Rayburn, William F. MD, MBA; Anderson, Britta L. BA; Johnson, Julia V. MD; McReynolds, Megan A. BS; Schulkin, Jay PhD
Periodic reviews of the sizes of academic departments are essential to determine whether a sufficient faculty workforce is available to fulfill missions in teaching, patient care, and research. An initial survey of departments of obstetrics and gynecology by Spellacy et al1 in 1975 served as a benchmark for future comparisons. Six subsequent manpower studies were conducted between 1977 and 1994 by Pearse et al2–7 in cooperation with the Association of Professors of Gynecology and Obstetrics and the American College of Obstetricians and Gynecologists. Nearly all chairs from each accredited U.S. medical school replied to those workforce surveys and predicted needs for teaching, research, and patient care.
Current data and projections about department sizes are important for faculty, chairs, the specialty as a whole, and those either considering or beginning an academic career in obstetrics and gynecology. Since the last survey in 1994, few changes occurred in the numbers of medical students or residency positions at university-based obstetrics and gynecology departments.8 Medical school enrollments are projected to expand by 30% by 2013, and more obstetrician–gynecologists will be needed in the workforce.8,9 In addition, the number of part-time faculty positions increased for many academic departments. Several clinical specialties, except for obstetrics and gynecology, published about the demand and advantages for selecting part-time faculty.10
The objective of the present investigation was to report results from the seventh survey on full-time faculty and from the first survey on part-time faculty. In doing so, long-term trends in the number and variety of faculty and in future directions of faculty growth can be better assessed for academic workforce needs.
MATERIALS AND METHODS
This study was approved by the Human Research and Review Committee (no. 08–442) at the University of New Mexico and the American College of Obstetricians and Gynecologists Institutional Review Board (no. 00003428). A faculty workforce survey was drafted in the same format as the original questionnaire created by the Association of Professors of Gynecology and Obstetrics in 1977.2 Certain questions were added at the request of the National Institute of Child Health and Human Development to assess the number of current research faculty and those needed in the future.3,4 Questions addressed the number of current faculty in each specialty. For comparison with the other reports, this survey differentiated between full-time (1.0 full-time equivalent) and part-time (0.5–0.9 full-time equivalent) faculty. We did not include faculty less than 0.5 full-time equivalent, because they constituted a small group and were too part-time to be eligible for paid benefits.
We sought to differentiate each faculty member using the following categories: sex, rank, degree (MD or DO, PhD, and other), and specialty (general obstetrics and gynecology, gynecology–oncology, maternal fetal medicine, reproductive endocrinology and infertility, female pelvic medicine, and reconstructive surgery). Other faculty usually consisted of master’s-trained providers (eg, certified nurse midwives, genetics counselors, physician assistants, nurse practitioners) with full-time faculty appointments at the instructor rank or higher (not letters of academic title or lecturers). Each chair was also asked to project the faculty size in their department in 5 years (2013).
Each survey was sent electronically in October 2008 to all chairs of obstetrics and gynecology departments at the 125 U.S. medical schools. Since the 1994 survey, two schools were combined (Medical College of Pennsylvania and Hahnemann University—now Drexel), two were added (Florida State University and Virginia Tech/Carilion), and Pennsylvania State University became classified as a public school. If the survey was not returned in 2 weeks, a reminder was sent to each chair. To ensure collection of the survey from all departments, the principal investigator conducted a personal interview by telephone with any chair who did not respond despite repeated reminders. When data accuracy was questioned, a review of the department’s Web site and a communication with the chair or department manager were also undertaken.
Data were analyzed using a personal computer-based version of SPSS 15.0 (SPSS Inc., Chicago, IL). Descriptive data were computed for primary analysis. Group differences with full-time faculty in past publications were analyzed using χ2, Kruskal-Wallis, Wilcoxon rank sum, and time series tests where appropriate. Statistical significance was defined at α<0.05 and at confidence intervals of 95%.
A total of 3,650 full-time faculty were reported by all 125 department chairs. Four fifths (2,910, 79.7%) of faculty were MDs, whereas the remainder were either PhDs (438, 12.0%) or others (302, 8.3%). The number of full-time faculty per department ranged widely (from 1 to 168), with the average department consisting of 29 full-time faculty. The mean number of full-time faculty per department increased from 25 in 1994 to 29 in 2008 (95% confidence interval 25–33).
Table 1 compares the mean and median numbers of full-time MD faculty per department who were general obstetrician–gynecologists (n=15) and in the various subspecialties (n=14). The most well-represented subspecialty was maternal–fetal medicine. Our survey included an average of two physicians per department who were listed as specialists in female pelvic medicine and reconstructive surgery. The newest group of certified specialists was in reproductive genetics.
Figure 1 compares the mean number of current full-time faculty per department with those in prior years when the survey was conducted. The total number of faculty per department doubled since 1977 and significantly increased over time (r=0.989, P<.001). The rate of growth of full-time faculty was the lowest (7.4%) in this survey compared with the others. The largest increase in numbers remained among MD faculty. The mean numbers of PhD faculty per department remained constant. In no department did the number of faculty decline.
Women now comprise the highest proportion of faculty. Figure 2 compares the proportion of women and men who were full-time faculty in obstetrics and gynecology since 1977. The proportion of women increased significantly over time (r=0.952, P<.001). More recently, the proportion of women who were faculty per department increased from 34.1% in the 1994 survey to 52.3% now (P<.001). The increases in the number and proportion of women were apparent in each faculty category (Table 2). Compared with men, women were more likely (P<.01) to be instructors (21.6% compared with 9.2%) or assistant professors (50.6% compared with 34.9%) than associate professors (19.0% compared with 26.8%) or professors (9.1% compared with 29.1%).
Eighty-four percent (105 of 125) of all departments had part-time faculty, with an average of 21.2% of total faculty in those departments having part-time positions. Two-thirds (67.2%) of those departments had 1 to 6 part-time faculty, with only six departments having more than 15 part-time faculty. The size of the department was not predictive of the number of part-time positions. There was a higher percentage of women than men having part-time positions (23.0% compared with 16.2%, P=.023), although the number of part-time faculty who were women was similar to men (539 compared with 445).
Department sizes were affected by the ownership of the school and by the emphasis on research productivity. As shown in Table 3, private schools had significantly more faculty than public institutions (F1,124=5.6, P=.02). This difference was completely accounted for by the number of MDs (F1,124=8.4, P<.005). The top 40 research-intensive schools, according to 2008 National Institutes of Health funding, had significantly more faculty than at the less research-intensive and the community-based medical school departments (F1,124=30.8, P<.001). This difference was accounted for by the number of MDs (F1,124=32.7, P<.001) and the number of PhDs (F1,124=13.3, P<.001). Many of these larger departments were private schools in the Northeast (American College of Obstetricians and Gynecologists districts I, II, and III) or schools in Texas (American College of Obstetricians and Gynecologists district XI). In contrast, departments with the smallest number of faculty were at public medical schools located in the South Central states (American College of Obstetricians and Gynecologists district VII). Community-based medical schools had the fewest faculty, consisting primarily of MDs.
Two-thirds of all chairs anticipated that there will be an increase in the number of faculty in the next 5 years. This proportion of chairs who projected an increased need for faculty was significantly higher than that reported in 1994 (67.2% compared with 48.8%, P<.0001). Only two chairs anticipated a decrease, which is significantly less than reported in the 1994 survey (1.6% compared with 22.0%, P<.0001). The greatest needs now and for the next 5 years were for general obstetrician–gynecologists and maternal–fetal medicine specialists at any rank, but most notably as entry-level assistant professors. These needs are similar to those reported in prior surveys.2–7 Twenty-seven departments reported not having specialists trained in female pelvic support and reconstructive surgery.
When asked to anticipate requests for part-time positions, chairs predicted that both current and future faculty will desire fewer working hours. For current faculty, two-thirds of department chairs anticipated that the number of part-time positions will increase (48.8%) or remain the same (46.4%), rather than decrease (5.6%). For faculty to be recruited, chairs anticipated the requests for part-time work will either increase (63.2%) or be unchanged (36.8%).
Written comments from the chairs were revealing. Repetitive comments related to more faculty wanting to work part-time, the current economic downturn prompting research to take a “backseat,” projections of faculty recruits being difficult if the chair was interim, and limited space (and resources) prohibiting more growth on campus.
According to the Liaison Committee on Medical Education in 2007, faculty in obstetrics–gynecology constituted 4.8% of all full-time clinical faculty and 3.9% of all faculty at U.S. medical schools.11 Current data, trend data, and projections reported here remain vital information for the specialty. Despite what have sometimes been viewed by chairs as financial limitations ahead at the time of each survey, they still projected growth in faculty sizes of their departments. The continued rate of faculty growth in the current survey was the lowest compared with prior surveys. This finding may be explained by the larger number of faculty, leveling off in the median number of residents taught per department (from 21 in 1977 to 23 in 2008), limited office or clinical space (and other resources), and a more competitive and costly health care environment with budgetary constraints.2–7
As documented in other specialties, most departments of obstetrics and gynecology have part-time faculty.11–16 It is not surprising that the chairs anticipate an increase in requests for part-time positions by future faculty. A recent study demonstrated an increase of part-time faculty in internal medicine by 88% in the past 20 years.17 Part-time faculty positions were seen as advantageous for the chair, faculty, and patients.16–18 Institutions are now developing policies to optimize recruitment and promotion of part-time faculty because the future of academic medicine is dependent more on maintaining part-time faculty members.19
Over the course of the past 30 years, the relative representation of women as medical students, residents, and faculty in the United States increased steadily.20 The percentage of women selecting residencies in obstetrics and gynecology remained unchanged over the past 30 years, whereas the percentage of women in each medical school class increased steadily.21 The numbers of men in each medical school class remained relatively stable, whereas the percent selecting the specialty declined from 10% to 2% over the past three decades. Findings in our investigation and the AAMC Women in U.S. Academic Medicine 2007–08 report confirm that half of all faculty in obstetrics and gynecology are now women.21 This proportion of women who are faculty is higher in obstetrics and gynecology than in any other clinical and basic science department.21 This increasing proportion of faculty who are women may be due to a larger number of women who wish to continue their scholarship in medicine and science.22 Perhaps the expansion of medical schools opened the door to more academic opportunities at a time when medical school–based practice presented a more controllable lifestyle than the predominant small-group private practice opportunities available to graduates in earlier years.22,23
Of interest, half of faculty continued to be generalist obstetrician–gynecologists. This contrasts with the finding that one in every four academic chairs in obstetrics and gynecology is a generalist.24 This nearly equal balance in faculty between generalists and subspecialists likely reflects the continued importance of generalists as educators and their roles as models for residents who mostly graduate to general patient care or other professional activities.25
The lack of increase in PhD faculty is disconcerting. Surgically oriented departments such as obstetrics and gynecology have always had the smallest percent (0.9%) of medical school PhD faculty.25,26 Not surprisingly, we found the highest number of PhDs to be among the top 40 research-intensive schools. By 1999, PhD faculty accounted for half or more of the total principal investigators on National Institutes of Health grants in surgical departments and from clinical departments at less research-intensive medical schools.26 Furthermore, the percent of principal investigators who are physician–scientists continues to decline in clinical departments.
In the comments section of our survey, several chairs stated that much time is spent with patient care, leaving less for academic pursuits. This survey was conducted after institution of more restricted duty hours for residents, and we did not query about the effect of faculty sizes and the reduced residency duty hours. If academic obstetrician–gynecologists’ clinical responsibilities become more, with less time for academic pursuits, the greater autonomy and income potential afforded by a more private office setting may become more attractive. Although not new, this concept may be more apparent as perceived lifestyle constraints and debt incurred from past medical education become more significant considerations. In addition, a loss of qualified faculty to private practice would add more of a teaching load on clinical faculty who already became more committed to patient care.
Larger departments, mostly at private medical schools in the Northeast, may have more financial stability, with little or no dependence on state appropriations and accompanying restrictions, more endowments, and more resources to attract and retain those faculty pursuing academic careers. Larger departments are more likely to have part-time faculty. Future studies to understand the roles of department size, geographic location, and other unassessed factors on the variation in recruitment and departure rates may shed light on the efforts to increase the academic workforce.
Our investigation had several strengths and certain limitations. Surveys from all schools (100% compliance) are presented here. The data were retrieved electronically and double-checked when necessary. Bias in reporting by chairs was minimal because recall was for the current period. Our data differentiated between the types of schools, examined sex more closely, and included the new subspecialty of female pelvic medicine and reconstructive surgery (or urogynecology). We observed trends over more than 30 years using the same basic questionnaire. We compared trends for full-time academic obstetricians and gynecologists with data from other surveys, while exploring the part-time positions. A potential limitation involved whether faculty appointments were provided to fellows in training and to other non-MD, non-PhD faculty who may have qualified as instructors at another medical school.
In conclusion, the number of full-time faculty in obstetrics and gynecology at U.S. medical schools more than doubled in the past 31 years. The modest growth since the reported survey in 1994 was only among MD faculty. Half of faculty continues to be generalist obstetrician–gynecologists. The most substantial change was the increase in women, who now constitute half of all faculty. The change in workforce to more part-time faculty is critical for academic chairs and deans to track so that faculty needs can be more accurately projected. Recruitment and retention of productive faculty who train our next generation of obstetrician–gynecologists will require the identification of nonclinical sources of funding (eg, department reserves, endowments, dean’s startup funds, university hospital, contracts with community hospitals), aside from patient care revenues, to support our critical missions, provide a balance between professional and lifestyle activities, and prepare for the expanded numbers of medical students and residents. To more accurately assess reasons for attrition, future studies should target those who left academia altogether or who move to another institution.
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© 2010 by The American College of Obstetricians and Gynecologists.