Women may be known as the great nurturers, but when it comes to healthcare, men still take care of business. Nationally, women account for only 14 percent of the top management positions. Of Florida's 211 hospital CEOs, a mere 33 are women. But in Sarasota-Manatee, women are breaking new ground, with four of the seven largest healthcare institutions now led by women-three of them brand new to the job.

None of these women, however, sees herself as battering through a glass ceiling. They all say they were mentored by men and promoted based on merit and performance. "In today's environment, it's the right person for the right job," says Gwen MacKenzie, president and CEO of Sarasota Memorial Hospital.

Instead, these high-powered executives prefer to focus on current and future challenges, chief among them how to keep their institutions solvent and how to provide essential services at a time when rapid population growth outstrips infrastructure development. "Growth does not pay for itself when it comes to ambulances and mental health services," emphasizes Mary Ruiz, president and CEO of Manatee Glen, a behavioral health care center in Bradenton.

TAKING IT TO THE NEXT LEVEL

Before taking over the reins of Sarasota Memorial Hospital, Gwen MacKenzie spent 25 years of her career at Detroit Medical Center, a nine-hospital system affiliated with Michigan's Wayne State University. She started out as an advanced practice nurse and worked her way up to executive vice president and chief operations officer. In that role, she was credited with a $110 million turnaround in the hospital's bottom line.

A soft-spoken woman, MacKenzie likes to rely on physicians to help with leadership issues. But while encouraging teamwork, she is not averse to making tough decisions. Within two months of her arrival in May, she cut 60 jobs to help address a $20 million annual deficit.

She is very much aware of SMH's role as a community asset and safety net. Because it is a nonprofit institution that must serve patients who cannot afford to pay, the hospital has to have a financial cushion. "No margin, no mission," says Mackenzie. "We need to make sure that we're well-run, efficient and cost-effective."

At the same time, she wants to build on the national recognition SMH has enjoyed for its patient care and specialization. "I want to be in the top 10 in the country in every category that can be measured," she says.

She anticipates that future growth will be in ambulatory and satellite facilities-walk-in medical centers with X-ray and surgery capability and aggressive expansion into South County.

MacKenzie and her husband Doug, a former football star at the University of Michigan, like to go kayaking and biking together. MacKenzie also runs after work, usually across the Ringling Causeway Bridge and back. "I have to keep pinching myself," she says with a smile, "do I really live here, or am I on vacation?"

UP TO THE CHALLENGE

At 36, Wendy Brandon combines ambition with a desire to make a difference. "I need to be challenged and to keep learning, or I feel like I'm dying," says the personable new chief executive officer of Englewood Community Hospital.

A business major in college, Brandon got her M.B.A. while working for Health Care Corporation of America at a number of its hospitals in Tennessee. She moved from being a physician's support analyst to associate administrator before becoming chief operating officer at Summit Hospital in Nashville. Now she is taking on the position of CEO for the first time.

As a newcomer to the area-she had lived all her life in Tennessee-Brandon is still getting her bearings, making sure that she knows everyone on the medical staff personally and learning about the community. "I want a personal connection with the people here," she says.

But she already sees some major challenges looming on the horizon. Attracting quality staff is a huge issue because of the dearth of affordable housing. Brandon also foresees a change in consumers-more early retirees with more disposable income and higher expectations of service. That means improving outpatient and ER coverage and adding more services, such as behavioral health programs.

Though taking the job at Englewood Community Hospital was the biggest jump in her career, Brandon says being in a smaller hospital and community makes it easier to balance her personal and professional life. In the past, she and husband Chuck, a C.P.A., traveled, played tennis and golfed. Now they have a two-year-old son, Winn, for whom they share the demands of parenting in every way. "It is important to me to be a mother and wife," Brandon says, "but I always will want to be challenged."

CONLICT CAN BE GOOD

A nurse by training, Melody Trimble joined Naples-based Health Management Associates 14 years ago as the director of an emergency room in a small town in Kentucky. Since then, the company has sent her to Oklahoma, Georgia and South Carolina. When HMA bought Venice's Bon Secours Hospital, it brought in Trimble as its new CEO.

A warm, outgoing leader who does not shy away from making hard decisions, Trimble was ideal for managing a hard transition from a not-for-profit hospital to a for-profit institution. She has high expectations and welcomes conflict. "Conflict, approached professionally and with respect, can bring out the very best in us and generate great ideas," she says. And she notes that the hospital is very much a work in progress.

She's had to reassure the community and staff that operating the hospital for profit will not shortchange patients or the community. "We're in the business of caring," she says. "We will continue to make clear financial decisions, and provide good care and sound clinical decisions."

The 46-year-old Trimble admits that striking a balance between her demanding job and her family isn't always easy. One of her daughters is a student at USF; the other is in high school and lives at home. Fortunately her husband, Mike, has been willing to put his real estate career on hold to be Mr. Mom for a while.

How does she cope with the frustrations of the job? "I tell people that, on those days when nothing goes right, to remember one day that was impeccable," she says. "I work to make every day that day."

MENTAL HEALTH CHAMPION

When she was hired by the former CEO of Manatee Glen, Mary Ruiz told him that she would only stay for three years, because she needed a great deal of variety and challenge. Eighteen years later, she says, "I'm still here, and I've never been bored."

She was promoted to chief executive nine years ago, making her the nonprofit behavioral healthcare center's first female, first Hispanic, and first non-clinician to hold the job (she has an M.B.A.).

During her tenure, she has grown the Bradenton-based institution from a sturdy $12 million to a $25 million annual budget. Clinicians' billable hours have risen from 1,000 to 1,600 a year. Outpatient care has greatly expanded. And the hospital wing-Manatee Glen is only one of six mental health care centers in Florida with a major in-patient hospital-has added a drug-rehab program and beds to its crisis center.

Ruiz minces no words when it comes to the future. "The failure of the U.S. healthcare policy is a threat to everyone," she warns. With costs being shaved to providers and hospitals closing, dealing with growth and maintaining access to care is a big concern. To buffer the institution, Ruiz works to build strong partnerships with the community, local government and foundations. She considers it ironic that while the business forecast is worrisome, the therapeutic possibilities are encouraging. "We can do so much more for people than ever before," she says.

The oldest of six children growing up in Louisiana, Ruiz was the first to attend college. She went to New College and met her husband in Sarasota. He recently retired as head of growth management in Sarasota. "I keep saying, it's so nice to have a man around the house," she jokes. The couple has a 15-year-old son.

At 50, Ruiz feels in her prime. "You have to be willing to take bold action and bold risks," she says. "That has been my signature throughout life."