Gender equality in academic medicine before, during and after COVID: what have we learned? A systematic review.

Gender equality in academic medicine before, during and after COVID: what have we learned? 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A systematic review. Elaine Burke, Catherine Darker, Isabelle Molly Godson-Treacy, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5103072/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Gender disparity at senior levels in academic medicine has been recognised for decades, but progress has been slow and confounded further by the COVID pandemic. While there are many papers describing this problem, there is little evidence for potential solutions. We aimed to describe the current evidence for interventions to enhance gender equality in academic medicine, and to compare interventions pre, during and post-COVID-19. We also wished to characterise the nature of the interventions, who delivered them, and whether they seek to “fix the women”, or target issues at organisational and systemic levels. Methods We searched five electronic databases in November 2022 and August 2023 and undertook hand-searching. We extracted data using a form developed for the study, and applied the TIDieR and Morahan frameworks to describe and characterise interventions. We used the QUADs tool to critically appraise included studies. Results The search of electronic databases yielded 1,747 studies. A further 62 were identified through hand-searching. Following removal of duplicates, 764 articles were screened for eligibility, and 199 full-text articles were screened. Of these, 27 met the inclusion criteria. The most commonly reported interventions were career development or leadership skills programmes, followed by mentorship and multi-faceted interventions. Most papers reported positive findings, but many relied on subjective measures. Robustly designed studies often reported mixed findings. The majority of interventions aimed to “fix the women”, with few addressing inequality at organisational level. We found no studies describing interventions aimed specifically at mitigating the effects of the COVID pandemic, and none describing the effects of the pandemic on their interventions. Conclusion Acknowledging the possibility of publication delay, we found that despite strong evidence of the negative effects of the pandemic on women’s research productivity, there were no new interventions designed to mitigate this. Many existing interventions create “institutional housekeeping” by relying on women for their delivery, this can result in failure, especially during a crisis like COVID. Most studies were low to moderate quality. More robust research, and a more holistic approach is needed, moving away from “fixing the women” to address the organisational and systemic structures which underpin inequality. Women's studies Educational Philosophy and Theory Health Policy Gender equality equity academic medicine women faculty retention recruitment Figures Figure 1 Background In 1988, it was noted that the number of women medical faculty at junior academic grades was increasing rapidly, but this effect was not seen at senior grades ( 1 ). Eight years later, in 1996, JAMA published a landmark paper describing the successful implementation of a multi-faceted intervention addressing gender inequality in academic medicine, reporting a 550% increase in the number of women associate professors over 5 years ( 2 ). The future looked hopeful – surely the increase in women entering medicine, along with effective strategies for recruitment and retention, would eventually translate into more women at leadership level. Decades later, this hope has not been realised – women continue to enter medicine at high levels, exceeding the rate of male entrants in the US in 2017 ( 3 ), yet remain underrepresented at the highest levels. Women make up 28.4% of full professors at US medical schools ( 4 ), 30% of professors in UK Higher Education Institutions (HEIs) ( 5 ), and occupy 26.2% of posts at the highest grade of academic staff in HEIs in 28 EU countries ( 6 ). The reasons for this disparity are complex. Many factors have been described: women in medicine are exposed to stereotypes associating women with family and men with careers ( 7 ), research funding applications are viewed less favourably when the PI is a woman ( 8 ), women are significantly less likely than their male peers to be credited as an author on a research paper ( 9 ), and a vicious cycle exists whereby women occupy lower academic ranks, have access to fewer resources and are therefore less productive, reinforcing stereotypes that women do not belong at higher academic levels ( 10 ). Pay disparities remain pervasive ( 11 ), and sexual and gender-based harassment directed against women in medicine and surgery is prevalent ( 12 , 13 ). These and other factors combine to create a culture that is not conducive to women’s career advancement, in spite of evidence for the benefits of gender equality: groups with more women have higher collective intelligence ( 14 ), Fortune 500 companies with female CEOs are more profitable ( 15 ), and gender heterogenous research teams produce better quality research ( 16 ). From an economic perspective, failure to achieve equitable participation in academic medicine represents a loss of talent ( 17 ), a serious concern for a workforce already at risk of becoming an “endangered species” ( 18 ). The situation was exacerbated by the COVID-19 pandemic. As early as May 2020, data from preprint servers showed that across disciplines, women’s publishing rate had fallen relative to men’s. This was attributed to increased caregiving responsibilities during the pandemic, and the effect of shifting to online work. This shift simultaneously increased the workload associated with teaching, disproportionately affecting women, and decreased the workload associated with hiring and curriculum committees – disproportionately affecting men, and releasing time to write research papers ( 19 , 20 ). This gap in academic productivity during the pandemic was particularly pronounced for women in health and medicine ( 21 ). Female faculty physicians at a children’s hospital were significantly more likely to report decreased academic productivity during the pandemic compared to male colleagues, and this was attributed primarily to unreliable childcare ( 22 ). Physicians on the front line were particularly vulnerable to negative impacts on psychological health, disruptions in research training and support systems including childcare, with a resultant impact on academic productivity ( 23 ). Female faculty at an academic medical centre in the US were twice as likely to have considered leaving academic medicine since the onset of COVID-19 compared to before (28% vs. 17%) ( 24 ). Women from less gender-equal countries with higher COVID-related mortality, and those from other groups who are under-represented in academic medicine, e.g., racially and ethnically marginalized groups, experienced the greatest impact on academic productivity ( 23 , 25 , 26 ). While there are many papers highlighting the issue of gender inequality across an array of specialties ( 27 – 31 ), and a variety of solutions proposed, few provide evidence for successful interventions ( 32 , 33 ). Furthermore, the evidence that does exist is often weak and lacking in methodological rigor. A systematic review of papers focused on interventions to improve outcomes for women in any field of academia found only 18 studies that met the criteria for full review, and the overall quality was low to moderate ( 33 ). Another systematic review of gender-concordant mentoring found a reliance on weak study designs; the authors cautioned against the use of interventions that seek to “fix the women” while inadvertently reinforcing gender-based stereotypes ( 34 ). This type of intervention, which relies on senior female faculty for its delivery, could be considered “institutional housekeeping”, i.e., the supportive labour of women to improve women’s situation in their institution, and which, like other forms of “women’s work”, may be unrecognised and unrewarded ( 35 ), paradoxically worsening the situation for women, albeit unintentionally. The aim of this systematic review is to describe the current evidence for interventions to enhance gender equality in recruitment and promotion in academic medicine. We also set out to compare interventions pre, during and post-COVID-19, and explore whether any specific interventions were implemented to mitigate the effects of the pandemic. Lastly, we wished to characterise the nature of the interventions, who delivered them, and whether they seek to “fix the women”, or target issues at organisational and systemic levels. Methods We drafted a protocol and registered our review with Prospero [CRD42023391086]. We report our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supplementary File 1) ( 36 ). Search Strategy A search strategy was developed with a medical librarian (DM) for 5 databases (MEDLINE, OVID, Embase, CINAHL, Web of Science, Google Scholar) and conducted in November 2022, repeated in August 2023. Hand searching was undertaken in August-September 2023. The full search strategy is available in Supplementary File 2. English language papers up to 15 years old were included. Eligibility Criteria The review sought studies on new interventions implemented with the aim of improving recruitment, retention and promotion for female clinical academics (Table 1 ) Table 1 Inclusion and Exclusion Criteria Types of studies Qualitative or quantitative original studies published in full including: • Interviews/focus groups • Surveys • Randomised control trials • Quasi-experimental pre- and post-intervention evaluations We excluded conference papers, papers in languages other than English, book chapters, opinion pieces, perspectives, commentaries and editorials, and studies reporting secondary data, e.g., systematic reviews and meta-analyses Study settings Schools/Faculties of Medicine in Higher Level Institutions or sub-divisions, e.g., clinical Departments or disciplines. We included interventions where the setting was unclear (e.g., possibly hospital-based) when they were aimed at clinical academic medical faculty. Population The population of interest were female clinical academics/physician scientists, or faculty within medical schools. We included some studies which were aimed at female physician scientists but also included non-physician clinical academics, and studies where it was not clear whether all participants held a dual clinical and academic role or single academic role, as long as the setting was academic on the basis that clinical academics/physician scientists could also benefit from the intervention. We excluded studies whose participants were full-time clinicians or undergraduate students and studies where the intervention was not specifically targeted at women. Interventions Any new intervention designed to enhance gender equality in recruitment, retention or promotion in academic medicine, e.g., unconscious bias training for faculty and hiring committees, mentoring programmes etc. We excluded studies where no evaluation took place or outcomes were not reported, and evaluations of pre-existing practices. Outcomes Outcomes could include measurements of success of female candidates applying for academic roles or promotions, research productivity, retention of female clinical academic staff and satisfaction with career progression. Study selection processes Study eligibility was assessed by five authors (EB, MGT, CK, MH and NS) using Covidence software. Each title and abstract was independently screened by two authors. Articles’ full texts were screened by four authors (EB, MGT, CK and NS) with each full text being screened independently by two authors. Discrepancies were resolved by discussion and involvement with a third author where necessary (EB or MH). Search, screening and selection results are shown in the PRISMA diagram (Fig. 1 ). Data extraction Data was extracted by EB using an Excel data extraction form designed specifically for this study. The following data were extracted: first author, year of publication, place of publication, pre/during COVID, participants, study type, intervention type, duration of intervention, classification of intervention, and results. Interventions were classified according to Morahan et al’s framework for organisational and individual assessment relative to the advancement of women physicians and scientists ( 37 ), (Table 2 ). This framework was chosen because it was developed specifically for academic medicine, and is based on a model of integrated leadership which starts at the early career stage through leadership roles. A second researcher, MGT, applied the data extraction tool to a subset of 7 studies and found significant agreement with EB’s findings for these studies, thereafter EB applied the tool to the remaining 20 studies. Table 2 Framework for gender equality in academic medicine Institutionally based approaches to women’s advancement (Morahan et al (37)) Equip the women Create equal opportunities Value relational skills and increase visibility Assess and revise work culture To provide a complete description of the nature of the interventions, we applied the TIDieR (Template for Intervention Description and Replication) framework. TIDieR is a 12 item checklist (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) which can be applied to all evaluative study designs ( 38 ). EB applied the framework to all studies; three other authors (CK, CD and MGT) each independently applied the framework to three sub-sets of studies and findings were collated; major discrepancies were resolved through discussion. Data synthesis Due to the small number of studies retrieved and their significant heterogeneity regarding outcomes measured, interventions, control group and statistical analysis, it was not possible to perform a meta-analysis. Quality assessment Quality assessment was undertaken using the Quality Appraisal for Diverse Studies (QUADS) tool. The QUADS tool was chosen because it has been developed for use in systematic reviews that include qualitative, quantitative and mixed-methods studies, and has been shown to demonstrate substantial inter-rater reliability, and content and face validity ( 39 ). All 27 studies were assessed using QUADS by EB. A subset of studies (n = 4) were assessed independently by two other authors (MGT and CD). Discrepancies were resolved through discussion where needed. Results The search of electronic databases yielded 1,747 studies. A further 62 were identified through hand-searching. Following removal of duplicates, 764 articles were screened for eligibility, and 199 full-text articles were screened. Of these, 27 met the inclusion criteria (Table 1 ). Characteristics of included studies Studies were published between 2008 and 2022. One study took place both before and during the COVID-19 pandemic ( 40 ), with the remaining studies all taking place before the pandemic. Three took place in the UK ( 41 – 43 ), one took place in both the USA and Ethiopia ( 44 ), and the remainder took place in the USA. Sample sizes ranged from 4 participants ( 45 ) to 3,268 participants ( 46 ). Eleven interventions were aimed at all or multiple levels of academic rank ( 40 , 41 , 43 , 47 – 54 ), seven were aimed at mid-career and/or senior faculty (assistant professor to full professor) ( 46 , 55 – 60 ), four were aimed at early and mid-career faculty (instructor to assistant professor) ( 44 , 61 – 63 ), three were aimed at assistant professor level only ( 64 – 66 ), and two were aimed at junior faculty (instructor, senior lecturer and lower) ( 42 , 45 ) (Table 3). Interventions The most commonly reported intervention, (10/27 papers) consisted of career development programmes (CDPs) and leadership skills programmes ( 44 , 46 , 50 , 51 , 55 – 60 ) with two interventions aimed specifically at developing specific skills for career advancement e.g., Curriculum Vitae (CV) preparation ( 65 , 66 ). Five of the papers were written about 3 national CDPs for women in academic medicine in the USA: the Association of American Medical College’s (AAMC) Early and Mid-Career Women in Medicine Programmes (EWIM and MWIM) and Drexel University’s Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) programme ( 46 , 56 – 58 , 60 ). Two papers describe findings at 1 and 5 years from a leadership development programme for women in radiology (LIFT-OFF) at Vanderbilt University Medical Centre, Nashville, Tennessee ( 40 , 51 ). Interventions aimed at more junior faculty tended to take the form of mentoring programmes ( 42 , 45 , 61 – 63 ). Mentoring took the form of facilitated peer mentoring in three studies ( 45 , 61 , 62 ); two of these studies report on the same mentorship programme after the pilot phase and longer term follow-up over approximately 4 years ( 61 ). Other mentoring programmes followed a more traditional dyadic approach with a senior faculty member matched to a junior member ( 42 , 63 ). Five interventions were multi-faceted and included activities such as CDPs combined with departmental task forces, a review of current hiring strategies, and provision of research funding for assistant professors ( 40 , 41 , 43 , 54 , 64 ). Two interventions involved the development of women-focussed groups and organisations ( 47 , 49 ) and one intervention consisted of an educational campaign to raise awareness and acceptance of family-friendly policies ( 52 ). Two interventions comprised diversity or implicit bias training for faculty and faculty search committees ( 48 , 53 ). Interventions varied in their duration from “brief” (15–30 minutes) to years-long ( 40 , 41 , 43 , 47 , 49 , 54 , 64 ) (Table 3). TIDieR Framework None of the papers provided sufficient detail to fulfil all 12 items on the TIDieR checklist. In particular, few reported on tailoring (if the intervention was planned to be personalised, titrated or adapted), modifications, intervention adherence or fidelity, or the extent to which the intervention was delivered as planned. Further, while most authors provided a rationale for their approach, only one cited specific theories which informed the intervention design (Resonant Leadership, Social Cognitive Theory and Social Network Theory)( 50 ) Intervention providers were senior faculty in 7 papers ( 42 , 44 , 47 , 48 , 63 – 65 ). Five of the interventions, predominantly mentorship programmes, relied on female faculty for their delivery ( 45 , 49 , 61 , 62 , 66 ). Five interventions used internal and/or external expertise in their delivery ( 40 , 51 , 53 , 55 , 59 ). Two papers describe the Athena SWAN programme which involves faculty at all levels ( 41 , 43 ). One multi-faceted intervention relied on senior faculty, local and national experts and institutional leadership ( 54 ). The remaining seven studies did not specifically describe the intervention providers ( 46 , 50 , 52 , 56 – 58 , 60 ). Modes of delivery of the intervention were highly variable and included 1:1 or 1:2 face to face sessions ( 42 , 63 , 66 ), small group sessions with interactive workshops, case-based discussions, book clubs and paired discussions ( 47 , 50 , 53 , 54 ), annual summits and lectureships ( 40 , 64 ), and online modules ( 40 ). A detailed description of each intervention and the TIDieR Framework is provided in Supplementary File 3. Morahan framework Most of the interventions (24/27) sought to “equip the women”, enhancing their knowledge and skills to enable them to advance their careers in academic medicine ( 40 – 47 , 49 – 51 , 54 – 66 ). Seven interventions sought to “create equal opportunities for women”, e.g., through developing departmental-level initiatives to improve female faculty’s career advancement ( 41 , 43 , 49 , 53 , 54 , 63 , 64 ). Eight interventions sought to “value relational skills and increase visibility”, e.g., through creating networking opportunities ( 40 , 41 , 43 , 49 – 51 , 54 , 59 ). Ten interventions sought to assess and revise workplace culture, e.g., training interventions to reduce implicit bias ( 40 , 41 , 43 , 44 , 48 , 49 , 52 – 54 , 64 ) (Table 3). Interventions pre-, during and post-pandemic Only one paper described an intervention that ran during the COVID pandemic ( 40 ). This intervention had been in place since 2015 and the authors did not describe the effects of the pandemic in their paper. No studies described interventions specifically designed to mitigate the effects of the pandemic on women’s academic productivity. Reported outcomes The most frequently used approach to data collection (n = 18) was feedback from faculty or participants either via a survey or interviews/focus groups ( 41 , 42 , 44 , 45 , 47 – 51 , 55 – 59 , 61 – 63 , 66 ). Three studies reported on data gathered from faculty rosters and databases ( 43 , 46 , 60 ), one study reported on publication data gathered from CVs and as search engines (PubMed and Ovid), and five combined data from surveys with other sources e.g., publications, hiring outcomes ( 40 , 52 – 54 , 64 ). The 12 papers reporting CDPs, leadership, or academic skills development programmes generally reported positive findings. Of these, 9 studies reported subjective findings such as self-reported increase in knowledge and competencies ( 44 , 50 , 51 , 55 – 59 , 66 ). Two of the remaining studies compared retention and promotion rates among women who participated in CDPs with female non-participants and male faculty ( 46 , 60 ) and produced statistically significant results. However, it is noted that women are nominated by their institutions to participate in these CDPs, and are likely to already be on track for leadership positions. Further, data on confounding factors such as participation in other CDPs was not available. The final study, describing a writing group for women, reported an increased publication rate after the intervention compared to before, however there was no comparator group ( 65 ). Of the 5 mentorship programmes, 4 reported positive findings based on subjective measures such as self-reported increase in skills and participant feedback ( 45 , 61 – 63 ), with some also noting academic output albeit without a comparator group. The 2 papers reporting on women-focussed professional organisations relied primarily on feedback from participants, which was generally positive ( 47 , 49 ). The remaining mentorship study reported statistically significant improvements in measures for job-related anxiety-contentment, self-esteem and self-efficacy ( 42 ). Of the 5 multi-faceted interventions, 4 reported objective measures including employment data and academic productivity with a comparator group, or a combination of objective data with participant feedback ( 40 , 43 , 62 , 64 ). Findings from these studies tended to be more mixed, with two reporting improvements in staff satisfaction and female representation ( 40 , 62 ), and the remaining two reporting no statistically significant improvement in female clinical academic employment ( 43 ), or other key measures including academic productivity ( 64 ). The final paper describing a multi-faceted intervention (Athena SWAN) was a qualitative study which reported positive impacts but also noted potential negative effects such as the disproportionate allocation of Athena-SWAN related work to female faculty, potential reinforcement of gender-based stereotypes, and a failure to challenge the underlying societal issues such as gendered divisions of labour ( 41 ). The 2 papers describing diversity or implicit bias training also reported positive findings: one reported a statistically significant decrease in implicit bias associating men with leadership, although this was immediately after the intervention, and the study lacked a control group ( 48 ). Another study looking at the effects of diversity training for faculty search committees reported statistically significant increases in hiring women faculty among participating departments ( 53 ). Lastly, the paper describing an educational campaign to raise awareness of family friendly policies reported an increased awareness of the policies but no improvement in the hiring or advancement of female academics ( 52 ). (Table 3). Study quality Studies scored an average of 20.19 out of a maximum possible score of 39 using the QUADS tool ( 39 ). Studies scored well on describing the study population and research setting, using appropriate data collection tools and analytic methods, but scored poorly on providing evidence that research stakeholders were consulted in research design and conduct, in providing a justification for the choice of analytic methods, and in describing the sampling approach in adequate detail. A full description of the QUADS score for each study is provided in Supplemental File 3. Discussion Gender inequality in academic medicine has been recognised for decades ( 1 ), but progress is slow ( 6 , 29 ), and has been set back even further by COVID ( 19 – 26 ), with the time to reach gender parity increasing by nearly 40 years since the pandemic ( 67 ). We report on findings from 27 studies describing interventions to improve gender equality in academic medicine published between 2008 and 2022. We found that the evidence supporting gender equality initiatives in academic medicine is scant, with few examples of unequivocal success. CDPs and leadership programmes for women, mentorship programmes and women’s support groups are popular and tended to report positive findings, but many of these studies relied on subjective measures ( 44 , 45 , 47 , 49 – 51 , 55 – 59 , 61 – 63 , 66 ). Multi-faceted interventions provided more objective evidence, but only 2 of the 5 studies reported statistically significant improvements in the representation of women faculty ( 40 , 54 ). Overall, as other reviews found ( 32 , 33 ), the quality of the studies included was low to moderate, with only 4 scoring > 66% using the QUADS tool ( 43 , 48 , 56 , 64 ). None of the studies fulfilled all 12 items on the TIDieR checklist: in particular only 2 papers provided information on intervention adherence or fidelity ( 41 , 64 ), and only 1 paper cited specific theories which were used to inform the development of their intervention ( 50 ). There may be several reasons why gender equality interventions in academic medicine have not achieved their desired impact. Firstly, medical professionals have recently been shown to over-estimate women’s true representation in different fields and at different ranks. This over-estimation can be associated with reduced support for gender-based initiatives, especially among male medical professionals ( 68 ). These findings may be part of a concerning trend occurring more broadly: 46% of > 20,000 adults surveyed across 30 countries agreed that we have gone so far in promoting women’s equality that we are discriminating against men ( 69 ). Relations between majority and minority groups tend to be viewed as a zero-sum game. The perception that bias against women is reducing and their success is rising can be interpreted as evidence that bias against men is rising and their success declining. This perception threatens men’s self-interest and can give the impression that an organisation’s practices violate meritocratic principles ( 70 ). Individuals are unlikely to support interventions that they perceive as being disadvantageous to them and fundamentally unjust. Gender equality can be seen as a “women’s issue”, and the responsibility of solving the issue left to women ( 35 ), creating an effect similar to minority tax experienced by those who are under-represented in medicine (URiM)( 71 ). The majority of interventions described above not only relied on women to implement and participate in, but also aimed to “equip the women” ( 40 – 47 , 49 – 51 , 54 – 66 ). Sending the message that women need help to achieve high levels of career success suggests that they inherently lack competence, and can result in increased discrimination ( 70 ). Moreover, interventions aimed at equipping women may fail to address the organisational and systemic factors that underpin inequality. Creating “institutional housekeeping” by leaving the work of solving gender equality to women faculty is not desirable, but interventions implemented from the top down, i.e., from organisational levels or external bodies, can also have unforeseen consequences. Organisations can engage in a type of “window dressing”, this involves creating an air of change but without taking action to produce true change, such as including the voices of minoritized staff in developing diversity initiatives ( 72 ). The imposition of external rewards or threats for achieving equality may reduce faculty’s intrinsic motivation to engage in equality-improving initiatives ( 70 , 73 ). Ultimately, practices aimed at enhancing equality cannot succeed when they co-exist with practices which undo equality. For example, training faculty search committees to identify more women candidates is futile if discriminatory practices exist at the hiring stage ( 72 ). Failure to consider unintended consequences and organisational practices which could undo equality initiatives, along with limited engagement with stakeholders could explain some of the mixed outcomes reported even for large multi-faceted interventions. Societal factors need to be considered too – in most countries, caring responsibilities still predominantly fall to women regardless of their occupation, and as seen during COVID, increased caring responsibilities translate to a significant barrier to women’s participation in the workplace on an equal footing to men ( 67 , 74 ). During the pandemic, this was shown to be particularly acute for women who occupy other groups who are URiM ( 26 ). Societal change, e.g., improved access to formal care services and more equitable distribution of caring responsibilities between men and women is needed alongside organisational change to facilitate gender equality in the workplace. Only 4 of the studies included in this review were published since 2020 (14.8%). Among these, only one described an intervention that ran during COVID, although the authors did not describe the effects of COVID on their programme ( 40 ), so there was not sufficient evidence to compare interventions pre, during and post-COVID. The lack of studies from the COVID-19 period may be due to publication delays. An alternative explanation is that interventions did not run during the pandemic, or people could not engage with them, and new interventions were not implemented. During the pandemic, physicians, especially those on the front line, experienced significant impacts on their psychological and physical health, and women were more likely than men to report emotional exhaustion and physical symptoms ( 75 ). Of the 27 papers included in this review, only 5 describe interventions which did not rely almost entirely on women faculty for either delivery, participation or both ( 48 , 52 – 54 , 64 ). During the pandemic, women faculty may not have the capacity to engage with initiatives to enhance gender equality, highlighting one of the problems with relying on women to solve the gender equality problem. Limitations Although an exhaustive search was conducted, some studies might have been missed, particularly those published in languages other than English, possibly explaining the predominance of interventions from the USA. Publication bias could also be an issue, and most of our studies reported positive findings. Another consideration is that our search was focussed on health care literature, and we excluded studies which described interventions aimed at groups other than physicians, so potentially successful interventions which included other groups are not reflected here. Lastly, we did not consider other groups who are traditionally URiM, and therefore intersectionality is not considered in this review. Recommendations and future research A different approach is needed if we are to reinvigorate the goal of gender equality in academic medicine and apply the lessons learned during COVID. We suggest that organisations take a more holistic view of integrating equality practices. Context is important, and unintended consequences need to be carefully considered. We suggest moving away from interventions that rely on women for their implementation, and those that seek to “fix the women”. A rigorous study might be one where the focus is on the organisational and systemic practices that enhance equality – and those that undo it. Engaging with stakeholders and in particular, minoritized groups, from planning through to evaluation is critical. Researchers might draw on theoretical frameworks, for example, those which conceptualise organisational change and facilitate a structured approach, such as Lewin’s Change Theory ( 76 ) or Kotter’s Eight-Step Model ( 77 ). When practices work well, we suggest that they are shared in sufficient detail that will allow other organisations to modify and implement them; authors could consider the use of a reporting framework such as TIDieR ( 38 ). Sending a strong signal that diversity benefits all and a true meritocracy addresses inequity will be key to garnering continued support. Research that builds on the evidence for the benefits of diversity and equity, considers intersectionality, explores the perspectives of minoritized faculty and highlights the kinds of organisational practices that undo equality will be needed if we are to finally achieve gender parity. Abbreviations AAMC Association of American Medical Colleges AAU Addis Ababa University CDP Career Development Programme CV Curriculum Vitae ELAM Executive Leadership in Academic Medicine programme EWIM Early-career Women in Medicine Career Development Programme HEIs Higher Education Institutions JAMA Journal of the American Medical Association MWIM Mid-career Women in Medicine Career Development Programme PACSWF Provost’s Advisory Committee on the Status of Women Faculty PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses QUADS Quality Appraisal for Diverse Studies REDE Recruitment to Expand Diversity and Excellence SAT Self-Assessment Team TIDieR Template for Intervention Description and Replication URiM Under-represented in Medicine WIR Women in Radiology group Declarations Ethics approval and consent to participate Ethics approval and consent are not required for a systematic review of the literature Availability of data and materials All data generated or analysed during this study are included in this published article [and its supplementary information files] Competing interests The authors declare they have no competing interests Funding No specific funding was awarded for this study Author’s contributions EB made substantial contributions to the study conception, study design, data acquisition, analysis and interpretation and drafted the manuscript. CD, CK, IMGT, NS and MH made substantial contributions to the study conception, study design, data acquisition, analysis and interpretation and revised the manuscript. DM made substantial contributions to the study conception, study design and data acquisition. All authors have approved the submitted version and agree to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. References Bickel J (1988) Women in Medical Education. N Engl J Med 319(24):1579–1584 Fried LP, Francomano CA, MacDonald SM, Wagner EM, Stokes EJ, Carbone KM et al (1996) Career development for women in academic medicine: Multiple interventions in a Department of Medicine. 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NWSA J 16(1):194–206 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71 Morahan PS, Rosen SE, Richman RC, Gleason KA (2011) The leadership continuum: A framework for organizational and individual assessment relative to the advancement of women physicians and scientists. J Women's Health 20(3):387–396 Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D et al (2014) Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ: Br Med J 348:g1687 Harrison R, Jones B, Gardner P, Lawton R (2021) Quality assessment with diverse studies (QuADS): an appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies. BMC Health Serv Res 21(1):144 Tomblinson CM, Snyder EJ, Huggett M, Bagga A, Spottswood SE, Omary RA et al (2022) Five Years Later: Impact of a Focused Women in Radiology Program. J Am Coll Radiol 19(2):389–400 Caffrey L, Wyatt D, Fudge N, Mattingley H, Williamson C, McKevitt C (2016) Gender equity programmes in academic medicine: A realist evaluation approach to Athena SWAN processes. BMJ Open ;6(9) Dutta R, Hawkes SL, Kuipers E, Guest D, Fear NT, Iversen AC (2011) One year outcomes of a mentoring scheme for female academics: a pilot study at the Institute of Psychiatry, King's College London. BMC Med Educ 11(1):13 Gregory-Smith I The impact of Athena SWAN in UK medical schools. Report. University, of, Sheffield; 2015 March 2015. Report No.: 2015010 Kvach E, Yesehak B, Abebaw H, Conniff J, Busse H, Haq C (2017) Perspectives of female medical faculty in Ethiopia on a leadership fellowship program. Int J Med Educ 8:314–323 Files JA, Blair JE, Mayer AP, Ko MG (2008) Facilitated peer mentorship: a pilot program for academic advancement of female medical faculty. J Womens Health (Larchmt) 17(6):1009–1015 Chang S, Morahan PS, Magrane D, Helitzer D, Lee HY, Newbill S et al (2016) Retaining faculty in academic medicine: The impact of career development programs for women. J Women's Health 25(7):687–696 Gaetke-Udager K, Knoepp US, Maturen KE, Leschied JR, Chong S, Klein KA et al (2018) A Women in Radiology Group Fosters Career Development for Faculty and Trainees. Am J Roentgenol 211(1):W47–W51 Girod S, Fassiotto M, Grewal D, Ku MC, Sriram N, Nosek BA et al (2016) Reducing Implicit Gender Leadership Bias in Academic Medicine With an Educational Intervention. Acad Med 91(8):1143–1150 Lin MP, Lall MD, Samuels-Kalow M, Das D, Linden JA, Perman S et al (2019) Impact of a Women-focused Professional Organization on Academic Retention and Advancement: Perceptions From a Qualitative Study. Acad Emerg Med 26(3):303–316 Pelfrey CM, Cola PA, Gerlick JA, Edgar BK, Khatri SB (2022) Breaking Through Barriers: Factors That Influence Behavior Change Toward Leadership for Women in Academic Medicine. Front Psychol. ;13 Spalluto LB, Spottswood SE, Deitte LA, Chern A, Dewey CM (2017) A Leadership Intervention to Further the Training of Female Faculty (LIFT-OFF) in Radiology. Acad Radiol 24(6):709–716 Villablanca AC, Li Y, Beckett LA, Howell LP (2017) Evaluating a Medical School's Climate for Women's Success: Outcomes for Faculty Recruitment, Retention, and Promotion. J Women's Health 26(5):530–539 Sheridan JT, Fine E, Pribbenow CM, Handelsman J, Carnes M (2010) Searching for excellence & diversity: Increasing the hiring of women faculty at one academic medical center. Acad Med 85(6):999–1007 Valantine HA, Grewal D, Ku MC, Moseley J, Shih MC, Stevenson D et al (2014) The gender gap in academic medicine: Comparing results from a multifaceted intervention for stanford faculty to peer and national cohorts. Acad Med 89(6):904–911 Chaudron LH, Anson E, Bryson Tolbert JM, Inoue S, Cerulli C (2021) Meeting the Needs of Mid-Career Women in Academic Medicine: One Model Career Development Program. J Women's Health 30(1):45–51 Dannels SA, Yamagata H, McDade SA, Chuang Y-C, Gleason KA, McLaughlin JM et al (2008) Evaluating a Leadership Program: A Comparative, Longitudinal Study to Assess the Impact of the Executive Leadership in Academic Medicine (ELAM) Program for Women. Acad Med 83(5):488–495 Helitzer DL, Newbill SL, Morahan PS, Magrane D, Cardinali G, Wu CC et al (2014) Perceptions of skill development of participants in three national career development programs for women faculty in academic medicine. Acad Med 89(6):896–903 Helitzer DL, Newbill SL, Cardinali G, Morahan PS, Chang S, Magrane D (2016) Narratives of participants in national career development programs for women in academic medicine: Identifying the opportunities for strategic investment. J Women's Health 25(4):360–370 Levine RB, González-Fernández M, Bodurtha J, Skarupski KA, Fivush B (2015) Implementation and evaluation of the Johns Hopkins University School of Medicine leadership program for women faculty. J Womens Health (Larchmt) 24(5):360–366 Chang S, Guindani M, Morahan P, Magrane D, Newbill S, Helitzer D (2002) Increasing Promotion of Women Faculty in Academic Medicine: Impact of National Career Development Programs. Journal of women's health 2020;29(6):837 – 46 Mayer AP, Blair JE, Ko MG, Patel SI, Files JA (2014) Long-term follow-up of a facilitated peer mentoring program. Med Teach 36(3):260–266 Varkey P, Jatoi A, Williams A, Mayer A, Ko M, Files J et al (2012) The positive impact of a facilitated peer mentoring program on academic skills of women faculty. BMC Med Educ 12(1):14 Voytko ML, Barrett N, Courtney-Smith D, Golden SL, Hsu FC, Knovich MA et al (2018) Positive Value of a Women's Junior Faculty Mentoring Program: A Mentor-Mentee Analysis. J Women's Health 27(8):1045–1053 Grisso JA, Sammel MD, Rubenstein AH, Speck RM, Conant EF, Scott P et al (2017) A Randomized Controlled Trial to Improve the Success of Women Assistant Professors. J Womens Health 26(5):571–579 Sonnad SS, Goldsack J, McGowan KL (2011) A Writing Group for Female Assistant Professors. J Natl Med Assoc 103(9):811–815 Von Feldt JM, Bristol M, Sonnad S, Abbuhl S, Scott P, McGowan KL (2009) The Brief CV Review Session: One Component of a Mosaic of Mentorship for Women in Academic Medicine. J Natl Med Assoc 101(9):873–880 World (2021) Economics, Forum. Global Gender Gap Report, Geneva, Switzerland: World Economic Forum; 2021 Begeny CT, Grossman RC, Ryan MK (2022) Overestimating women's representation in medicine: a survey of medical professionals' estimates and their(un)willingness to support gender equality initiatives. BMJ Open 12(3):e054769 Ipsos (2024) Global Attitudes Towards Women's Leadership. King's Global Institute for Women's Leadership, King's College London, Ipsos; March 2024 Leslie LM (2019) Diversity Initiative Effectiveness: A Typological Theory of Unintended Consequences. Acad Manage Rev 44(3):538–563 Rodríguez JE, Campbell KM, Pololi LH (2015) Addressing disparities in academic medicine: what of the minority tax? BMC Med Educ 15(1):6 Grzelec A (2024) Doing gender equality and undoing gender inequality—A practice theory perspective. Gend Work Organ 31(3):749–767 Ryan RM, Deci EL (2000) Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol 55(1):68–78 Equality EIfG (2023) A better work–life balance – Bridging the gender care gap. Publications Office of the European Union Barello S, Palamenghi L, Graffigna G (2020) Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry Res 290:113129 Lewin K (1947) Frontiers in Group Dynamics: Concept, Method and Reality in Social Science; Social Equilibria and Social Change. Hum Relat 1(1):5–41 Kotter JP (1995) Leading Change: Why Transformation Efforts Fail. HArvard Buisness Review. May-June 1995 Additional Declarations The authors declare potential competing interests as follows: No, I declare that authors have no interests, affiliations, or associations that might be perceived to influence the results and/or discussion reported in this preprint submission. Supplementary Files SupplementaryFile1PRISMAchecklist.docx Supplementary File 1 PRISMA Checklist SupplementaryFile2SearchStrategy.docx Supplementary File 2 Search Strategy SupplementaryFile3TIDieRFramework.xlsx Supplementary File 3 TIDieR Framework SupplementaryFile4QUADSAssessment.xlsx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5103072","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":355218369,"identity":"e42b3439-f9f7-4d81-9e02-0a3fb21309c3","order_by":0,"name":"Elaine 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learned? A systematic review.\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eIn 1988, it was noted that the number of women medical faculty at junior academic grades was increasing rapidly, but this effect was not seen at senior grades (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Eight years later, in 1996, JAMA published a landmark paper describing the successful implementation of a multi-faceted intervention addressing gender inequality in academic medicine, reporting a 550% increase in the number of women associate professors over 5 years (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The future looked hopeful \u0026ndash; surely the increase in women entering medicine, along with effective strategies for recruitment and retention, would eventually translate into more women at leadership level. Decades later, this hope has not been realised \u0026ndash; women continue to enter medicine at high levels, exceeding the rate of male entrants in the US in 2017 (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), yet remain underrepresented at the highest levels. Women make up 28.4% of full professors at US medical schools (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), 30% of professors in UK Higher Education Institutions (HEIs) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and occupy 26.2% of posts at the highest grade of academic staff in HEIs in 28 EU countries (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe reasons for this disparity are complex. Many factors have been described: women in medicine are exposed to stereotypes associating women with family and men with careers (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), research funding applications are viewed less favourably when the PI is a woman (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), women are significantly less likely than their male peers to be credited as an author on a research paper (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e), and a vicious cycle exists whereby women occupy lower academic ranks, have access to fewer resources and are therefore less productive, reinforcing stereotypes that women do not belong at higher academic levels (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Pay disparities remain pervasive (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), and sexual and gender-based harassment directed against women in medicine and surgery is prevalent (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). These and other factors combine to create a culture that is not conducive to women\u0026rsquo;s career advancement, in spite of evidence for the benefits of gender equality: groups with more women have higher collective intelligence (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), Fortune 500 companies with female CEOs are more profitable (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), and gender heterogenous research teams produce better quality research (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). From an economic perspective, failure to achieve equitable participation in academic medicine represents a loss of talent (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), a serious concern for a workforce already at risk of becoming an \u0026ldquo;endangered species\u0026rdquo; (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe situation was exacerbated by the COVID-19 pandemic. As early as May 2020, data from preprint servers showed that across disciplines, women\u0026rsquo;s publishing rate had fallen relative to men\u0026rsquo;s. This was attributed to increased caregiving responsibilities during the pandemic, and the effect of shifting to online work. This shift simultaneously increased the workload associated with teaching, disproportionately affecting women, and decreased the workload associated with hiring and curriculum committees \u0026ndash; disproportionately affecting men, and releasing time to write research papers (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This gap in academic productivity during the pandemic was particularly pronounced for women in health and medicine (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Female faculty physicians at a children\u0026rsquo;s hospital were significantly more likely to report decreased academic productivity during the pandemic compared to male colleagues, and this was attributed primarily to unreliable childcare (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Physicians on the front line were particularly vulnerable to negative impacts on psychological health, disruptions in research training and support systems including childcare, with a resultant impact on academic productivity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Female faculty at an academic medical centre in the US were twice as likely to have considered leaving academic medicine since the onset of COVID-19 compared to before (28% vs. 17%) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Women from less gender-equal countries with higher COVID-related mortality, and those from other groups who are under-represented in academic medicine, e.g., racially and ethnically marginalized groups, experienced the greatest impact on academic productivity (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile there are many papers highlighting the issue of gender inequality across an array of specialties (\u003cspan additionalcitationids=\"CR28 CR29 CR30\" citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), and a variety of solutions proposed, few provide evidence for successful interventions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Furthermore, the evidence that does exist is often weak and lacking in methodological rigor. A systematic review of papers focused on interventions to improve outcomes for women in any field of academia found only 18 studies that met the criteria for full review, and the overall quality was low to moderate (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Another systematic review of gender-concordant mentoring found a reliance on weak study designs; the authors cautioned against the use of interventions that seek to \u0026ldquo;fix the women\u0026rdquo; while inadvertently reinforcing gender-based stereotypes (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). This type of intervention, which relies on senior female faculty for its delivery, could be considered \u0026ldquo;institutional housekeeping\u0026rdquo;, i.e., the supportive labour of women to improve women\u0026rsquo;s situation in their institution, and which, like other forms of \u0026ldquo;women\u0026rsquo;s work\u0026rdquo;, may be unrecognised and unrewarded (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), paradoxically worsening the situation for women, albeit unintentionally.\u003c/p\u003e \u003cp\u003eThe aim of this systematic review is to describe the current evidence for interventions to enhance gender equality in recruitment and promotion in academic medicine. We also set out to compare interventions pre, during and post-COVID-19, and explore whether any specific interventions were implemented to mitigate the effects of the pandemic. Lastly, we wished to characterise the nature of the interventions, who delivered them, and whether they seek to \u0026ldquo;fix the women\u0026rdquo;, or target issues at organisational and systemic levels.\u003c/p\u003e \u003cp\u003eMethods\u003c/p\u003e \u003cp\u003eWe drafted a protocol and registered our review with Prospero [CRD42023391086]. We report our findings according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Supplementary File 1) (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSearch Strategy\u003c/p\u003e \u003cp\u003eA search strategy was developed with a medical librarian (DM) for 5 databases (MEDLINE, OVID, Embase, CINAHL, Web of Science, Google Scholar) and conducted in November 2022, repeated in August 2023. Hand searching was undertaken in August-September 2023. The full search strategy is available in Supplementary File 2. English language papers up to 15 years old were included.\u003c/p\u003e \u003cp\u003eEligibility Criteria\u003c/p\u003e \u003cp\u003eThe review sought studies on new interventions implemented with the aim of improving recruitment, retention and promotion for female clinical academics (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInclusion and Exclusion Criteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of studies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQualitative or quantitative original studies published in full including:\u003c/p\u003e \u003cp\u003e\u0026bull; Interviews/focus groups\u003c/p\u003e \u003cp\u003e\u0026bull; Surveys\u003c/p\u003e \u003cp\u003e\u0026bull; Randomised control trials\u003c/p\u003e \u003cp\u003e\u0026bull; Quasi-experimental pre- and post-intervention evaluations\u003c/p\u003e \u003cp\u003eWe excluded conference papers, papers in languages other than English, book chapters, opinion pieces, perspectives, commentaries and editorials, and studies reporting secondary data, e.g., systematic reviews and meta-analyses\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSchools/Faculties of Medicine in Higher Level Institutions or sub-divisions, e.g., clinical Departments or disciplines. We included interventions where the setting was unclear (e.g., possibly hospital-based) when they were aimed at clinical academic medical faculty.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe population of interest were female clinical academics/physician scientists, or faculty within medical schools. We included some studies which were aimed at female physician scientists but also included non-physician clinical academics, and studies where it was not clear whether all participants held a dual clinical and academic role or single academic role, as long as the setting was academic on the basis that clinical academics/physician scientists could also benefit from the intervention.\u003c/p\u003e \u003cp\u003eWe excluded studies whose participants were full-time clinicians or undergraduate students and studies where the intervention was not specifically targeted at women.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAny new intervention designed to enhance gender equality in recruitment, retention or promotion in academic medicine, e.g., unconscious bias training for faculty and hiring committees, mentoring programmes etc.\u003c/p\u003e \u003cp\u003eWe excluded studies where no evaluation took place or outcomes were not reported, and evaluations of pre-existing practices.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutcomes could include measurements of success of female candidates applying for academic roles or promotions, research productivity, retention of female clinical academic staff and satisfaction with career progression.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStudy selection processes\u003c/p\u003e \u003cp\u003eStudy eligibility was assessed by five authors (EB, MGT, CK, MH and NS) using Covidence software. Each title and abstract was independently screened by two authors. Articles\u0026rsquo; full texts were screened by four authors (EB, MGT, CK and NS) with each full text being screened independently by two authors. Discrepancies were resolved by discussion and involvement with a third author where necessary (EB or MH). Search, screening and selection results are shown in the PRISMA diagram (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData extraction\u003c/p\u003e \u003cp\u003eData was extracted by EB using an Excel data extraction form designed specifically for this study. The following data were extracted: first author, year of publication, place of publication, pre/during COVID, participants, study type, intervention type, duration of intervention, classification of intervention, and results. Interventions were classified according to Morahan et al\u0026rsquo;s framework for organisational and individual assessment relative to the advancement of women physicians and scientists (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e), (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This framework was chosen because it was developed specifically for academic medicine, and is based on a model of integrated leadership which starts at the early career stage through leadership roles. A second researcher, MGT, applied the data extraction tool to a subset of 7 studies and found significant agreement with EB\u0026rsquo;s findings for these studies, thereafter EB applied the tool to the remaining 20 studies.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFramework for gender equality in academic medicine\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitutionally based approaches to women\u0026rsquo;s advancement (Morahan et al (37))\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEquip the women\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCreate equal opportunities\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValue relational skills and increase visibility\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAssess and revise work culture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo provide a complete description of the nature of the interventions, we applied the TIDieR (Template for Intervention Description and Replication) framework. TIDieR is a 12 item checklist (brief name, why, what (materials), what (procedure), who provided, how, where, when and how much, tailoring, modifications, how well (planned), how well (actual)) which can be applied to all evaluative study designs (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). EB applied the framework to all studies; three other authors (CK, CD and MGT) each independently applied the framework to three sub-sets of studies and findings were collated; major discrepancies were resolved through discussion.\u003c/p\u003e \u003cp\u003eData synthesis\u003c/p\u003e \u003cp\u003eDue to the small number of studies retrieved and their significant heterogeneity regarding outcomes measured, interventions, control group and statistical analysis, it was not possible to perform a meta-analysis.\u003c/p\u003e \u003cp\u003eQuality assessment\u003c/p\u003e \u003cp\u003eQuality assessment was undertaken using the Quality Appraisal for Diverse Studies (QUADS) tool. The QUADS tool was chosen because it has been developed for use in systematic reviews that include qualitative, quantitative and mixed-methods studies, and has been shown to demonstrate substantial inter-rater reliability, and content and face validity (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). All 27 studies were assessed using QUADS by EB. A subset of studies (n\u0026thinsp;=\u0026thinsp;4) were assessed independently by two other authors (MGT and CD). Discrepancies were resolved through discussion where needed.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe search of electronic databases yielded 1,747 studies. A further 62 were identified through hand-searching. Following removal of duplicates, 764 articles were screened for eligibility, and 199 full-text articles were screened. Of these, 27 met the inclusion criteria (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCharacteristics of included studies\u003c/p\u003e \u003cp\u003eStudies were published between 2008 and 2022. One study took place both before and during the COVID-19 pandemic (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), with the remaining studies all taking place before the pandemic. Three took place in the UK (\u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), one took place in both the USA and Ethiopia (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), and the remainder took place in the USA. Sample sizes ranged from 4 participants (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) to 3,268 participants (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEleven interventions were aimed at all or multiple levels of academic rank (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan additionalcitationids=\"CR48 CR49 CR50 CR51 CR52 CR53\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), seven were aimed at mid-career and/or senior faculty (assistant professor to full professor) (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58 CR59\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e), four were aimed at early and mid-career faculty (instructor to assistant professor) (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), three were aimed at assistant professor level only (\u003cspan additionalcitationids=\"CR65\" citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), and two were aimed at junior faculty (instructor, senior lecturer and lower) (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e) (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eInterventions\u003c/p\u003e \u003cp\u003eThe most commonly reported intervention, (10/27 papers) consisted of career development programmes (CDPs) and leadership skills programmes (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58 CR59\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) with two interventions aimed specifically at developing specific skills for career advancement e.g., Curriculum Vitae (CV) preparation (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Five of the papers were written about 3 national CDPs for women in academic medicine in the USA: the Association of American Medical College\u0026rsquo;s (AAMC) Early and Mid-Career Women in Medicine Programmes (EWIM and MWIM) and Drexel University\u0026rsquo;s Hedwig van Ameringen Executive Leadership in Academic Medicine (ELAM) programme (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Two papers describe findings at 1 and 5 years from a leadership development programme for women in radiology (LIFT-OFF) at Vanderbilt University Medical Centre, Nashville, Tennessee (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eInterventions aimed at more junior faculty tended to take the form of mentoring programmes (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e). Mentoring took the form of facilitated peer mentoring in three studies (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e); two of these studies report on the same mentorship programme after the pilot phase and longer term follow-up over approximately 4 years (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Other mentoring programmes followed a more traditional dyadic approach with a senior faculty member matched to a junior member (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFive interventions were multi-faceted and included activities such as CDPs combined with departmental task forces, a review of current hiring strategies, and provision of research funding for assistant professors (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Two interventions involved the development of women-focussed groups and organisations (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) and one intervention consisted of an educational campaign to raise awareness and acceptance of family-friendly policies (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Two interventions comprised diversity or implicit bias training for faculty and faculty search committees (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Interventions varied in their duration from \u0026ldquo;brief\u0026rdquo; (15\u0026ndash;30 minutes) to years-long (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eTIDieR Framework\u003c/p\u003e \u003cp\u003eNone of the papers provided sufficient detail to fulfil all 12 items on the TIDieR checklist. In particular, few reported on tailoring (if the intervention was planned to be personalised, titrated or adapted), modifications, intervention adherence or fidelity, or the extent to which the intervention was delivered as planned. Further, while most authors provided a rationale for their approach, only one cited specific theories which informed the intervention design (Resonant Leadership, Social Cognitive Theory and Social Network Theory)(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eIntervention providers were senior faculty in 7 papers (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR64\" citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e). Five of the interventions, predominantly mentorship programmes, relied on female faculty for their delivery (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Five interventions used internal and/or external expertise in their delivery (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Two papers describe the Athena SWAN programme which involves faculty at all levels (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). One multi-faceted intervention relied on senior faculty, local and national experts and institutional leadership (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). The remaining seven studies did not specifically describe the intervention providers (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan additionalcitationids=\"CR57\" citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eModes of delivery of the intervention were highly variable and included 1:1 or 1:2 face to face sessions (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e), small group sessions with interactive workshops, case-based discussions, book clubs and paired discussions (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), annual summits and lectureships (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e), and online modules (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA detailed description of each intervention and the TIDieR Framework is provided in Supplementary File 3.\u003c/p\u003e \u003cp\u003eMorahan framework\u003c/p\u003e \u003cp\u003eMost of the interventions (24/27) sought to \u0026ldquo;equip the women\u0026rdquo;, enhancing their knowledge and skills to enable them to advance their careers in academic medicine (\u003cspan additionalcitationids=\"CR41 CR42 CR43 CR44 CR45 CR46\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR55 CR56 CR57 CR58 CR59 CR60 CR61 CR62 CR63 CR64 CR65\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeven interventions sought to \u0026ldquo;create equal opportunities for women\u0026rdquo;, e.g., through developing departmental-level initiatives to improve female faculty\u0026rsquo;s career advancement (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Eight interventions sought to \u0026ldquo;value relational skills and increase visibility\u0026rdquo;, e.g., through creating networking opportunities (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Ten interventions sought to assess and revise workplace culture, e.g., training interventions to reduce implicit bias (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e) (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eInterventions pre-, during and post-pandemic\u003c/p\u003e \u003cp\u003eOnly one paper described an intervention that ran during the COVID pandemic (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). This intervention had been in place since 2015 and the authors did not describe the effects of the pandemic in their paper. No studies described interventions specifically designed to mitigate the effects of the pandemic on women\u0026rsquo;s academic productivity.\u003c/p\u003e \u003cp\u003eReported outcomes\u003c/p\u003e \u003cp\u003eThe most frequently used approach to data collection (n\u0026thinsp;=\u0026thinsp;18) was feedback from faculty or participants either via a survey or interviews/focus groups (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan additionalcitationids=\"CR48 CR49 CR50\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Three studies reported on data gathered from faculty rosters and databases (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e), one study reported on publication data gathered from CVs and as search engines (PubMed and Ovid), and five combined data from surveys with other sources e.g., publications, hiring outcomes (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 12 papers reporting CDPs, leadership, or academic skills development programmes generally reported positive findings. Of these, 9 studies reported subjective findings such as self-reported increase in knowledge and competencies (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Two of the remaining studies compared retention and promotion rates among women who participated in CDPs with female non-participants and male faculty (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e) and produced statistically significant results. However, it is noted that women are nominated by their institutions to participate in these CDPs, and are likely to already be on track for leadership positions. Further, data on confounding factors such as participation in other CDPs was not available. The final study, describing a writing group for women, reported an increased publication rate after the intervention compared to before, however there was no comparator group (\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf the 5 mentorship programmes, 4 reported positive findings based on subjective measures such as self-reported increase in skills and participant feedback (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e), with some also noting academic output albeit without a comparator group. The 2 papers reporting on women-focussed professional organisations relied primarily on feedback from participants, which was generally positive (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). The remaining mentorship study reported statistically significant improvements in measures for job-related anxiety-contentment, self-esteem and self-efficacy (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOf the 5 multi-faceted interventions, 4 reported objective measures including employment data and academic productivity with a comparator group, or a combination of objective data with participant feedback (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Findings from these studies tended to be more mixed, with two reporting improvements in staff satisfaction and female representation (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e), and the remaining two reporting no statistically significant improvement in female clinical academic employment (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), or other key measures including academic productivity (\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). The final paper describing a multi-faceted intervention (Athena SWAN) was a qualitative study which reported positive impacts but also noted potential negative effects such as the disproportionate allocation of Athena-SWAN related work to female faculty, potential reinforcement of gender-based stereotypes, and a failure to challenge the underlying societal issues such as gendered divisions of labour (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 2 papers describing diversity or implicit bias training also reported positive findings: one reported a statistically significant decrease in implicit bias associating men with leadership, although this was immediately after the intervention, and the study lacked a control group (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Another study looking at the effects of diversity training for faculty search committees reported statistically significant increases in hiring women faculty among participating departments (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Lastly, the paper describing an educational campaign to raise awareness of family friendly policies reported an increased awareness of the policies but no improvement in the hiring or advancement of female academics (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). (Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eStudy quality\u003c/p\u003e \u003cp\u003eStudies scored an average of 20.19 out of a maximum possible score of 39 using the QUADS tool (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Studies scored well on describing the study population and research setting, using appropriate data collection tools and analytic methods, but scored poorly on providing evidence that research stakeholders were consulted in research design and conduct, in providing a justification for the choice of analytic methods, and in describing the sampling approach in adequate detail. A full description of the QUADS score for each study is provided in Supplemental File 3.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eGender inequality in academic medicine has been recognised for decades (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), but progress is slow (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), and has been set back even further by COVID (\u003cspan additionalcitationids=\"CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), with the time to reach gender parity increasing by nearly 40 years since the pandemic (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e). We report on findings from 27 studies describing interventions to improve gender equality in academic medicine published between 2008 and 2022.\u003c/p\u003e \u003cp\u003eWe found that the evidence supporting gender equality initiatives in academic medicine is scant, with few examples of unequivocal success. CDPs and leadership programmes for women, mentorship programmes and women\u0026rsquo;s support groups are popular and tended to report positive findings, but many of these studies relied on subjective measures (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR56 CR57 CR58\" citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan additionalcitationids=\"CR62\" citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Multi-faceted interventions provided more objective evidence, but only 2 of the 5 studies reported statistically significant improvements in the representation of women faculty (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). Overall, as other reviews found (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), the quality of the studies included was low to moderate, with only 4 scoring\u0026thinsp;\u0026gt;\u0026thinsp;66% using the QUADS tool (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). None of the studies fulfilled all 12 items on the TIDieR checklist: in particular only 2 papers provided information on intervention adherence or fidelity (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e), and only 1 paper cited specific theories which were used to inform the development of their intervention (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere may be several reasons why gender equality interventions in academic medicine have not achieved their desired impact. Firstly, medical professionals have recently been shown to over-estimate women\u0026rsquo;s true representation in different fields and at different ranks. This over-estimation can be associated with reduced support for gender-based initiatives, especially among male medical professionals (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e). These findings may be part of a concerning trend occurring more broadly: 46% of \u0026gt;\u0026thinsp;20,000 adults surveyed across 30 countries agreed that we have gone so far in promoting women\u0026rsquo;s equality that we are discriminating against men (\u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e). Relations between majority and minority groups tend to be viewed as a zero-sum game. The perception that bias against women is reducing and their success is rising can be interpreted as evidence that bias against men is rising and their success declining. This perception threatens men\u0026rsquo;s self-interest and can give the impression that an organisation\u0026rsquo;s practices violate meritocratic principles (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). Individuals are unlikely to support interventions that they perceive as being disadvantageous to them and fundamentally unjust.\u003c/p\u003e \u003cp\u003eGender equality can be seen as a \u0026ldquo;women\u0026rsquo;s issue\u0026rdquo;, and the responsibility of solving the issue left to women (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), creating an effect similar to minority tax experienced by those who are under-represented in medicine (URiM)(\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e). The majority of interventions described above not only relied on women to implement and participate in, but also aimed to \u0026ldquo;equip the women\u0026rdquo; (\u003cspan additionalcitationids=\"CR41 CR42 CR43 CR44 CR45 CR46\" citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan additionalcitationids=\"CR50\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan additionalcitationids=\"CR55 CR56 CR57 CR58 CR59 CR60 CR61 CR62 CR63 CR64 CR65\" citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Sending the message that women need help to achieve high levels of career success suggests that they inherently lack competence, and can result in increased discrimination (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). Moreover, interventions aimed at equipping women may fail to address the organisational and systemic factors that underpin inequality.\u003c/p\u003e \u003cp\u003eCreating \u0026ldquo;institutional housekeeping\u0026rdquo; by leaving the work of solving gender equality to women faculty is not desirable, but interventions implemented from the top down, i.e., from organisational levels or external bodies, can also have unforeseen consequences. Organisations can engage in a type of \u0026ldquo;window dressing\u0026rdquo;, this involves creating an air of change but without taking action to produce true change, such as including the voices of minoritized staff in developing diversity initiatives (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). The imposition of external rewards or threats for achieving equality may reduce faculty\u0026rsquo;s intrinsic motivation to engage in equality-improving initiatives (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e, \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e73\u003c/span\u003e). Ultimately, practices aimed at enhancing equality cannot succeed when they co-exist with practices which undo equality. For example, training faculty search committees to identify more women candidates is futile if discriminatory practices exist at the hiring stage (\u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e72\u003c/span\u003e). Failure to consider unintended consequences and organisational practices which could undo equality initiatives, along with limited engagement with stakeholders could explain some of the mixed outcomes reported even for large multi-faceted interventions.\u003c/p\u003e \u003cp\u003eSocietal factors need to be considered too \u0026ndash; in most countries, caring responsibilities still predominantly fall to women regardless of their occupation, and as seen during COVID, increased caring responsibilities translate to a significant barrier to women\u0026rsquo;s participation in the workplace on an equal footing to men (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e, \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e74\u003c/span\u003e). During the pandemic, this was shown to be particularly acute for women who occupy other groups who are URiM (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Societal change, e.g., improved access to formal care services and more equitable distribution of caring responsibilities between men and women is needed alongside organisational change to facilitate gender equality in the workplace.\u003c/p\u003e \u003cp\u003eOnly 4 of the studies included in this review were published since 2020 (14.8%). Among these, only one described an intervention that ran during COVID, although the authors did not describe the effects of COVID on their programme (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), so there was not sufficient evidence to compare interventions pre, during and post-COVID. The lack of studies from the COVID-19 period may be due to publication delays. An alternative explanation is that interventions did not run during the pandemic, or people could not engage with them, and new interventions were not implemented. During the pandemic, physicians, especially those on the front line, experienced significant impacts on their psychological and physical health, and women were more likely than men to report emotional exhaustion and physical symptoms (\u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e75\u003c/span\u003e). Of the 27 papers included in this review, only 5 describe interventions which did not rely almost entirely on women faculty for either delivery, participation or both (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). During the pandemic, women faculty may not have the capacity to engage with initiatives to enhance gender equality, highlighting one of the problems with relying on women to solve the gender equality problem.\u003c/p\u003e \u003cp\u003eLimitations\u003c/p\u003e \u003cp\u003eAlthough an exhaustive search was conducted, some studies might have been missed, particularly those published in languages other than English, possibly explaining the predominance of interventions from the USA.\u003c/p\u003e \u003cp\u003ePublication bias could also be an issue, and most of our studies reported positive findings. Another consideration is that our search was focussed on health care literature, and we excluded studies which described interventions aimed at groups other than physicians, so potentially successful interventions which included other groups are not reflected here. Lastly, we did not consider other groups who are traditionally URiM, and therefore intersectionality is not considered in this review.\u003c/p\u003e \u003cp\u003eRecommendations and future research\u003c/p\u003e \u003cp\u003eA different approach is needed if we are to reinvigorate the goal of gender equality in academic medicine and apply the lessons learned during COVID. We suggest that organisations take a more holistic view of integrating equality practices. Context is important, and unintended consequences need to be carefully considered. We suggest moving away from interventions that rely on women for their implementation, and those that seek to \u0026ldquo;fix the women\u0026rdquo;. A rigorous study might be one where the focus is on the organisational and systemic practices that enhance equality \u0026ndash; and those that undo it. Engaging with stakeholders and in particular, minoritized groups, from planning through to evaluation is critical. Researchers might draw on theoretical frameworks, for example, those which conceptualise organisational change and facilitate a structured approach, such as Lewin\u0026rsquo;s Change Theory (\u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e76\u003c/span\u003e) or Kotter\u0026rsquo;s Eight-Step Model (\u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e77\u003c/span\u003e). When practices work well, we suggest that they are shared in sufficient detail that will allow other organisations to modify and implement them; authors could consider the use of a reporting framework such as TIDieR (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSending a strong signal that diversity benefits all and a true meritocracy addresses inequity will be key to garnering continued support. Research that builds on the evidence for the benefits of diversity and equity, considers intersectionality, explores the perspectives of minoritized faculty and highlights the kinds of organisational practices that undo equality will be needed if we are to finally achieve gender parity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAAMC\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Association of American Medical Colleges\u003c/p\u003e\n\u003cp\u003eAAU\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Addis Ababa University\u003c/p\u003e\n\u003cp\u003eCDP\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Career Development Programme\u003c/p\u003e\n\u003cp\u003eCV\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Curriculum Vitae\u003c/p\u003e\n\u003cp\u003eELAM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Executive Leadership in Academic Medicine programme\u003c/p\u003e\n\u003cp\u003eEWIM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Early-career Women in Medicine Career Development Programme\u003c/p\u003e\n\u003cp\u003eHEIs\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Higher Education Institutions \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJAMA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Journal of the American Medical Association\u003c/p\u003e\n\u003cp\u003eMWIM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Mid-career Women in Medicine Career Development Programme\u003c/p\u003e\n\u003cp\u003ePACSWF\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Provost\u0026rsquo;s Advisory Committee on the Status of Women Faculty\u003c/p\u003e\n\u003cp\u003ePRISMA\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e\n\u003cp\u003eQUADS\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Quality Appraisal for Diverse Studies\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eREDE \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Recruitment to Expand Diversity and Excellence\u003c/p\u003e\n\u003cp\u003eSAT\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Self-Assessment Team\u003c/p\u003e\n\u003cp\u003eTIDieR\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Template for Intervention Description and Replication\u003c/p\u003e\n\u003cp\u003eURiM\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Under-represented in Medicine\u003c/p\u003e\n\u003cp\u003eWIR \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Women in Radiology group\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eEthics approval and consent are not required for a systematic review of the literature\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files]\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare they have no competing interests\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo specific funding was awarded for this study\u003c/p\u003e\n\u003ch2\u003eAuthor\u0026rsquo;s contributions\u003c/h2\u003e\n\u003cp\u003eEB made substantial contributions to the study conception, study design, data acquisition, analysis and interpretation and drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eCD, CK, IMGT, NS and MH made substantial contributions to the study conception, study design, data acquisition, analysis and interpretation and revised the manuscript.\u003c/p\u003e\n\u003cp\u003eDM made substantial contributions to the study conception, study design and data acquisition.\u003c/p\u003e\n\u003cp\u003eAll authors have approved the submitted version and agree to be personally accountable for the author\u0026rsquo;s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBickel J (1988) Women in Medical Education. 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Publications Office of the European Union\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarello S, Palamenghi L, Graffigna G (2020) Burnout and somatic symptoms among frontline healthcare professionals at the peak of the Italian COVID-19 pandemic. Psychiatry Res 290:113129\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewin K (1947) Frontiers in Group Dynamics: Concept, Method and Reality in Social Science; Social Equilibria and Social Change. Hum Relat 1(1):5\u0026ndash;41\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKotter JP (1995) Leading Change: Why Transformation Efforts Fail. HArvard Buisness Review. May-June 1995\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Trinity College Dublin","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Gender equality, equity, academic medicine, women faculty, retention, recruitment","lastPublishedDoi":"10.21203/rs.3.rs-5103072/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5103072/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGender disparity at senior levels in academic medicine has been recognised for decades, but progress has been slow and confounded further by the COVID pandemic. While there are many papers describing this problem, there is little evidence for potential solutions. We aimed to describe the current evidence for interventions to enhance gender equality in academic medicine, and to compare interventions pre, during and post-COVID-19. We also wished to characterise the nature of the interventions, who delivered them, and whether they seek to “fix the women”, or target issues at organisational and systemic levels.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe searched five electronic databases in November 2022 and August 2023 and undertook hand-searching. We extracted data using a form developed for the study, and applied the TIDieR and Morahan frameworks to describe and characterise interventions. We used the QUADs tool to critically appraise included studies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe search of electronic databases yielded 1,747 studies. A further 62 were identified through hand-searching. Following removal of duplicates, 764 articles were screened for eligibility, and 199 full-text articles were screened. Of these, 27 met the inclusion criteria.\u003c/p\u003e\n\u003cp\u003eThe most commonly reported interventions were career development or leadership skills programmes, followed by mentorship and multi-faceted interventions. Most papers reported positive findings, but many relied on subjective measures. \u0026nbsp;Robustly designed studies often reported mixed findings. The majority of interventions aimed to “fix the women”, with few addressing inequality at organisational level. We found no studies describing interventions aimed specifically at mitigating the effects of the COVID pandemic, and none describing the effects of the pandemic on their interventions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAcknowledging the possibility of publication delay, we found that despite strong evidence of the negative effects of the pandemic on women’s research productivity, there were no new interventions designed to mitigate this. Many existing interventions create “institutional housekeeping” by relying on women for their delivery, this can result in failure, especially during a crisis like COVID. Most studies were low to moderate quality. More robust research, and a more holistic approach is needed, moving away from “fixing the women” to address the organisational and systemic structures which underpin inequality.\u003c/p\u003e","manuscriptTitle":"Gender equality in academic medicine before, during and after COVID: what have we learned? 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