This is the speech as drafted and it may differ to the delivered version.
Good culture, good care: why more female leaders means better outcomes for doctors and patients alike
Professor Dame Carrie MacEwen's speech from the Academy of Medical Royal Colleges, Royal College of Physicians of Edinburgh & Royal College of Surgeons of Edinburgh event on Women in Leadership on 28 April 2023.
It is a real privilege to be here on home turf today surrounded by such inspiring speakers and guests.
When I was invited to speak today, I was asked to talk a bit about ‘how I did it’. The truth is that I can’t profess any great wisdom about how I ended up here. There was no divine plan. And most of the time I just fell into things. I feel sure that being a very curious individual – always asking questions, researching accepted beliefs and never turning down an opportunity – almost certainly helped. But I also know that one of the things I really missed when I was coming up was having other women I could look to, who could offer some advice on how to navigate the system and act as proof that the life I wanted could be achieved.
So in that vein, I thought I’d share a few reflections about my career, and what I’ve learnt along the way.
My leadership journey
I wanted to be a doctor for as long as I can remember. My childhood was spent fixing dolls, or the dog, and dreaming of the day I’d be fixing patients.
My father was an ophthalmologist and a huge inspiration to me. I remember him talking about how most women in his year at university had given up medicine because they just couldn’t make the juggle between their professional and personal lives work. But he thought that was changing, and was hugely encouraging to me.
I went to Dundee for medical school, moving from west to east coast as I left my hometown of Glasgow (that's a big deal if you're Scottish – at least it wasn’t Edinburgh!)
The year was 1975 and, unbelievably, there was still a cap on the number of female medical students allowed in. Thinking about it now it seems absurdly late for such a thing to be in place, but that was the reality. Thankfully, the Sex Discrimination Act was passed that year, which finally did away with the cap.
I was pretty clear that I wanted to do surgery and eventually I decided I wanted to be an ophthalmologist.
As I progressed through my education and training, I can’t say I thought too much about being a woman and how that might have been affecting my experience. It really was a case just getting on with it. My main objective was to be a good clinician – that is what tends to define us as doctors – and that took up most of my energy.
But as I look back now, I can see that other people did consider it to be an issue.
Sexist comments were so frequent they were routine. I remember approaching the table to do one of the viva portions of my fellowship exam and hearing one male examiner say to the other “oh god it’s a girl”. They both just laughed! Another time, when I was a new senior registrar, I picked up the phone to a doctor asking to speak to said senior registrar and was told “that’s not possible, you’re a woman”.
But perhaps the biggest low came when I was bullied by one notorious consultant just before I sat my fellowship exam. That was a miserable experience and it had a horrible impact on my confidence.
At the time, for all these unacceptable behaviours, my tactic was just to keep quiet and keep my head down. That felt like the only viable option at that stage. And for the few women I saw around me, I think that was the accepted way of doing things. But it’s not an approach I’d recommend.
In the end, what helped me most was talking to my peers and hearing that we were all experiencing similar behaviours. Solidarity is the best medicine when you’re being singled out.
There were plenty of times when, on a practical level, I wondered if I could make the juggle work.
Having children presented a particular balancing act, especially when my husband, a fellow doctor, was working in another city. With three children under the age of four and no family nearby I had to shell out a lot of money on childcare. At that time, it really was not acceptable to reduce hours or take time off for caring responsibilities. So much so that it felt like I was working for free.
In the end I chose to view it as an investment in my future career, and my future self.
Sadly that bargain has remained part of many people’s calculations, despite everything else that has changed.
I consider myself a clinician first and foremost and was until my mid-50s. But I saw in practice the difficulties women were having progressing in their careers, because ‘doing everything’ is simply not always possible. Less than full time (LTFT) training was, at that stage, starting to become a realistic prospect. It was known as flexible training initially – to indicate that some allowances were being made – and then less than full time (rather than part time) because commonly the hours being worked were still more than 60. And I knew how much that would have helped me when I was training. So I took on the role of Associate Dean for Less than Full Time Training for East Scotland to help develop, promote and practically manage this as a viable option. Initially this was just another thing added to my workload, but I was permitted a session a week from clinical commitments once the new contract came in.
I was always interested in research, training and education and I became honorary head of department and senior examiner for the Royal College of Ophthalmologists. From there I became Vice President and was then elected President of the College. I saw the presidency as a chance to make change, and I spent those 3 years developing and sharing new ways of providing patient care and setting up multi-disciplinary ophthalmic training.
After the College, I was going to go back to being clinician full-time. But I was somehow persuaded to apply to be Chair of Academy of Medical Royal Colleges. I saw this as another chance to build relationships across specialties to the benefit of patients. You could have knocked me over with a feather when I got the phone call saying I'd got it.
Throughout it all, the support of friends, family and good colleagues was a constant tonic. It’s something that I felt especially keenly when I became President of the Royal College. This was during a high point for female representation at Royal Colleges, including my friend Dame Clare Marx, who was President of the Royal College of Surgeons at the time.
Clare was also my link to the GMC, where I became a Council member in 2021. When Clare announced her diagnosis of pancreatic cancer, I took on the role as Chair, first on an interim basis and then was appointed permanently last year.
Why diversity matters
So far from settling down into a cosy retirement, I’ve taken on the most scrutinised role of my career! But one with the greatest potential for change.
One of the reasons I took on this role (which I have to say caused some surprise – even dismay! – amongst friends and peers) is the platform it gives me to promote the things I care about.
The role of compassionate clinical cultures is one of them. I firmly believe that fair working environments and proper representation lie at the heart of good patient outcomes. Doctors are skilled professionals and should be treated as such – this is not always the case.
Copious evidence shows that the culture in which a doctor works determines the care they’re able to provide. Doctors who feel supported, valued and heard deliver better care than those who feel excluded or marginalised.
That’s why healthy working environments are as important to good patient outcomes as surgical ability or technical skill.
Diversity of thought and approach is central to this. The sharing of new ideas and alternative approaches is what drives forward progress. That’s why lies behind all the service development work I carried out as College President. That doctor with the different perspective could call out an issue that would otherwise be missed. Or offer a way forward that would never have occurred to the other people in the room.
Fundamentally, the medical profession should be representative of the population it serves. Gone are the days when doctors could consider themselves to have a lofty position above those they treat. Instead of paternalism, today’s patients want to feel understood by their practitioners.
Role modelling is a be a big driver of representation. You can’t be what you can’t see. And certainly as I was progressing through my career, I didn’t see anyone around me doing what I wanted to do.
Women doctors who had completed training, in general, were few. Those who were managing to have a career and a family life were even fewer. Those who seemed to be reaching the highest heights seemed to be doing so to the exclusion of everything else. I didn’t want that. Not only did I have three children to care for, I wanted to play sport, see friends and enjoy a nurturing social life.
That’s really what stoked my lifelong interest in LTFT training. And as it’s become more routine and more accepted, I’ve seen how it’s helped keep people in profession who would otherwise have left. These are people, both men and women I should say, who would have been lost to medicine, but instead went on to become consultants and GPs.
But while I might have been an outlier back then, I think the desire for balance is commonplace today. In fact, as our data tell us, it is set to become even more so.
What our data tell us
The workforce is becoming more ethnically diverse, but it has been becoming more female for a long time. The term ‘feminisation of the medical workforce’ was used increasingly from the mid-1990s as a driver for change. 2017 was forecast as the year that the number of women on the medical register would exceed the number of men. But all these years later and it’s still not happened. That’s despite more than 60% of medical students being female and, at the other end, older, mainly male, doctors retiring1.
It should be said that Scotland is a notable exception here, with 53% of its workforce being female, compared to half in the UK overall2.
Between 2017 and 2021, we saw a 20% increase in the number of female doctors holding a licence, compared to a 14% increase in male doctors3. But with the increase in international medical graduates (IMGs) – most of whom are male – the scales have not yet tipped.
While all specialties had an increasingly female composition between 2012 and 2021, some, like obstetrics and gynaecology, paediatrics and general practice, remain more female than others. At the other end of the spectrum, surgery was just 15% female in 20214. When we look at representation at senior levels, the stats are even more stark. The ratio of male to female consultant surgeons, for example, is still only 8:15.
What accounts for this disparity? We can certainly make some assumptions about the nature of surgical training and the extent to which it’s compatible with a work/life balance. Culture, too, plays a crucial role. As much as pioneers like Clare Marx blazed a trail, we know surgery remains male-dominated. That can lead to exclusionary behaviours and even overt hostility and sexual misconduct.
The point is that there should be no barrier that stops a woman pursuing whatever medical career she desires. If there is a minority of women in surgery it should be because a minority of women wants to do it, not because a majority feels they can’t. Ultimately, it should all come down to choice.
There is an irrefutable moral argument for improving the representation of women at senior levels in medicine. But there’s also an ironclad business case. Yes we should have more female leaders because that’s the right thing to do for them. But it’s also the right thing to do for those with whom they work and those they treat.
We’ve come a long way from when I started medical school in 1975. Our data on medical students tell us that the future is female, and that diversity is to be celebrated.
The key will be ensuring that today’s cohort are given the support they need to pursue long and successful careers in their chosen field – be it supportive cultures that make them feel just as valued as men, or practical support like LTFT training.
There are plenty of little girls today fixing dolls or dogs and imagining they’re patients.
My hope is that by the time they grow up, being a senior female medic won’t be a remarkable thing at all.
 p. 06 ibid.
 p.28 Ibid.
 p.28 – 29 ibid.