Women need to learn the rules of the game to advance in medical management.

Many of the behaviors that women have learned in order to be successful as women in our society are counterproductive in the business world. In order to make the move from medicine to management, women physicians will need to carefully examine their behaviors and place those that are a bad fit with a male-dominated business world on hold or eliminate them entirely. Only after they have learned to deal effectively with management situations on the basis of the rules already in place can they expect to bring "woman's touch" to the business world and begin to change the rules. While not all women exhibit the behaviors described in this article, many of them continue to display at least some of them.

More women are becoming doctors. In 1974, 11.1 percent of medical school graduates were female. In 1994, that number had increased to 38 percent.[1] As enough time passes for women physicians to gain management experience, more and more of them will be ready to become physician executives.

It takes some time for women to get the credentials that are needed to move in this direction. When recruiters call looking for physicians, they always mention some baseline requirements. They want the physician to be board certified in a specialty, have done patient care for at least five years, have good communication skills, and have management experience. Physicians can get the experience by serving on committees in hospitals (utilization review, quality assurance, long-range planning, and privileging and credentialing), by moving up the medical staff hierarchy, and by working part time for insurance companies or HMOs doing utilization review and quality assurance. These experiences cannot be acquired overnight.

In addition to the above requirements for the move to management, they have to acquire some new skills as well as give up some behaviors they learned as young girls. As you read this article, keep in mind that this is a "guys are taller than gals issue." Guys are taller than gals. Do you know some gals who are taller than guys? Yes, but would you say as a general rule guys are taller than gals? Yes. As I describe the behaviors, you may think that you do not fall into this category and that you know women who don't, but you probably know more women who do.

Women physicians have already moved into a traditionally male-dominated field, so they may have given up or never had some of the behavior mentioned. However, I have counseled with enough women who display some of these behaviors that I think they are worth listing.

Much of the material in this article is taken from a recent book by Pat Heim entitled Hardball for Women, Winning at the Game of Business.[2] Heim's predominant theme is that women need to find ways to gain power in organizations. To do that, they have to learn to play the masculine game of hardball. Once they have the power, they can change the game, but to get it, they usually have to adhere to rules that have been established by men. In this article, I have selected the advice that would seem most useful to women physicians that I've talked to who are in or want to be in medical management.

In the present climate of concern about political correctness, I know it is risky to mention that men and women do things differently, but my experience continues to confirm that they do. Heim's initial premise declares: "I believe that pretending men and women are the same only damages women's chances of succeeding and requires that we continue to adapt to the male culture of business."

First some background about how girls and boys are raised. Girls: "For the most part, girls play with only one person, usually a best friend. As a result, girls learn exceptional interpersonal skills, including how to `read' and respond to others' emotions.... Girls grow up in flat organizations rather than hierarchies. They learn to cooperate within this structure. Rather than having a coach or a top banana tell them what to do, girls cooperate in a web of relationships for the sake of preserving the friendship. It doesn't take long for a little girl to discover that if she wants to be the leader and she starts pushing her playmates around, relationships will suffer; friends will call her bossy and avoid her. As a result, she tries to keep the power dead even."

Boys: "All games that boys play involve adversarial relationships: us versus them. Boys learn that competition and conflict are stimulating and fun, to be embraced and not avoided. Boys also learn that when the game is over, it's over....boys learn to do what the coach says, period....it's important to look like a mean, aggressive player - even if you're not feeling all that tough. In order to act aggressively, boys learn power plays: posture, facial expressions, verbal bantering, and other trappings of power. In truth, how you speak, present yourself, and are introduced all contribute to the illusion of power. In the game of business, if you don't know how to do something, often the best idea is to fake it?"

A grown-up version of these behaviors appears in organizations. "In the male culture...power isn't simply the ability to get things done; men must display and strut their power by ordering others around to underscore their leadership position. In the female culture, on the other hand, strutting power can cause one to lose it, especially among female employees.... If we are all equal, what's the point of throwing one's weight around? But such displays...are part and parcel of the hierarchical system. The person on top gets to give the orders."

The following recommendations are aimed at gaining power in an organization:

Be on the lookout for a mentor.

"[H]aving a mentor may be more critical to a female's success than it is to her male colleagues'. In an extensive study of individuals who had made it into the senior ranks of organizations, it was found that only 38 percent of these successful men had mentors, but all of the women executives had them. A mentor doesn't appear to be optional for women, probably because women are less familiar with how hardball is played."

"Asking someone to be your mentor is much like asking someone to be your friend. It doesn't work that way, but typically you'll have an opportunity to work or talk frequently with more experienced colleagues. When the chemistry seems right and you feel you can ask for advice, insight, or suggestions, then you have the beginnings of a mentor relationship."

Don't cry or admit that you do.

"A senior woman executive told me that during a particularly trying period, she would cry all the way home in her car. She mentioned this to her male mentor, the company CEO. `I could tell he saw me as weak because of this, so I never mentioned it again.'"

"It's important not to cry, scream, or seem wild-eyed if you want to be taken seriously. If you feel as if you're going to explode, get yourself out of the situation until you've calmed down enough to direct your anger. But you don't want to wait so long that the issue becomes old business."

Don't be sexy at work.

Being sexy is an art form that involves how you dress, move your body, hold your head, focus your eyes, and choose your tone of voice. These skills can be quite useful in a social setting, but the wrong choices at the office can hurt your chances of advancement. "Once a woman's sexuality becomes the focus, her work fades into the background."

Don't be too tough or too soft.

"If you are too controlling, people will feel resentful, like mere cogs in a wheel. They may dig in, move at a snail's pace, sabotage your efforts, or worse. If you're too warm and open, your department may love you and everyone in it, but it's unlikely that much will get accomplished. It's the balance that makes all the difference and yet is so difficult to achieve."

Stop the negative talk in your head.

"Listen to your internal dialogue. If you catch yourself being self-critical say, `Oh, c'mon, You did what you had to do.' [If you have a lot of negative dialogue in your head and have a hard time breaking the habit]...place a rubber band on your wrist. If you can't seem to get out of a negative frame of mind, give it a snap every time you find yourself slipping into self-criticism. This aversion therapy will grab your attention, if nothing else."

You may have to give up some of your friends.

"Although I would love to say that it's possible to maintain close friendships with co-workers whom you must manage, from my experience and the testimony of hundreds of women I've worked with, it's virtually impossible over the long run to remain a bosom buddy with a friend who has become your employee. If you're playing hardball, you may have to sacrifice a friendship for the sake of a job."

Women have often reported to me that other women give them the most trouble when they move into management. Heim offers an explanation for that behavior: "I believe that women employees don't make a conscious decision to attack, but rather their cattiness is an unconscious attempt to reflatten the hierarchy."

I have also talked to women physician executives who are having a difficult time reporting to a female superiors. "Frequently, women who must serve hierarchical females feel resentful because they take as personal attacks the natural displays of power required of those in authority.... If you find yourself in this situation, you may discover that you have more difficulty serving your boss than you would if she were a man.... If so, for the sake of your job and your sanity, you may find it beneficial to imagine that your boss is a man."

Don't say "I feel...", say "I think...."

Many women say "I feel" when they could just as easily say "I think." It is just a habit, and it's an important one to break at work. One woman had a female boss whose style was "very male" and who viewed "...openness as time-consuming and unproductive." So the female subordinate, who was used to having a very supportive style, said, "I've had to take `feel' out of my vocabulary."

Be powerful in a different way from a man.

"To be comfortable with her power, a woman must be both powerful and feminine. She can't be powerful in the same ways as a man, because she is judged on women's standards. Nevertheless, she can be clear on her goals and she can hold onto them tenaciously, without resorting to tantrums, foul language, or other male power-grabbing behavior." Describing one woman who has found a balance between being powerful and feminine, Heim says, "She is warm, charming, and funny, but when you have pushed her beyond her limits, you know it; her demeanor turns chillingly serious."

Within reason, act as if you know what you are doing.

"Even when women call the shots, they often feel as if they're imposters. They're never sure they have enough information, knowledge, or whatever else it takes to be the one in the driver's seat. One of the most senior women in corporate America taught me an important lesson on this score a few years ago. We were having dinner one evening when I asked her, `How did you get where you are today?'

"She replied, `Well, the first five years, I was unconscious. There I was, a brand-new Harvard MBA, and people came at me as if I had all the answers. I thought they wanted me to take out my calculator and tell them the way the world worked, but I didn't know any more than anyone else. I hid for five years so people would stop asking for answers I didn't have.'

"Intrigued, I asked her what changed things. `One day I woke up and realized that all the men I worked with were making up the answers,' she told me. `I decided that if they could make up the answers, so could I. Once I started acting as if I knew what was going on, the promotions came thick and fast.'"

Pay attention to your voice and body language.

Women tend to "speak briefly with a high pitch and low volume, whereas men claim the floor by speaking loudly and at length in declamatory tones."

"Cocking your head to one side displays curiosity. Even dogs and cats do it.... But, if you're speaking at the time, it also signals subordinate status. Men hold their heads upright when they speak.... [If] a woman's head is down and tilted to the side while she smiles broadly, such a move indicates extreme powerlessness.... When a woman listens and nods, a man may think she is a pushover, when in fact she's merely indicating she heard what he said.

"Women...often unconsciously signal their vulnerability by swinging up at the end of a statement.... Don't turn statements into questions, especially if you're under fire. Avoid tag questions and swing that voice down at the end of your statement." You can make the necessary changes to your style with the help of a voice and acting coach.

Don't make statements that sound insecure.

"[K]eep in mind the first rule of swimming with the sharks: Don't bleed."

"`I may be wrong but....'

`I'm not sure about this, however.....'

`This is probably a stupid idea, but....'

`I hate to interrupt, but....'

"These undermining declarations are another way of saying, 'I don't want to catch you off-guard. Get ready for stupidity.' This is bleeding for the sharks."

Learn to take negative feedback and not let it cripple you.

"[B]oys learn that the general flow of negative feedback is meant to make them stronger, more effective players .... They train themselves to get over feeling hurt and come to appreciate a `tough coach.' [B]oys take negative feedback for what it's worth - instruction on what it takes to win - and move on."

"Because of our childhood play patterns, women don't practice receiving criticism, never learn to associate it with skill building, and, Most important, don't know how to separate someone's negative perceptions from who they are as people. Indeed, most often women personalize criticism and take it on face value as being true. Many women need external approval to feel successful."

"Boys learn to shed others' negative remarks because they spend so much time bantering. Girls, on the other hand, have a harder time deflecting criticism because they've had little practice thwarting it. Our lack of training' can have serious consequences in the workplace .... [W]e embrace criticism from every Tom, Dick, and Harry. A woman may never ask a colleague for technical advice because she knows he can't find his way out of a paper bag. But if he's dishing out negative feedback, she's the first in line for a big helping. The truth is, positive strokes are often so important to us, we give power to others in order to get their blessing. We have been taught to please others, and when we don't get their approval, we feel like failures. ln addition, because we have little practice taking negative feedback, we can't discriminate sources when we do get it."

"When receiving criticism, we should say, `This is Harold's opinion about this behavior at this time.' ... By mentally drawing a box around the criticism, we consciously contain it and limit its power over us.... Don't dwell on your failure feelings. Learn from your mistakes and move on."

"... [S]tatistically about half the time boys lose. Rather than feeling devastated by the failure, however, the repeated experience of losing teaches boys how to take a loss, learn from it, and move on."

Be judicious about letting people know your goals.

"Can you succeed without showing just how driven you are? It's not easy but it can be done. The trick here is to get your internal engine revving at full bore, but to refrain from expressing your desires verbally .... It's also important to note that an ambitious woman should never believe - not even for a second - that her performance will win her the position. She's got to talk her way into it." Example: "If a female director would like to move into the position of vice president of communication, she might be best served by conveying her ambition indirectly. She could indicate her suitability for the position to her superiors by noting how she had previously demonstrated abilities requisite to do a vice president's job. She could also share her exciting and interesting new ideas regarding corporate communication."

"Our best bet may be to target what the authors of Breaking the Glass Ceiling call the narrow band of acceptable behavior: to be strong enough to be noticed but not so strong as to be labeled overbearing.'"

Make money for the company.

"The more money you bring into the company, the more power you'll wield, because, in the game of hardball, money is equated with winning."

Pay attention to what is important to the boss.

When women physicians move into the management arena, they usually have a boss somewhere. If not at the site where she works, then in another city. "Whatever your job description says, mentally add one more item: Make the boss look good. You don't have to like her or agree with her. You just need to make her look like a winner. If the boss looks good, she's going to value you highly, and you'll be a lot more likely to advance in the future."

Once enough women have gained power in organizations, they can examined a myriad of strategies to help women play the game of business and win. Some if not many of these maneuvers may feel uncomfortable to us. But to change the game, we've got to get the power first, and that usually requires adhering to the established rules.

AUTHOR TO SPEAK AT ACPE 

NATIONAL INSTITUTE IN NOVEMBER

Pat Heim, PhD, author of Hardball for Women, will speak at the College's National Institute on Health Care Leadership and Mangement on Nov. 13. She has asked women members of the College to share with her any information that they have on the following topics so that she can incorporate it in her presentation:

* What do you see as the biggest stumbling block to advancing in your organization?

* What kinds of feedback are you getting on your management style?

Please send your information to Barbara Linney at College headquarters or fax it to her at 813/287-8993.

References

[1.] Jonas, H., and others. "Educational Programs in U.S. Medical Schools, 1993-1994." JAMA 272(9):694-701, Sept. 7, 1994. [2.] Heim, P., with Susan K. Golant. Hardball for Women. Winning at the Game of Business. New York, N.Y.: PLUME, published by Penguin Group, 1993.