LYPSON, MONICA L.; GRUPPEN, LARRY; STERN, DAVID T.
The United States is becoming more ethnically diverse. Black/African Americans (12.1%), Native Americans (0.9%), and Hispanic/Latinos (12%) represent 25% of the U.S. total population.1 On average, however, over the last decade only 10% of medical school graduates were from underrepresented minority (URM) groups, despite initiatives such as the Association of American Medical Colleges' (AAMC's) Project 3000 by 2000. (The AAMC defines the major groups of URMs as Native Americans, Black/African Americans, Mexican Americans, and mainland Puerto Ricans.) Current trends demonstrate that we are slow if not stagnant in our ability to provide the public with a diverse physician work-force.
When medical students consider career choices, academic physicians are often the role models students look to, in order to formulate their ideas and personae of what it means to be a “physician.” Unfortunately, only 4.1% of all medical school faculty are from URM groups.2 Recent studies on promotions indicate that racial and ethnic minorities are less likely to be promoted compared with white faculty regardless of “tenure status and receipt of NIH grant funding”3,4 While these raw percentages do not take cohort effects into account, this demonstrates a problem for developing a diverse faculty in academic medicine.
In addition to providing role models, increasing the diversity of academic physicians may help to inform and promote unexplored research agendas. These individuals may also help to address the health disparities that have historically occurred in this country.5,6,7,8 A diverse faculty can promote these areas of scholarship to students, while simultaneously demonstrating that URM faculty can succeed in academic medicine.
Career decisions made by clinical investigators seem to occur most often during medical school.9,10 The AAMC's graduation questionnaires between 1980 and 1999 report that 20–30% of all fourth-year medical students envision a future in academics.11 However, little is known regarding the actual number of medical school graduates who choose careers in academic medicine. This study aims to identify the trends in entrance into academic medicine, with particular attention to the future careers of minority medical students.
We sought a national database that would reflect faculty trends in U.S. medical schools. To investigate this question we chose to estimate the percentage of graduates from 1980–1993 who were faculty members in 1999. This descriptive approach allowed us to identify graduates who opted for academic medicine as a career during this recent period.
The AAMC collects self-reported measures from nearly all medical school graduates in a yearly graduation questionnaire.12 In addition, the AAMC collects annual data on U.S. medical school faculty through the Faculty Roster System (FRS). It is estimated that the roster picks up 90–92% of all active full-time faculty.3 These data provide demographic information about faculty, including racial/ethnic make-up, gender, and year of medical school graduation. Standard language in the FRS provides a definition of selected minorities, which include African American (black), Mexican/Chicano, Native Alaskan/Native American/American Indian, and mainland and commonwealth Puerto Rican. In addition, we compared our findings with those for white (not of Hispanic origin) and Asian/Pacific Islanders. Further breakdown of large ethnic/racial groups is not possible given the limitations of the data; thus in this paper we focus on selected minorities as defined above.
The roster was initiated in 1966; however, starting in 1980, the AAMC implemented a system that allowed for categorization into the following sections: background, current appointments, employment history, and education/training. The data are self-reported, at the time of faculty appointment.
The data used in this study were obtained from this roster and the AAMC Databook, which provided numbers of medical school graduates. The Databook provides statistical information as it relates to medical education; data about applicants, faculty, and research funding are included.
Our findings are based on those full-time medical school faculty in 1999 who had graduated between 1980 and 1993.11,12 We excluded faculty who graduated between 1994 and 1999, to focus only on those individuals who were likely to have completed their graduate medical training, and were pursuing careers in academic medicine. We did not distinguish between faculty tracks; we were interested in total number of faculty with academic titles. Further reasoning suggest that medical students do not differentiate among faculty tracks.
Descriptive statistics, multivariable regressions, and trend analyses in multivariate analyses of variance were performed. First, the population of faculty was characterized with standard descriptive statistics. We found the percentage of graduates from each year 1980–1993 who were in academic medicine in 1999. Initially a linear regression by each race/ethnicity was performed to examine the data. Upon checking the model, due to the curvilinear nature of the data we found that a quadratic model fit best. All analyses were performed using standard statistical software.
In 1999, there were a total of 89,830 U.S. medical school faculty members; 73% were male and 27% were female. A total of 4.1% (3,647) described themselves as being of selected minority backgrounds: 2.8% were African American, 0.8% were Puerto Rican, 0.4% were Mexican American, and 0.1% were of Native American heritage. A total of 10.5% described themselves as being of Asian/Pacific Islander descent. The remaining 80% described themselves as white. A total of 3.3% of faculty declined to list their ethnic backgrounds. In 1996–97, the last year from which the data are available, of the 3.9% who listed themselves as minorities, approximately 16% (373/2,291) of the African American faculty held positions at Howard, Meharry, and Morehouse (historically black medical schools), and 53% (358/674) of the Puerto Rican faculty had positions at Ponce, University of Puerto Rico, and Universidad Central del Caribe.13
Of all students who graduated between 1981 and 1993, on average 41.6% of Asian, 17.6% of white, and 10.3% of selected minority graduates were currently members of academic faculties. However, when examined closely, these numbers reflect a notable and consistent decline in careers in academic medicine. From the graduating class of 1981, 10.7% of minority graduates, 19.8% of white graduates, and 51.5% of Asian graduates were identified as medical school faculty in 1999. From the graduating class of 1993, only 6.57% of minority graduates, 11.6% of white graduates, and 14.1% of Asian graduates were identified as medical school faculty in 1999 (Figure 1).
The analyses of the temporal trends present in the proportion of graduates entering academics for each ethnicity indicated that the best-fitting models for white and minority graduates included both a linear and an inverse quadratic component, in other words, the curve was a flattened inverted “U” (Table 1 and Figure 1). These models fit the data very well, accounting for 83% of the total variance in minority graduates and for 92% of the total variance in white graduates.
For the proportion of Asian graduates entering academic careers, a simple negative linear model without a quadratic component, in other words, a simple straight line sloping downwards, fit the data well, accounting for 83% of the variance. Our results provide no evidence for an increasing proportion of minority faculty over time. This is occurring at the same time that there is an overall trend of decreasing entry into academic medicine by all graduates. There is, however, evidence of a substantial effect of recruitment of Asians into the academic ranks during the 1980s.
There is a decreasing secular trend in numbers of medical school graduates who become academic faculty. Concern regarding the numbers of academic physicians is not new. From the late 1970s on, there have been numerous articles discussing the decrease in clinical investigators.10,15,16,17,18 Over 20 years ago, James Wyngaarden claimed that “clinical investigators were an endangered species.”15 Cadman echoed these concerns 1994 regarding research faculty in academic internal medicine.19 The trend away from academic medicine in the 1990s may have been due to the same factors that are causing the numbers of medical school applicants to decline. According to Jordan Cohen, president of the AAMC, the reasons can include (1) a strong economy and increasing variety of career opportunities, (2) “natural ebb and flow of interest” in medicine, (3) loss of autonomy in the profession, and (4) increasing educational debt.20
Our data present an overall picture of selected/underrepresented minorities in comparison with whites and Asians. Our results are most interesting regarding the numbers of Asian/Pacific Islander medical school graduates who entered academic medicine through 1999. In the 1980s approximately 50% of all Asian graduates went into academic medicine. During this same period the percentage of Asian graduates also increased rapidly. Population growth alone is not enough to explain our findings. Currently, 10% of all faculty are Asian.2 Nevertheless, our data show a decline in interest in academic careers among Asian graduates, from 75% in 1982 to 14% by 1993. Further investigation in the areas of immigration trends and ethnic representation of medical school students and faculty would be intriguing.
The lack of an increase in the percentage of URMs joining the academic ranks is most disturbing. Despite public and clear initiatives by medical schools, other organizations (such as the Bureau of Health Professions Divisions of Student Assistance, the Faculty Loan Repayment Program, and the AAMC's Health Services Research Institute for Minority Faculty, funded through the Agency for Health Care Policy and Research) and foundations (such as The Robert Wood Johnson Foundation's Minority Medical Faculty Development Program), with administrative and financial incentives to draw URMs into academic medicine, all initiatives to date have failed to achieve their global goals. Postulated reasons for the persistent underrepresentation of minority physicians include “inadequate or inappropriate career counseling, admission policies, attrition rates, education debt and the lack of appropriate mentors and role models.”21
What is keeping URMs from enrolling in medical school? Are these the same reasons as for other applicants or are they disproportionately diverted from this process? And why are underrepresented minorities failing to join academic faculty despite strong incentives to encourage their participation? Further detailed studies of faculty incentives, motivation, and interest will help to reveal the causes of this dilemma.
This study provides a point estimate of the prevalence of minority faculty in 1999. Our findings are biased towards identifying long-term appointments of academic faculty, and do not account for immigration into or emigration from the cohort of academic faculty. In this work we included faculty at historically black medical schools and from the Puerto Rican Commonwealth universities; future research would benefit from the exclusion of these faculty to reveal estimates of minorities in academic medicine in substantially smaller proportion than calculated in this study. Within the FRS data set, 3.3% of medical school faculty decline to list their racial or ethnic identities and thus were excluded from our analysis.2 We are uncertain as to which categories these faculty members would fall into. There are arguments in both directions as to why a faculty member would or would not include ethnicity on this form, but no clear direction of bias has been hypothesized. However, even if we were to assume that they were URMs, their presence would not increase the number of URM faculty enough to reflect the percentage of URM medical school graduates or the percentage of URMs in the U.S. population.
Minority medical students are often at a disadvantage due to the lack of role models who look like them and perceive the world in similar ways. Given that those in academic medicine are often viewed as the leaders of medicine, it will benefit the profession to have a diverse and representative array of faculty members. If the leaders in academic medicine can demonstrate the value of diversity, the rest of the profession, and perhaps others, will follow suit. Our findings reveal a downward trend that fewer medical students in general, regardless of ethnic background, are entering careers in academic medicine. Except for Asian/Pacific Islanders, there is no evidence for increasing URM representation in academic faculty despite strong incentives for participation.
Academic medical centers must consider what it is about the environment or work of academic medicine that does not make it inviting to young scholars. Especially disheartening is that despite focused efforts in the area of minority faculty development, recruitment and retention programs have not led to an increase in the numbers of underrepresented faculty. In addition to efforts to champion a diverse faculty, focus should be placed on support and faculty development for all trainees and junior faculty interested in academic medicine. Finally, additional research is needed to determine the characteristics and initiatives that will continue to supply our academic medical centers with the best and brightest faculty. Without an influx of young, diverse faculty, our academic medical centers risk critical shortages of teachers, and further disconnection between medical centers and the populations they are meant to serve.
3. Fang D, Moy E, Colburn L, Hurley J. Racial and ethnic disparities in faculty promotion in academic medicine. JAMA. 2000;284:1085–92.
4. Palepu A, Carr PL, Friedman RH, Amos H, Ash AS. Moskowitz MA. Minority faculty and academic rank in medicine. JAMA. 2000;280:767–71.
5. Johnson DG, Lloyd SM, Miller RL. A second survey of graduates of a traditionally black college of medicine. Acad Med. 1989;64:87–94.
6. Moy E, Bartman BA. Physician race and care of minority and medically indigent patients. JAMA. 1995;273:1515–20.
7. Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. Am J Public Health. 1997;87:817–22.
8. Zuckerman S, Kenney GM, Dubay L, Haley J, Holahan J. Shifting health insurance coverage, 1997–1999. Health Aff. 2001;20:169–77.
9. Donnelly MB, Jarecky RK, Rubeck R, Murphy-Spencer A, Parr P, Schwartz R. Factors influencing medical student's choice of academic medicine as a career. J Ky Med Assoc. 1996;94:186–90.
10. Davis WK, Kelley WN. Factors influencing decisions to enter careers in clinical investigation. J Med Educ. 1982;57:275–81.
15. Rosenberg LE. Physician—scientists—endangered and essential. Science. 1999;283:331–2.
16. Wyngaarden JB. The clinical investigator as an endangered species. N Engl J Med. 1979;301:1254–9.
17. Daughaday WH. Presidential address: The care and nurture of clinical investigators. J Lab Clin Med. 1970;75:6–10.
18. Kelch RP, Novello AC. Training pediatric scientists. Pediatr Res. 1989;25:1–5.
19. Cadman EC. The academic physician—investigator: a crisis not to be ignored. Ann Intern Med. 1994;120:401–10.
20. AAMC. U.S. Medical school applicants still exceed available positions: underrepresented minority applicants increase for the first time since 1996. Press release: October 25, 2000, 〈http://www.aamc.org/newsroom/pressrel/001025.htm
〉. Accessed 6/28/02.
21. Harris DL, Mullan F, Simpson CE, Harmon RG. The current and future need for minority medical faculty. J Assoc Acad Minority Physicians. 1991;2:14–7.