For more than 30 years, researchers have measured, analyzed, and documented the representation and role of women in academic medicine, and they have found a significant increase in the absolute number and in the percentage of women entering medical school and pursuing careers in academic medicine.1–12 For example, in 2011, women composed 47% of each matriculating medical school class compared with 29% in 1980. Although the gender parity of academic faculty has lagged behind that of medical students, it is improving. In 2011, women accounted for 37% of full-time medical school faculty and 44% of newly hired full-time faculty.12 However, the percentage of female physicians at higher academic ranks and in senior leadership positions has not similarly increased. In 2011, only 13% of women in academic medicine had attained the rank of full professor compared with 11% in 1980. Despite some reported improvements, no permanent leadership positions have a greater percentage of women than men.8,12
Concurrent with these increases in the number of female academic faculty has been the emergence and maturation of alternative academic tracks for medical faculty.13,14 By the 1970s, the traditional tenure track (TTT) was no longer the only option for medical school faculty. New options for careers within academic medicine emerged as faculty faced increasing clinical and educational demands. Revenue generated by faculty providing patient care was playing an increasingly important role in the financial survival of academic medical centers.15 First formally reported in 1984,16 separate academic track types are now offered by more than three-fourths of medical schools for faculty primarily involved in the mission-critical work of clinical care and teaching; these are most commonly identified as clinician–educator tracks (CETs).17–19
During the same period, the overall percentage of tenured or tenure-eligible clinical faculty dropped from approximately 60% in 1984 to 30% in 2010. Overall, the percentage of tenured positions is also declining for both male (from 61% to 36%) and female (from 52% to 27%) faculty; however, the rate of decline is faster for women.20,21 Reasons for this decline include changes in the fundamental concept of tenure, changes in tenure policies to address work–life balance challenges, and a rise in new MD clinical faculty appointed to non-tenure-eligible tracks.22,23 Faculty on the CET type may be offered tenure, but it is less likely than for those on the TTT type. Promotion and recognition of faculty on the CET type are evolving and have lagged behind promotion and recognition of faculty on the TTT type.14,15,24,25
Although most U.S. medical schools now offer a variety of faculty track types, no one has analyzed the gender differences within each. We examined data from the 2011 Faculty Roster of the Association of American Medical Colleges (AAMC) to assess full-time male and female faculty representation on the CET and TTT types within individual U.S. academic medical centers. We explored the relationship between gender and the likelihood of appointment to the CET type versus the TTT type as a possible barrier to the advancement of women in academic and leadership positions.
The AAMC Faculty Roster collects multifaceted information on academic faculty at accredited MD degree-granting U.S. medical schools. For our study, we used the March 31, 2011, snapshot of full-time faculty, as voluntarily reported to the Faculty Roster by each school.26 The Faculty Roster staff generated the data we used in our study and provided them to us in aggregate.27
The AAMC Faculty Roster includes eight faculty track types (see Table 1).28 These designations facilitate the grouping of disparately named (but similarly functioning) faculty tracks across medical schools,27 as a particular medical school may report numerous faculty tracks, which the AAMC then assigns to one of their eight designations.
The Mayo Clinic institutional review board reviewed our protocol for the use of the AAMC Faculty Roster data and deemed their use exempt. The AAMC provided the Faculty Roster data according to the terms of the protocol approved by the Mayo Clinic institutional review board. The AAMC gave permission for these data to be published and provided feedback and guidance to ensure the accurate interpretation of the data.
A total of 134 U.S. medical schools provided data for the March 31, 2011, Faculty Roster snapshot. Six schools did not offer either the TTT type or the CET type, so we excluded them from further analysis. The 128 remaining schools offered at least one of four track types: TTT, CET, research track (RT), or other. We excluded from our analysis any schools that did not report the number of faculty on a given track type and any schools with fewer than 10 full-time faculty per TTT or CET type.
For each medical school included in our analysis, we calculated the proportion of full-time female faculty and full-time male faculty identified on the TTT or CET type. Specifically, for each medical school, the proportion of women on the CET type equaled the total number of female full-time faculty on the CET type divided by the total number of female full-time faculty, whereas the proportion of men on the CET type equaled the total number of male full-time faculty on the CET type divided by the total number of male full-time faculty. We performed the same calculations for faculty on the TTT type.
We created a scatterplot by plotting the proportion of male faculty on the CET type against that of female faculty on the CET type for each medical school. We added a 45-degree line to the plot. Any point above that line indicated that the school had a higher proportion of female than male full-time faculty on the CET type. We performed the same calculations for faculty on the TTT type. We conducted all statistical analyses using SAS 9.2 (SAS Institute Inc., Cary, North Carolina).
The AAMC Faculty Roster data included information from 134 medical schools representing 138,508 full-time faculty members. Of these, 50,376 (36%) were women, 87,980 (64%) were men, and 152 faculty had gender listed as unknown.
Table 2 summarizes the number of schools reporting each faculty track type (TTT, CET, RT, and other), and the total number and percentage of full-time faculty on each track type. The TTT and CET types were the most commonly reported, with the TTT type identified in 123 of 134 schools (92%) and the CET type in 106 (79%).
Most (96% [128/134]) schools identified one or more track types. These 128 schools accounted for 89% of all medical school faculty in the database. Table 3 summarizes the number and distribution of the faculty track types (TTT, CET, RT, and other). However, Table 3 does not account for the fact that medical schools may have additional faculty tracks classified under track types that we did not study (e.g., adjunct, emeritus, visiting, or volunteer).
We excluded from our final analysis 14 of the 123 schools offering the TTT type and 16 of the 106 schools offering the CET type because the schools did not report the number of faculty on these track types. We also excluded from our analysis 7 schools that offered the TTT and 7 schools that offered the CET type because they each reported fewer than 10 full-time faculty members on the given track type. Therefore, the total number of schools with the TTT type included in our final analysis was 102, whereas the total number of schools with the CET type was 83.
Figure 1 depicts our scatterplots with the proportion of male faculty on the TTT (or CET) type plotted against the proportion of female faculty on that track type for each medical school. Among the 102 schools offering the TTT type, only 20 (20%) had a higher proportion of female faculty, whereas 82 (80%) had a higher proportion of male faculty on that track type. Among the 83 schools offering the CET type, 64 (77%) reported a higher proportion of female faculty and 19 (23%) reported a higher proportion of male faculty on that track type.
Over the past 30 years, women have accounted for an increasing proportion of medical school students and academic medicine faculty. In 2011, women composed 47% of medical school matriculants, 44% of newly hired faculty, and 37% of full-time permanent faculty.12 Despite these gains, considerable efforts to increase the proportion of women attaining advanced academic ranks and holding leadership positions have had limited success.2–4,7–10,12,29–32 In 2011, for example, only 13% of women in academic medicine attained the rank of full professor, a gain of only two to three percentage points over 30 years.8,12 Despite modest gains, no permanent leadership position in academic medicine has a greater proportion of women than men.12 Women account for a mere 12% of medical school deans and 14% of department chairs.12 The slow progress women have made in attaining senior positions speaks to the failure of the pipeline theory,8,33 which postulated that adding a sufficient number of trained and qualified female physicians in the lower ranks of academic medicine would eventually result in a proportionate increase in the number of women in senior leadership positions.
Although women have been entering academic medicine in increasing numbers, the available faculty positions have been redefined and have undergone significant change. Although the traditional tenure system remains intact, since 1984 a notable drop from 60% to 33% has occurred in the percentage of female clinical faculty who are tenured or tenure eligible.21 At the same time, the number of TTT positions has steadily declined, and a variety of alternative track positions have emerged.13,14,16,23
A recent study documented this proliferation of track types, revealing that U.S. medical schools offer an average of 3.6 (range of 1–8) faculty tracks.23 The Faculty Roster data we examined categorized disparately named faculty tracks into eight defined types, including the now widely offered CET type. First reported in 1984, the CET type is now offered at three-fourths of schools, with a growing number of faculty pursuing this track type.18,22 This growth has occurred in an era of increasing financial pressures and the open acknowledgment of the important role that clinical revenues play in funding academic medical centers. In the 1960s, clinical revenues accounted for only 3% of funding in academic medical centers. By 2005, that percentage had jumped to 45%.13,15
Our findings demonstrate that 77% of the medical schools offering the CET type had a higher proportion of female than male full-time faculty on this track type. In contrast, only 20% of the schools with the TTT type had a higher proportion of female than male full-time faculty on this track type.
The CET type offers both men and women the opportunity to contribute as academic faculty without the demanding timetable for research and publication that is typically associated with TTT appointments. These newer faculty track types have various requirements for promotion and tenure but typically contrast sharply with the rigorous time limitations of the TTT type.15,23 Promotion criteria for faculty on the CET type have been a challenging area of discussion since the track’s inception.13,14,17 Without the defined academic productivity and rank requirements of the TTT type (e.g., “publish or perish”), clinician–educator faculty who face ever-increasing clinical demands may put less emphasis on producing measurable academic products, such as publications in peer-reviewed journals or grant-funded research. Academic medical centers have been evolving institutional promotion standards to give CET type faculty credit for teaching and clinical contributions.14,17 Despite these efforts, promotion rates for clinician–educators continue to lag behind those for their TTT type colleagues.15
These promotion rates and our findings, which showed a greater proportion of women on the CET type, may offer insight into why women have not advanced to higher ranks and senior leadership positions at the expected rates. At the same time, more women have entered academic medicine, new CET types have become available, and the proportion and availability of TTT positions have declined. Because CET type availability and the decline in tenure opportunities would presumably be the same for men, the Faculty Roster data we analyzed did not reveal whether the higher proportion of women on the CET type versus the TTT type will balance out over time, giving women the same opportunities as men for promotion, or whether women are in a “never catch up” phenomenon. Analyzing both earlier Faculty Roster data and Faculty Roster data over time may provide a more complete picture of the importance of our findings.
Researchers have identified many barriers to the advancement of women in academic and leadership positions, including specialty choice, self-defined career goals, gender bias, the culture of academic medicine, and higher female faculty attrition rates than those of their male colleagues.30,34–44 In addition, women more often report an interest in teaching as the primary reason for entering academic medicine.39 They are more often members of departments such as family medicine and pediatrics38 or generalists in departments of medicine. These demanding clinical areas may have fewer tenure opportunities or may lead to higher departure rates.42 Women as teachers and as caregivers fit with described societal norms. Whether women are freely choosing or are encouraged to pursue these traditional career paths in education and in clinically demanding primary care specialties is not clear.36
Our findings also revealed that female faculty are more likely than their male colleagues to be on the CET type, if one is available, and less likely to be on the TTT type, if one is available. We do not know whether this finding is purely reflective of specialty choice, research interests, or career goals, or whether an effort, biased or otherwise, exists to encourage women to pursue the CET type rather than the TTT type. Faculty on the CET type continue to lag behind their colleagues on the TTT type in academic promotion. As advanced academic rank is often a prerequisite for leadership positions, our finding that women are more likely to be on the CET type deserves further analysis.
Our study has a number of strengths. We used the well-established AAMC Faculty Roster database, which captures information from more than 80% of accredited MD degree-granting U.S. medical schools and contains extensive information regarding the national distribution of full-time academic medical faculty. A total of 134 medical schools representing 138,508 full-time faculty members provided information in 2011 for the Faculty Roster regarding faculty track types. Almost all provided gender-specific information about faculty appointments to the available track types. As the majority of U.S. medical school faculty are included in this database, we were able to analyze their data in our study.
Our study also has several limitations. The AAMC Faculty Roster relies on voluntary reporting of data. As not all schools report data, the database is incomplete. In addition, the 134 medical schools that provided information for the Faculty Roster did so without further verification of the validity of their responses. Also, the data are reported in aggregate and do not reflect divisions at the department, specialty, or individual level. Relevant to our study is the fact that medical schools individually report their track types. The eight faculty track types defined by the AAMC are one way to group these disparately named (but similar) faculty tracks across medical schools.27 We relied on the Faculty Roster in assigning the various tracks submitted by the reporting medical schools to the TTT and CET types. For example, a medical school could have separate tracks called clinician–educator and clinical associate. These faculty tracks would appear in the Faculty Roster under their official names, but both would be reported as the CET type,27 which we in turn used in our analysis. Next, large interinstitutional variability may exist in faculty roles and requirements by track type. Furthermore, by excluding data from the smallest schools and data from the 2% of faculty reported as adjunct, emeritus, visiting, or volunteer, we may not have fully characterized the relationship of gender and track type. This variability deserves further analysis as it may identify factors influencing the identified differences in proportions of male and female faculty on the TTT and CET types.
In summary, 77% of the medical schools offering the CET type had a higher proportion of female full-time faculty than male full-time faculty on this track type. In contrast, among schools with the TTT type, the proportion of female full-time faculty on this track type exceeded the proportion of their male counterparts only 20% of the time. Although much more work is needed to further understand these findings, they are cause for concern. This documentation that faculty on the CET type lag behind their TTT colleagues in academic promotion leads us to believe that the greater proportion of women on the CET type may contribute to continued challenges in gaining academic and leadership parity for women in academic medicine.
Acknowledgments: The authors would like to acknowledge the Association of American Medical Colleges’ Faculty Roster staff, in particular Rae Anne Sloane and Tai Pham for their time, review, and answers to our queries.
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