians an organization promotes into
leadership roles because they will not stay. Different structures are a necessity to retain female
physician leaders. It is recommended that healthcare administrators and physician leaders
examine their existing structures and policies to address and support the unique needs of female
physician leaders. One way to alter the workplace culture to be more supportive would be to
create flexible schedules that allow more time to balance work-life responsibilities (Hoss et al.,

60
2011). Women might be more inclined to seek leadership positions if the organization had a
culture encouraging men and women to prioritize family needs (Roth et al., 2016). Many
participants struggled to balance clinical duties, leadership duties, and caring for children and
families. When faced with a choice, many participants left leadership positions to dedicate more
time and energy to their family. Some practices that organizational leaders should examine
include meeting times, call-off policies, and processes for how leaders are chosen. Engaging
female physicians in feedback around these processes is essential to understanding their
perspectives on organizational policies and procedures that create barriers and challenges to or
support balancing family responsibilities and leadership duties.
One of the structural barriers discussed by participants was the lack of administrative
time provided to physician leaders to carry out their leadership duties. This led to the participants
sharing that much of their leadership tasks were completed outside of normal working hours.
This was not sustainable for anyone, let alone female leaders who often fulfilled multiple roles
besides their leadership roles (e.g., parent, caregiver, clinician). To show a female physician
leader she is valued, an organization should provide appropriate time for them to fulfill their
leadership roles without the expectation that they will sacrifice their personal time for their
leadership role.
Recommendation 2: Improve Organizational and Departmental Culture
The research literature has found that a lack of a supportive organizational culture
perpetuates inconsistent gender equity practices and undermines opportunities for women’s
advancement and promotion (Mousa et al., 2023). Traditional bureaucratic organizational
structures have stifled creative and collaborative relationships, making them inconducive to
women’s transformational leadership styles (McDonagh & Paris, 2013). The pervasive culture in

61
healthcare still embraces a male leadership model that does not allow for the optimal inclusion of
women (McDonagh & Paris, 2013). This was expressed by most participants, who faced
organizational or departmental cultures that were not supportive of women, not transparent,
male-dominated, and not collaborative. Toxic behaviors such as leaving participants out of
meetings, the use of discriminatory language and practices, secrecy, and bullying were
experienced by many participants in this study. Leaders did not address these behaviors, and
there was no accountability. This made participants feel they were not supported in their
leadership roles.
Some participants described the challenge of working in specialties that were still maledominated. There is a need for more women to be provided a space at the table. However, it
doesn’t matter if space is provided if the culture does not support them taking space. Their voices
must be heard, respected, and believed. When men lead a department, there may be a need for
more awareness or understanding of childcare needs or infertility challenges. Participants tended
to describe their departments as being led by male physician leaders whose wives did not work;
therefore, these leaders were relieved of childcare duties. Thus, these leaders may have a blind
spot for working women’s lived experiences. This is why it is important to have women in
leadership positions, valuing their input and collaborative leadership styles. Women can bring
perspectives that will benefit others within the organization. This is why diversity in a leadership
team is important; it impacts the experiences of those on the team. When female physician
leaders feel valued, their leadership styles are embraced, and their voices and ideas are heard,
they can thrive in their roles and create meaningful organizational change.

62
Recommendation 3: Provide Leadership Development Training
It is beneficial for leaders to receive leadership development training. According to study
participants, physicians are not consistently provided with leadership development skills as part
of their medical training, so they are often unprepared when they attain a leadership position.
Leadership development programs are essential for preparing the next generation of leaders and
strengthening teams of leaders to work in more collaborative environments; however, women are
often not a focus of these essential programs (McDonagh & Paris, 2013). Including females in
these training programs will increase their confidence in their leadership skills and set them up
for success. Leadership development training provides the skills necessary to create a supportive
culture and appropriately handle challenging situations. Most participants who received
leadership development training found it helpful, and those who did not felt it would have been
valuable in their role.
It is important to note that this is not a recommendation because participants lacked
leadership skills. It is a recommendation to ensure equity in professional development
opportunities provided to both males and females. These programs should also focus on
education around gender equity to bring awareness to the needs of female physician leaders.
Leadership development training programs will not be beneficial if there is a culture that does
not support the learnings gleaned through these programs. Organizations must be open to doing
things differently for female physicians to flourish. Providing leadership development training to
both males and females may help improve organizational culture and provide environments
where female physician leaders feel supported.

63
Recommendation 4: Provide Formal Mentoring
Formal mentors and sponsors can be helpful in supporting female physician leaders.
Mentors and sponsors are vital in encouraging women to seek and apply for leadership positions
(Chisholm-Burns et al., 2017). Mentors act as advisors who offer career guidance and help
navigate organizations (Chisholm-Burns et al., 2017). Participants who had mentors expressed
how helpful their mentors were in assisting them in navigating challenging situations, providing
advice or validation, or just listening. This helped the participants feel less isolated and more
supported. One participant said it would have been helpful to have a female mentor who was
further along in her career so she could share lessons learned along the way. A research study
validated that the ability to engage with and observe more seasoned women gave junior
physicians a sense of confidence that encouraged them to advance (Lin et al., 2019).
Some participants distinguished between informal and formal mentors. Those with more
informal mentoring relationships felt that having a more formal mentor relationship might have
been more helpful. Many participants who had mentors found them on their own. Given that all
participants indicated that mentors were helpful, healthcare organizations should consider
developing mentorship programs that provide mentors to female physician leaders.
Additionally, there is a difference between mentors and sponsors. Sponsors take on the
role of promoter—they market, advocate, and advance the cause of others (Chisholm-Burns et
al., 2017). Participants in a study of female emergency department physicians reported benefiting
from sponsorship, primarily in the form of senior members nominating junior members for
leadership positions (Lin et al., 2019).
Many of the participants in this study had mentors, but none indicated they had sponsors.
One participant said their mentor helped provide support. When it came to seeking out and

64
applying for more senior positions, having a relationship with a sponsor could have been helpful,
as this participant was continually passed over for positions that were given to men with less
experience. A sponsor could also be helpful to female physicians in advocating for women in
leadership positions. Organizations should consider providing sponsors to increase the number of
female physicians in leadership and help these female leaders feel supported. Sponsors can be
helpful in promoting females into leadership, but if the structures and cultures are not in place to
support them, female leaders will not be retained in leadership roles.
Recommendation 5: Exit Interviews
Most participants indicated they were not offered an exit interview when they left their
leadership positions. Some indicated they had someone reach out by phone or email to ask why
they were leaving, but very few had formal interviews. This prevented organizations from
understanding root causes to inform efforts to enact change. A lack of exit interviews also left
participants feeling as though the organization did not care that they were leaving their roles or
wanted to understand their lived experiences. The research literature shows that using data from
exit interviews can support organizations in retaining their key employees (Hossain et al., 2017).
If an organization is interested in retaining female physician leaders, it should conduct exit
interviews with women who leave their leadership roles and use the data to inform change
initiatives that will positively impact those women still in leadership roles.
Limitations and Delimitations
One limitation of this study was the lack of racial diversity among the participants.
Seventy percent of the participants were Caucasian. This limits the information on what it is like
to be a female person of color in a leadership role, which might have uncovered additional
challenges or insights.

65
This study included female physicians in formal leadership roles (e.g., chief, assistant
chief, and chief medical officer). However, some female physicians lead in non-formal
leadership roles (e.g., committee lead or a department champion); these women may also have
chosen to leave their roles and/or decided not to pursue formal leadership opportunities. Their
voices are not represented in this study.
This study drew from varied specialties, but more information from other specialties
would help understand the different challenges that might be present across departments.
Participants in this study shared that some departments (e.g., the emergency department) were
still very male-dominated, which presented challenges for female physician leaders, so it would
have been helpful to understand if other specialties were also still male-dominated.
Another limitation is that this study captures only the female perspective of those who
have left leadership. The perspectives of male physician leaders on why female physicians leave
leadership could provide further insight into the factors that impact their experience. Some
female physicians are currently in leadership roles and may be considering leaving their roles;
their voices are not represented. This information could be helpful in further understanding
retention, as they are still in their leadership position.
Recommendations for Future Research
One recommendation for future research is to expand the participant pool. Future studies
should include those who are outside of formal leadership positions and also male physician
leaders. Many female physicians begin their leadership journey by leading a committee or
becoming champions for specific work. Depending on their experiences in these roles, they may
or may not continue to advance into more formal leadership positions. Those who decide not to
advance could provide helpful insights into factors that impact retention and advancement.

66
Interviewing male physicians who have left leadership roles would allow researchers to compare
and contrast why males versus females leave leadership positions. Understanding the similarities
and differences between the experiences of male and female physician leaders would provide
additional information to organizations on retaining their female physician leaders.
Another recommended study would be to interview female physicians who are in
leadership roles, are satisfied with their experience, and plan to remain in their roles.
Understanding what contributes to their positive experiences would help organizational leaders
understand what keeps women in leadership roles and what makes them successful. Those
findings would provide helpful information about what impacts retention the most.
Conclusion
This study focused on exploring the reasons female physicians leave leadership roles. It is
important to increase the number of female physicians in leadership roles furthermore, retaining
the female physicians currently in leadership positions is also imperative. There are benefits to
having women in leadership roles but the challenge is that women are leaving those positions.
Greater gender diversity in leadership positions has been found to enhance organizational
performance, with positive effects reported around employee engagement, satisfaction, and
retention (Hunt et al., 2020; Hoss et al., 2011). This study uncovered why female physicians
leave their leadership roles and provides information that organizational leaders can put into
practice to retain female physician leaders. Many organizational leaders may not be aware of the
gender discrimination that still occurs in the healthcare setting. By bringing more awareness of
the experiences of these leaders to the forefront, we can change policies and practices to better
support and retain female physical leaders and leverage their valuable contributions.

67
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Appendix A: Recruitment Email
Subject line: Invitation to participate in a research study about the retention of female
physician leaders in healthcare
Dear (participant’s name),
My name is Natalie Whitlock, and I am a doctoral student at the University of Southern
California. I am contacting you today about the opportunity to participate in a research study to
understand the experiences of female physicians who have left leadership positions.
Women represent a large majority (76%) of the healthcare workforce but are generally
underrepresented in leadership positions. I want to understand what factors contribute to female
physicians leaving their leadership roles. The hope is that this information could be helpful to
organizations in identifying ways to retain female physician leaders. Your insights and
experiences could substantially contribute to my study.
Study Details
The research study explores the reasons female physicians have left leadership positions.
Participants must identify as female, be a physician, and have left a leadership position. Your
responses will be handled with the utmost confidentiality, and your personal information will be
kept strictly anonymous to ensure your privacy. The findings from this study will be used for
academic purposes only, and any publication or presentation will be devoid of any identifying
information.
Benefits of Participation
By participating in this study, you will help provide insights that could impact the
retention of female physician leaders in healthcare. Should you have any questions or concerns

77
about the study or the survey, please do not hesitate to contact me at nwhitloc@usc.edu. I am
more than happy to provide any clarification you may need.
Please consider participating in this study. Your valuable input will significantly impact
advancing our knowledge of this important topic. Thank you for your time and consideration.
Thank you,
Natalie Whitlock
Doctoral Student, Organizational Change and Leadership
University of Southern California
760-717-0713

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Appendix B: Interview Questions
Interview questions Probe Key concept
addressed
1. What leadership position were you in,
and how long were you in the
leadership role?
Describe the makeup of the
department (size, gender-mix,
structure)
2. How would you describe the
organizational culture while you were in
your leadership role?
Tell me about how that made you
feel.
Retention,
social
cognitive
theory
3. Please describe the support you
received by leadership during your time
in a leadership role.
Do you have an example of a time
support was given or not given?
Retention,
social
cognitive
theory
4. Please describe any leadership training
or resources your organization provided
you
Did you find the training helpful?
Why or why not?
Retention,
social
cognitive
theory
5. How would you describe your
leadership style?
Can you describe what a day was
like when you were a leader?
Retention
6. Did you have a mentor? If so, how
helpful was that in obtaining a
leadership role, and how beneficial was
it while in your leadership role?
Tell me why it was beneficial or
not beneficial.
How did you get a mentor?
Retention,
social
cognitive
theory
7. Can you describe any factors at home
that impacted your experience as a
leader?
Explore the role of the caregiver,
spouse, etc. What does your
spouse do for a living?
Retention,
social
cognitive
theory
8. Tell me about how your gender relates
to your experience as a leader.
Example- were you expected to
have a specific leadership style?
Retention,
social
cognitive
theory
9. Tell about how, if at all, you
experienced burnout while in your
leadership role.
Retention,
social
cognitive
theory

79
Interview questions Probe Key concept
addressed
10. What factors contributed to your
decision to leave your leadership
position?
What was the reaction when you
left your role?
Retention,
social
cognitive
theory
11. What personal factors contributed to
leaving your leadership role? (if not
addressed above)
Depending on what participant
reveals, may need to explore
burnout more
Retention,
social
cognitive
theory
12. What role did the organization
contribute to you leaving your
leadership role? (if not addressed
above)
Retention,
social
cognitive
theory
13. What advice would you give an
organization trying to retain female
physician leaders?
Retention
14. Is there anything else you would like
to share with me about your experience
as a female physician leader or about
your decision to leave that position?
15.What is your age?
16. What is your race/ethnicity?

80
Appendix C: USC IRB Approval

Abstract (if available)

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Asset Metadata

Creator Whitlock, Natalie E. (author)

Core Title Investigating the personal and organizational factors influencing the departure of female physicians from healthcare leadership roles

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Degree Conferral Date 2024-12

Publication Date 09/11/2024

Defense Date 08/26/2024

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag female physician leaders,healthcare,mentorship,OAI-PMH Harvest,organizational factors,personal factors,physician leaders,physician leadership,retention,social cognitive theory,workplace culture

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hocevar, Dennis (committee chair), Malloy, Courtney (committee member), Washburn, Mary (committee member)

Creator Email natalie.e.whitlock@gmail.com,nwhitloc@usc.edu

Unique identifier UC11399ANL0

Identifier etd-WhitlockNa-13518.pdf (filename)

Legacy Identifier etd-WhitlockNa-13518

Document Type Dissertation

Format theses (aat)

Rights Whitlock, Natalie E.

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Source 20240912-usctheses-batch-1211 (batch), University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

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