Women as a Growing Force in Critical Care Medicine-the Journal, Profession, and Society.

Abstract

KEY POINTS Society of Critical Care Medicine is a leading professional organization for women in governance positions. Critical Care Medicine has seen an increase in the number of women as authors of editorials and highly cited articles and has a diverse editorial board of at least 25% women. Additional opportunities to recruit and promote women into the critical care medical workforce should be developed. Can you imagine Critical Care Medicine (CCM) as a profession, a society, or a journal without the contribution and influence of women? Early accounts of the impact of women in critical care came from the experience of bedside nurses. Fifty years ago, few women physicians specialized in critical care, held leadership positions, published as lead authors, or served on editorial boards. Over time, women have become widely dispersed throughout these arenas (Fig. 1). The representation in critical care that women are experiencing in 2022 is partly due to the trailblazers, their professional expertise, and expanding opportunities. The objective of this article is to describe the intertwined contributions of women to the Society of CCM (SCCM) and the journal CCM at this 50-year anniversary. Women have been trendsetters in leadership and medical journalism and important for the future growth of women in SCCM journals.Figure 1.: Timeline of Society of Critical Care Medicine (SCCM) key milestones and landmark events for women. ACCM = American College of Critical Care Medicine, CCM = Critical Care Medicine.The experiences of the authors within SCCM and CCM are broad and varied, leading to perspectives based on profession, from membership to leadership, as committee volunteers, and as clinicians, authors, and researchers. Although there were many challenges for women in the early years of the organization and journal that are still typical, the determination of many women has led to continuous improvements in inclusivity and equity. Organizational culture and successful roles for women are the result of highly engaged individuals at all levels of the leadership and the staff (male and female). Thus, this article is intended to celebrate women in SCCM and their roles with CCM and identify opportunities for the future. METHODOLOGY Women leaders in SCCM were contacted for impressions of their experiences and recollections to supplement that of the authors. Early issues of CCM were screened for editorial board membership. Literature searches were conducted on search terms related to women in critical care, medical leadership, academics, and publishing. Authorship (first and last) data for CCM were obtained using Dimensions (Digital Science & Research Solutions Ltd., Cambridge, MA) and NamSor (NamSor SAS, LLC., Ile-de-France, France) to identifyauthors’ gender, excluding abstracts and case reports. The top 50 CCM articles cited in each decade were evaluated for women first authors in Scopus (Elsevier citation database; Elsevier, Amsterdam, The Netherlands). In addition, SCCM staff provided statistics on many aspects of membership by women. EARLY SCCM TRAILBLAZERS Involvement of women in the early years of CCM mirrored their involvement in SCCM and the field of medicine in general. Except for in the field of nursing, women held mostly supportive roles, and frontline organizational leadership positions were rare. The organizers of the Society were men, and as Max Harry Weil, MD, points out in his first article of CCM, “Our Council is made up of accomplished, dedicated and uniquely responsible men” ([1], bold text added for emphasis) Women were likely not overtly excluded; there just were not many women in medicine or critical care. In 1970 when the Society was being organized, only 8% of practicing physicians and 13% of medical school applicants were women (2). Despite the low numbers, women were involved in the early years of the Society. Founded to include a multidisciplinary and multiprofessional team, the inclusion of nurses, who were primarily women, was prominent and unique among medical societies. Trailblazing nurse leaders Norma Shoemaker, RN, MN, FCCM, and Diane Adler, RN, MA, FCCM, contributed to the establishment of the Society and held important leadership positions, including Executive Director, Council member, Executive Committee, and Treasurer, helping to create the fledging organization. These pragmatic women recognized the need for members to pay dues and to establish a financial base for the organization (D Adler, personal communication, April 2022). They kept SCCM thriving during the first decade with a cadre of volunteers. Norma Shoemaker was the driving force behind the early annual meeting programs and exhibit halls. Membership in SCCM grew from 238 in 1973 to over 1,000 in 1979 and has grown progressively since 1990 to now over 16,000 members (3). The mission remains focused on improved patient outcomes relying on the diversity of the multiprofessional team with a continued stated future “SCCM envisions a world in which all critically ill and injured persons receive care from a present integrated team of dedicated trained intensivists and critical care specialists” (3). Although physicians represent 64% of the current SCCM membership, other members include pharmacists (12%), nurses (12%), physician assistants (5%), and others (8%) (4). Unfortunately, exact figures are incomplete in the membership database, since submission of gender is voluntary. It is known that in 2019, slightly more than one-fourth of United States critical care physicians were women (5). In an evaluation of surveyed societies by the World Federation of Societies of Intensive and CCM, women were found to be underrepresented in training programs, faculty positions, and leadership roles (6). The challenges faced by women in medical fields mirror those of women in other professions with reduced recruitment, greater time spent on family and dependent care, and reduced wages relative to male counterparts. Despite these challenges, early women leaders were able to influence the culture and programs of SCCM in ways that paved the way for those that followed. Additional women of note who also helped forge the way for other women leaders in the Society include Carolyn Bekes, MD, MCCM, and Maurene Harvey, RN, MPH, CCRN, MCCM. Dr. Bekes was a member of Council for 10 years and was the first woman to serve as SCCM President from 2000 to 2001 (7). As a member of the American College of CCM (ACCM), Dr. Bekes was a primary contributor to the Guidelines on Critical Care Services and Personnel, first published in CCM in 1999 and many other projects (8). The purpose of the guidelines was to optimize ICU structure and function across institutions. Ms. Harvey also contributed to many influential SCCM task forces and stakeholders’ meetings promoting the critical care nurse’s contributions to patient care, including models of critical care delivery, and exploring the extent of postintensive care syndrome (9,10). Ms. Harvey was the first nurse to serve as SCCM President from 2002 to 2003. Early contributions of these and other women leaders set the tone for SCCM’s inclusivity. Their success, in part, was driven by the founder’s commitment to the team concept. Nurses have always been key members of the team and women remain a majority. Women serve in top leadership roles, including 10 of the last 22 as President (among a total of 51) and 12 of all 29 Chancellors of the ACCM (L Redford, personal communication, April to September, 2022) (11,12). SCCM ranked highest when comparing women in leadership with other societies within critical care and among other medical specialty societies (13). Dr. Bekes continued trailblazing as the first woman Chancellor serving three terms from 1991 to 1994, and Diana L. Nikas, RN, MN, FCCM, was the first nurse to serve as Chancellor from 1999 to 2000. Additionally, a multiprofessional culture extends beyond gender to various disciplines with 46 physicians, three nurses, and two pharmacists serving as President (11). The governing Council of SCCM has consistently had more than 40% women members since 2000 and multiple professions, also including respiratory care and nutrition (L Redford, personal communication, April to September, 2022) (Fig. 2).Figure 2.: Percent women in Society of Critical Care Medicine (SCCM) leadership—governing Council and American College of Critical Care Medicine Board of Regents (L Redford, personal communication, 2022) (11 , 12).The ACCM is the affiliated organization of Fellows of CCM (FCCM) and Masters of CCM (MCCM) and is governed by the Chancellor and Board of Regents. Women have comprised at least 30% of the ACCM Regents in recent decades, an improvement from 20% at the inception in 1988 (L Redford, personal communication, April to September, 2022) (Fig. 2). More than 1,300 individuals have been recognized as Fellows and 100 as Masters since 2011, with annual growth. Women comprise 27% of the MCCM and 30% of the FCCM designations, among those with self-designated gender in the SCCM database. Fellows must be recognized as a leader and demonstrate personal commitment to critical care excellence. Thus, these women have been important contributors to the profession and organization. MEDICAL JOURNALISM Throughout the history of the CCM journal, women have played an increasing role in editorial leadership. Traditionally, men have held top leadership positions in medical journals, 79% of editor-in-chief in 2019, although that is slowly changing as evidenced by a woman as editor-in-chief of JAMA (14,15). Only two women, Diane Adler, PhD, RN, FAAN, and Judith Hudson-Civetta, RN, BSN, were members of the CCM editorial board in its first decade (1980–1990). Progress has been steady since 2004, when only three women (5%), Charold Baer, RN, PhD (1993–2004), Marion Danis, MD (1998–2016), and Margaret Parker, MD, MCCM (1991 to present), were editors. Women currently fill approximately 25% of the associate or senior editor positions in CCM and represent 29% of editorial board members (8 nonphysicians) (16). Critical Care Explorations, SCCM’s newest journal publication launched in 2019, includes women as 46% of senior or associate editor (2 nonphysicians) and half of the editorial board (5 nonphysicians) (17). The PCCM editorial board has at least 27% women overall with a similar percentage of the senior or associate editors (18). These numbers are the result of an ongoing strategic initiative to improve diversity in editorial board composition. Women authors have been contributors to CCM throughout its history, but the pace of change has accelerated. For the top cited articles, the most notable change occurred after 2010, perhaps due to increasing workforce numbers or other unknown factors. Women are now first authors for more than 25% of highly cited articles (19) (Fig. 3). Similarly, more than 30% of editorials in CCM have women first authors since 2013 (20) (Fig. 4). Published contributions in CCM from women as senior authors increased from 4% to 17% over the same period. These findings are similar to other critical care journals for the period of 2008–2018. Women were 30.8% of first authors and 19.5% of senior authors in that report (21). Only 11 women were among the top 100 most prolific authors. When the senior author was a woman, the odds of women coauthors rose substantially, adjusted odds ratio 1.93 (95% CI 1.71–2.17). Chary et al (22) found similar results with significant variation by country for women as first authors, from 6.1% in Japan to 56.6% in Finland. The Canadian Critical Care Trials Group evaluated their publications and found that 37% of authors were women, 13.7% were from a visible minority group, 73% of articles included authors from more than one profession, and more than half were from more than one medical discipline (23). A critical mass of women in any given profession may be an important component of publishing rates as numbers are different in nursing where 90% are women. A study completed in 2011 demonstrated that women represented about 70% of first authors in the United Kingdom, 82% in Australia, and 93% in the United States (24).Figure 3.: Percent women listed as first author in the top 50 cited manuscripts in Critical Care Medicine (CCM) by decade, using Scopus (19).Figure 4.: Percent women as first author of editorial in Critical Care Medicine (CCM) by decade. Data on articles and editorials searched using Dimensions (Digital Science & Research Solutions Ltd., Cambridge, MA) to identify first and last authors, and NamSor (NamSor, LLC., France) to identify authors’ gender. Abstracts and case reports were excluded (20).The authors of this CCM Anniversary Reflection have created and been afforded many opportunities to publish in CCM and other journals. However, they have faced rejections, complex requests from reviewers, and a variety of other limitations, similar to male authors. Whether these have been quantitatively or qualitatively different or more challenging is unknown, as overall acceptance of papers to CCM remains below 25% of submissions due to the competitive quality and volume of submitted papers; thus, performance of quality research remains fundamental to publishing success. RESEARCH Despite greater challenges, women are making their mark as SCCM funded researchers, with half of the first six SCCM Discovery Grants and 47% of SCCM-Weil Research Trust grants awarded to women into 2022 (L Redford, personal communication, April to September, 2022). These grants are a key part of SCCM providing research opportunities for both established and junior researchers. The SCCM-Weil Trust funds research to foster discovery and innovation for future advances in critical care. The highest research award is the ACCM Distinguished Investigator award that recognizes an established and active SCCM investigator for meritorious and pioneering clinical research. It has been awarded to three women among the last 10 recipients, all of whom have extensive publication resumes (L Redford, personal communication, April to September, 2022). SCCM AWARDS Women have been recognized for a variety of other substantial contributions to SCCM. From 1996 to 2022, two women (Norma Shoemaker and Deborah Cook, MD, FRCPC, MSc, DABIM) were recipients of the Lifetime Achievement Award (7.1% of 28) (L Redford, personal communication, April to September, 2022) (7). This significant award recognizes individuals who have meritorious contributions to the field through advancement of medical science, education, or medical care throughout a career, and hopefully, the higher number of women with long careers will alter this ratio. Distinguished Service Awards are given to members who have made exceptional leadership contributions over an extended duration. Women received this award 32.5% of the time through 2022 (29/89 recipients) along with 11 nonphysicians (L Redford, personal communication, April to September, 2022). This rate is compatible with the leadership gender profile of SCCM. SPEAKERS In 2018, men outnumbered women as speakers at numerous critical care conferences; however, progress has been made since that report (23). Medical programs and panels with speakers who were all men spawned negative social media feedback from both men and women. Men have declined to participate due to the lack of women representation forcing some programs to alter speaker choices (25). With a strategic direction to improve diversity, the 2022 SCCM Congress included 427 speakers, of which 49% identified their gender as a woman, an increase from 39% in 2020. Further, women comprised 58% of the annual Congress cochairs during the last 4 years (L Redford, personal communication, April to September, 2022). Strategies to increase participation of women speakers have been proposed to raise the lower rates in other critical care meetings (26). These include diversity policies for planning committees, speakers, and chairs, including at least 30% women who are involved in speaker selection, that conferences should publish gender, professional background, and academic metrics for the program committee, speakers, and delegates, and that an international directory should list credentials and scholarly focus for women speakers. They also suggested that a measure of the impact of these changes should be tracked. Attendance of women at academic conferences is important to enhance new knowledge and to engage in networking. Yet, this can be challenging for some women due to personal and professional commitments. Enhancing conference attendance through provision of childcare and nursing suites may enable greater in-person attendance and opportunities for women to speak at academic conferences. Maintaining virtual options for speaking and attendance may further enable more women to participate. MEDICAL WORKFORCE In 2019, the percentage of critical care physicians in the United States was unbalanced with approximately 73.2% men and 26.8% women, despite an equivalent enrollment in medical schools (5). This ratio partially explains the uneven representation of women in many critical care professional leadership positions and publications. The Association of American Medical Colleges acknowledges that gender equity is a key factor in achieving excellence in academic medicine and promotes action on workforce, research, leadership and compensation, and recognition (27). Drivers of gender inequity include recruitment barriers such as ICU workload and hours, male leadership perpetuating a recruitment imbalance, and lack of sufficient role models, mentors, and networks (28). Consequently, programmatic practices to recruit and retain more women into critical care are necessary starting with students and residents. As a profession, we need to acknowledge and change the culture to include modified work hours to accommodate parental and caregiver responsibilities. Additionally, strategies to retain women in CCM include mentorship programs (inclusive of diverse backgrounds and lifestyles), support for family or parenteral leave, and opportunities for altered work accommodations (e.g., job sharing) (29). The challenges for women professionals were exacerbated during COVID-19 and further disrupted the well-being and productivity of women in academic science and medicine. Women, especially those in their early or mid-careers, have published less as key authors (30,31). Ironically, enhanced focus on the impact of the pandemic may ultimately catalyze changes that could improve opportunities for women in academic roles through increased awareness, changes in promotion criteria, and increased roles for men in the home (32). A strategic focus on the needs of all critical care team members is necessary, especially with issues of overwork and burnout. SCCM AND CCM STRATEGIC PLANNING A plan of action to increase participation and visibility of women requires a stepwise and strategic approach that applies to both men and women. Education on gender bias, mentorship and programs that facilitate growth, and career advancement for women are being developed by the new SCCM Leadership, Empowerment, and Development initiative. SCCM embraced the need for increased inclusion following a 2016 task force report that led to adoption of a Diversity Statement, Standards of Professional Conduct, creation of a Diversity and Inclusion Committee, and other strategies to increase the number of women as nominees, speakers, and leaders (3,4,26). The theme of the 2022 SCCM Congress was Diversity, Equity, and Inclusion and provided significant programming around that topic. Projects geared toward women, such as the SCCM’s Women in Critical Care Knowledge Education Group, provide a sense of community and connect women to develop new opportunities (33). Continued effort is necessary to increase participation of women in SCCM journals as authors, reviewers, editorial board members, associate editors, and ideally a future editor-in-chief. Strategic sponsorship of qualified women as editorial writers, promoting women researchers to first author and encouraging poster authors to publish their research is still needed. Focused training for journal reviewers can be helpful to recruit participants, and programs are being developed by SCCM. Current reviewers are encouraged to collaborate with trainees and colleagues on reviewer assignments to increase their participation. These building blocks take time and require enthusiasm on the part of the woman and their mentors (both men and women). Some women may require training and coaching in self-advocacy to effectively promote their interests and their work. Women are encouraged to volunteer in SCCM or other organizations to enhance their personal development and networking opportunities. The support received from SCCM will hopefully foster their roles as change agents. CONCLUSION CCM as a profession, as a publication, and as a specialty has come a long way in the past 50 years. The Society and the journal started with a group of likeminded men and evolved into a Society and journals with both men and women participating in leadership positions and as active contributors. Progress is the result of strategic and deliberate actions toward recognition and promotion of women. The continued expansion of roles for women in all critical care disciplines requires an adequate workforce and a need for continued recruitment, mentoring, sponsorship, and coaching. SCCM is working to address these issues decisively through their ongoing Diversity, Equity, and Inclusion initiatives. The role that SCCM and their journals have played in developing women for successful leadership, academics, and scholarship positions has been exceptional. Ongoing implementation of strategies to mentor and sponsor women in leadership, research, and journalism will amplify the contributions of women in critical care in the future. Our members are following in the steps of many trailblazing women to serve as the role models for tomorrow. ACKNOWLEDGMENTS We thank Meghan Lane-Fall, MD, MSHP, FCCM, for her contributions to the conceptualization of this document, Charold Baer, RN, PhD, Marion Danis, MD, Diane C. Adler, PhD, RN, FAAN, and many others for their willingness to share memories.