Borges, Nicole J. PhD; Navarro, Anita M. MEd; Grover, Amelia C. MD
I'm not sure ... that I made a conscious choice to choose academic medicine as a medical career ... it was just that I never really thought about anything else.... I actually never considered anything else.
Academic medicine is one of several options available to a physician deciding on a practice. During the 1980s, women entered academic medicine at higher-than-expected rates,1 and today women enter medical school in equal proportions to men, yet of the 125,070 current medical school faculty, only 35% are women.2 After reviewing more than 300 articles, the authors of a recent literature review found that the reasons physicians, particularly women, choose academic medicine are unclear.3 Of the 300 articles, the authors reviewed 60 that focused on gender; however, only two specifically addressed the reasons women choose academic medicine.4,5 According to the review,3 these two articles indicated that the intellectual challenge of academic medicine is as important to women as it is to men, but achieving national recognition as a physician or being viewed as a leader (valuable to many in academia) is less important to women than it is to men.5 Additionally, women physicians are less likely than their male colleagues to identify role models for professional–personal balance,5 and the literature suggests that women choose academic careers because of the quality of life, earnings potential, and organizational rewards.4 Changing the environment of academic medicine could enhance career satisfaction and success for both women and men.3
The remaining 58 articles (of the 60 reviewed) focused on women's advancement in medicine and more general concerns (e.g., satisfaction, barriers) regarding their careers in academic medicine after they had already embarked on this pathway. The literature on women in academic medicine that has been published since the review (which included articles published through 2006)3 continues to focus on such issues.6,7 This current study builds on the literature review's examination of gender to focus on how women physicians embark on careers in academic medicine; specifically, it explores the question “Why, how, and when, do women physicians choose a career in academic medicine?”
Our inquiry is important and timely. Women continue to enter medicine in larger numbers than ever before, and understanding how they decide to enter academic medicine is vital, especially in light of surmounting physician shortages and faculty retirements. Prompted by the development of the Association of American Medical Colleges (AAMC) Careers in Medicine Program8 during the last decade, many medical schools currently offer support for students who are making decisions about specialty.9 Although medical educators, counselors, and advisors are better equipped than ever before to help students make informed decisions about specialty choice, they lack knowledge and an understanding regarding the next step in physician career development—that is, choosing a practice option or career path in medicine. Understanding women physicians' choices to pursue careers in academic medicine will help begin to fill the gap regarding academic medicine as a practice option, particularly for women physicians.
To answer the question “Why, how, and when do women physicians choose a career in academic medicine?” we interviewed women physicians in the academic medicine community. We felt that interviewing women would provide fresh insights and allow a deeper analysis of factors promoting careers in academic medicine because such qualitative approaches offer us the ability to understand the meaning participants attach to their experiences.10
After obtaining institutional review board approval from our respective institutions, we mailed a letter to the women liaison officers (WLOs) of each of the AAMC-member medical schools in the central and southern regions of the United States. The letter included information about the study and a request for a list of the names of women physician faculty at each institution. We also asked for the women faculty members' academic rank, ethnicity/race, and specialty. After we received the roster from each school's WLO, we randomly sorted the names of prospective participants from each school so that their names were not in alphabetical order. We then sorted participants by academic rank and ethnicity. Finally, we produced a representative list of women physicians in academic medicine by randomly selecting prospective participants on the basis of their academic rank and ethnicity. For example, if one school had three non-Caucasian women listed as associate professors, we used a random process to select a prospective participant from within this grouping to ensure diversity in our sample. Once we identified prospective participants and created a representative sample of women physicians, one of us, the principal investigator of this study (N.J.B.), contacted the WLO at each school, asking her to e-mail the prospective participants to notify them of their selection for the study and to inform them that a study investigator would be contacting them. If the WLO agreed, the principal investigator then directly e-mailed prospective participants describing the study and inviting them to participate. Once the prospective participant agreed to participate in the study, we obtained consent and scheduled a phone interview.
We developed a structured set of questions (Appendix) based both on Savickas'11 Career Style Interview and on the input of career development and medical education experts. We pilot tested the questions with a convenience sample of six women physicians in academic medicine who were not part of the interview sample, and we made no changes. In 2010, project team members (the authors and one medical student) conducted and digitally recorded one-on-one phone interviews with women physicians in academic medicine. Interviews lasted from 10 to 45 minutes, and a qualified transcriptionist produced verbatim transcripts of the interviews. We sent participants a $50 gift card for participating in this study.
Three of us, the coinvestigators of the study (N.J.B., A.M.N., A.C.G.), first reviewed all of the transcripts for accuracy and broad themes. Once we agreed on the themes, each of us selected three to six interviews for preliminary assessment in an effort to establish a codebook. Two of us (N.J.B. and A.M.N.) coded a small subset of transcripts and reviewed the coding to achieve consensus on the codebook. Then, each of us (N.J.B. and A.M.N.) individually used the resulting codebook to qualitatively evaluate, respectively, half of the remaining transcripts. Last, one of us, the remaining coinvestigator (A.C.G.), reviewed all of the coded transcripts to verify coding and to resolve any discrepancies.
We contacted 73 WLOs, and, of those, 7 (9.6%) returned lists of faculty. We contacted 81 of the women physicians from these lists, and, of those, we interviewed 53 (65.4%). We used 13 interview transcripts to produce the codebook.
The 53 women physicians in academic medicine who participated in this study represented seven medical schools in the central (n = 3) and southern (n = 4) regions of the United States, according to the AAMC's geographic regions. See Table 1 for further demographic and career information on the participants. The distribution of participants' academic rank and ethnicity in our study is slightly higher than national figures.2
Why did women choose academic medicine?
We asked the women in our study to rank-order the aspects of academic medicine (teaching, research, administration, clinical practice) in which they were most interested when they made the decision to enter academic medicine. The majority of women physicians (33 [62.3%]) ranked teaching as the aspect in which they were most interested. In comparison, 15 (28.3%) of women ranked clinical practice first, 4 (7.5%) ranked research first, and only 1 woman (1.9%) ranked administration first (Table 2).
Through our thematic analysis of the transcripts, we identified five main themes (and several subthemes) related to why the women we interviewed chose academic medicine careers: (1) fit, (2) aspects of the academic health center (AHC) environment, (3) the influence of people in their lives, (4) exposure to academic medicine, and (5) an interest in practicing clinical medicine.
The concept of fit.
In career development theory, the concept of fit is central to understanding people's career decisions.12 “Fit” posits that people know that the career paths they have taken suit them because they feel a sense of congruence between their lives and their careers; they are satisfied with their decisions and how they have played out in their lives. Many participants in this study saw academic medicine as a good fit for themselves, as illustrated by one woman who noted:
I hardly ever, never from the day I contemplated being a physician, ever had a picture of myself hanging out a shingle somewhere and practicing medicine ... in the community ... it just was not part of the picture for me.... I never had that vision. I always had a vision of being in a medical school ... where I could do research and teach and do other things.
The subthemes under fit that we identified were prestige, personality, interest, and salary as a nonissue (Table 3). Prestige seemed to be a quality associated with a career in academic medicine that attracted some women in our study. They perceived, and sought for themselves, a certain distinction associated with the practice of academic medicine and with its reputation for being on the forefront of medical knowledge and research. For several women, personality emerged as a lens through which to view their congruence with the academic medicine environment. These women articulated having similar traits as others with whom they work (e.g., passion for teaching or research), and they saw various aspects of their personalities as suited to working in a competitive, multifaceted environment. Other participants noted their interest in academic medicine as a practice option. They said that it was the practice option that most captivated them. Some participants discussed the idea that salary was a nonissue. That academic medicine physicians often earn less than doctors in private practice did not matter to these participants, as exemplified by one participant's words: “for me I really did not care that much about what my salary was going to be.”
Related to the notion of fit were aspects particular to AHCs; certain qualities of the academic medicine setting drew some women to practice in this environment. The nine subthemes under AHC environment constitute the qualities that attracted some women: mobility, intellectual stimulation, teaching, variety, training opportunities, remaining current, subspecialty practice, lifestyle / flexibility, and patient acuity (see Table 3). Our study participants perceived these qualities as congruent with their own values or with their perceptions of what is important in the practice of medicine.
The influence of individuals in these women's lives also emerged as a key factor in their decisions to practice academic medicine. This theme's four subthemes—mentors, role models, colleagues, and parents/family members—delineate the various roles played by the people who encouraged the women in our study to consider and ultimately choose an academic medicine career path. One woman noted,
[A]s I was doing my fellowship, I came into contact with academic [specialists] who I sort of found [to be] mentors and people I looked up to, and I thought “I want to be just like them.”
And another woman stated,
I was feeling a push away from private practice and feeling a pull toward academic medicine ... because of the people I was working with.
The women also discussed various types of exposure to academic medicine, including both positive and negative events, as key factors in their career decisions. One interviewee commented,
I had a lot of exposure to research and mentors who were very involved in that arena and [who] gave me a very positive experience.
Although they did not elaborate on it in great depth, many women alluded to patient care, taking care of patients, and the more clinical aspects of medicine when describing why they chose academic medicine.
How did women choose academic medicine?
Five themes capture how our participants made the decision to enter academic medicine: (1) change in specialty, (2) dissatisfaction with former career, (3) emotionality, which includes the two subthemes of affinity and fear, (4) parental influence, and (5) decision-making styles, which includes four subthemes: serendipitous/passive, reflective/intuitive, active/planned, and foreclosure (see also Table 4).
Change in specialty.
Career changes prompted some participants to consider academic medicine. These women initially entered one specialty and later decided to work in another specialty or to further subspecialize, and these new choices prompted them to think about and ultimately to choose academic medicine. To illustrate, one interviewee said:
I was a community [specialist], sort of a private practice [specialist].... I realized this was not the career I wanted to pursue for the rest of my life ... made calls back to the academic center to see if there was an academic position.
This respondent went on to subspecialize and received additional training in a specialty that is more common to academic medicine than to private practice. In other, similar cases, academic medicine was the only environment in which some of the women could practice because theirs is not a subspecialty frequently found in private practice.
Dissatisfaction with former career.
Dissatisfaction with their initial specialty choices prompted some women to enter academic medicine. One woman explained,
I did private practice for a year ... it wasn't a learning environment ... it wasn't how I had seen myself living the whole rest of my life.
Such women pursued a position in academic medicine but maintained their specialty.
Many participants mentioned emotional aspects, using words such as “like,” “love,” and “fear,” to describe elements of their decisions. Participants expressed sentiments of affinity most often in relation to teaching (“I've loved teaching”), and they expressed fear in describing managing a practice (“I wasn't so sure about the business aspects of medicine”). Both fondness for teaching and concerns regarding practice management pushed them toward academic medicine (see also Table 4).
Parental influence emerged as a theme in how—as well as in why—women chose careers in academic medicine. Our participants usually described the influence of their parents in an indirect but positive manner:
I come from a family of teachers ... not physicians ... but teachers ... and always loved to teach.
In our analysis of our participants' explanations of how they made their decisions, we noted various decision-making styles, which we labeled serendipitous/passive, reflective/intuitive, active/planned, and foreclosure (see Table 4).
When did women choose academic medicine?
Thematic analysis revealed four themes that offer explanations of when our participants decided to enter academic medicine: (1) as a practicing physician, (2) as a fellow, (3) as a resident, and (4) as a medical student (Table 5). None of our participants indicated that they had decided on academic medicine prior to medical school. Overwhelmingly, participants indicated that as medical students they did not know enough about academic medicine to choose it as a career. Three women we interviewed made the decision to practice academic medicine while attending medical school, but, among our study participants, their experiences seem to be the exception rather than the rule. Among the women we interviewed, fellowship or residency seemed to be critical points in considering academic medicine; some women indicated that they became more aware of academic medicine as a career path during residency but did not solidify their decision to work as an academic physician until during a fellowship. Finally, some participants chose academic medicine while in practice, sometimes after trying private practice first. These respondents each had their individual reasons for entering academic medicine.
Knowledge of academic medicine during education and training years
Although our main objective was to answer the question “Why, how, and when do women choose careers in academic medicine?” we also asked the women we interviewed what they knew about the field of academic medicine during their education and training. Participants indicated that during medical school they knew very little—they described themselves as “naïve” regarding careers in academic medicine. For example, one interviewee said, “In medical school … nothing…. I really didn't know anything [about academic medicine].” Participants indicated that as residents they knew a little bit more than they did as students. Several themes related to why, how, and when women chose academic medicine careers reemerged in participants' responses to this final query: the influence of others including parents; aspects of the AHC environment, particularly variety; and fit, especially salary as a nonissue (see Table 6). The theme of exposure reemerged the most often among respondents.
Discussion and Conclusions
This qualitative study of women academic physicians and their reflections provides insight into the process of selecting academic medicine as a career. The current study helps to fill a void in the literature, contributes to an area of inquiry that greatly needs further investigation, and begins to answer questions raised by the extensive literature review conducted in 2010.3 The environment in which one trains seems to be a substantial influence. For example, those participants who received training in teaching hospitals expressed formative experiences resulting from simply being in an environment where teaching and research were a daily presence. In addition to the environments where the physicians trained, the people around them, including faculty, mentors, role models, and family, serve as influential factors. Some women are fortunate to cross the path of someone or multiple “someones” who suggest, introduce or expose them to, and shape their interest in academic medicine. The serendipitous nature of these chance encounters may indicate that physician educators miss opportunities to cultivate the talents of trainees who have not necessarily been identified as having interests in academic medicine but who, nonetheless, may be—or could become—interested.
Medical schools and residency programs can take steps to purposefully and thoughtfully introduce careers in academic medicine to medical students and residents. Just as a school works with individual medical students as they investigate various specialty choices, so, too, a school could provide early exposure to practice options through formal or informal experiences, such as specialty interest groups, panel discussions, career interviews, and shadowing experiences.
The women physicians in academic medicine whom we interviewed frequently mentioned an interest in teaching as a reason for pursuing a career in academia. Some of our respondents were aware of their affinity for teaching prior to entering medical school, whereas others' interest in teaching surfaced during residency or fellowship when they actually had the opportunity to teach medical students and other trainees. Programs and initiatives, including teaching electives for medical students, aimed at developing medical students' and residents' teaching competencies are becoming more common.13,14 These increased opportunities for medical trainees to understand and learn teaching skills may lead more students and residents to consider academic careers.
As with all research studies, our study has limitations. We developed a codebook through consensus, and one of us reviewed the assessments of our other team members; nonetheless, others may have identified different themes and subthemes. Because qualitative work focuses on the particulars of a phenomenon, the results of this study may not be generalizable to all women in academic medicine. We attempted to gather a representative sample of women physicians based on rank, specialty, and ethnicity, but we did not necessarily capture all perspectives. Further, our study sample included only women physicians in the southern and central regions of the United States. In addition, women in this study self-selected to participate. Other women physicians in academic medicine had the opportunity to participate but chose not to for unknown reasons. Finally, we did not interview men who work as physicians in academic medicine. A study of male physicians in academic medicine could provide further insights into and understanding of how men and women differ from and parallel one another in coming to their decisions to enter academic medicine careers. Given that the number of women in medical school has only recently equaled the number of men and that male faculty continue to far exceed the number of women faculty,1,2 we felt that focusing this study on women physicians was important.
Although not surprising, it was unsettling to learn that entering a career in academic medicine was not necessarily an active, planned decision; rather, it was serendipitous or circumstantial. Physician career development—specifically, engaging medical students in the decision-making process early—is important if the medical education community wants to have physicians who are satisfied with their specialty and practice-setting decisions. Educators have an obligation to medical students and residents to develop their knowledge and skills, including those related to career development, for effectively practicing medicine. Our study shows that faculty can play a key role in helping students and residents with their career planning. On the basis of the findings of this study, we suggest that medical educators and administrators seriously consider providing programming and opportunities at their schools and residency programs to expose not only women, but all medical trainees, to careers in academic medicine. Assisting these trainees as they determine whether the AHC environment is a good fit for them is vital for the future of academic medicine.
The authors wish to thank Jeremy Reese, MD, who helped conduct phone interviews as part of his fourth-year elective in medical education research, and Laura Johnson, MEd, who transcribed the interviews. They would also thank Lionel Howard, EdD, at the George Washington University Graduate School of Education and Human Development (Washington, DC) for his consultation on this study.
This project was funded by the American Medical Association Foundation Joan F. Giambalvo Memorial Scholarship program, presented in association with the American Medical Association Women Physicians Congress. Dr. Borges is the 2009 recipient of the Joan F. Giambalvo Memorial Scholarship. Dr. Grover received support from the National Institutes of Health Building Interdisciplinary Careers in Women's Health grant.
Ethical approval was granted by institutional review boards at Wright State University (Dayton, Ohio) and Virginia Commonwealth University (Richmond, Virginia) and through an internal exemption at the Association of American Medical Colleges (Washington, DC).
The authors have previously presented some of this research as the following: Borges NJ, Navarro AM, Grover A. Women physicians' reflections on choosing an academic medicine career. Research paper presented at the annual meeting of the Association for Medical Education in Europe, Vienna, Austria, September 2011; and as Borges, NJ, Navarro AM, Grover A. A qualitative study of women physicians and their choice of a career in academic medicine. Oral abstract presented at the Research in Medical Education (RIME) conference at the annual meeting of the Association of American Medical Colleges, Denver, Colorado, November 2011.