Although 14.6% of all academic faculty at U.S. medical schools identify themselves as members of minority groups, only 3.9% identify themselves as black, Native American, Mexican American, or Puerto Rican, 1 groups that the Association of American Medical Colleges (AAMC) classifies as “underrepresented” (meaning that their proportions in the physician population are smaller than their proportions in the general population). 2 The underrepresentation of minority persons on medical faculties has several causes, including few minority medical school graduates, indebtedness of postgraduate trainees, shortage of role models, and lack of awareness of opportunities in academic medicine. 3,4 Traditionally, underrepresented minority (URM) groups have chosen primary care specialties. 5 This pattern may be changing as these groups enter specialties and subspecialties in greater numbers. The greater debt burden accumulated by URM students may influence them to choose higher-paid specialties. 6 In a national, representative sample of medical school faculty we explored the specialty choices, compensation, and career satisfaction of minority faculty relative to their majority counterparts.
Survey Sample and Instrument
In 1995, we conducted a survey, described in more detail elsewhere, 7 of a stratified random sample of 4,051 fulltime salaried faculty at 24 U.S. medical schools. These 24 schools were randomly selected from the 106 medical schools within the contiguous United States that had faculties of more than 200 with at least 50 women and ten URM faculty. We did not sample any Puerto Rican or historically black medical schools. We mailed the survey questionnaire to all URM faculty and to a random sample of non-minority faculty. Of the 4,051 faculty, 1,038 were ineligible because they had left their institutions, were not full-time faculty, or had died. We mailed a reminder postcard to non-respondents and, if necessary, called them and mailed them a second questionnaire.
The self-administered questionnaire asked 177 questions about faculty demographics; professional goals and work situation; current academic environment and rank; mentoring relationships; experiences with bias, discrimination, and harassment; academic productivity; family responsibilities; faculty compensation; and career satisfaction. Many of the questions were taken from previously published studies. 8,9 The Boston University School of Medicine Institutional Review Board approved this study.
We coded departments as follows: primary care (general internal medicine, general pediatrics, family medicine, and geriatrics); medical specialties (internal medicine subspecialties, pediatric subspecialties, neurology, physical medicine, radiology, emergency medicine, anesthesia, and psychiatry); surgical specialties (general surgery and its subspecialties); and basic science. For analysis, we created three groups from the self-reported ethnic/racial categories in the questionnaire: majority faculty (white, not of Hispanic origin); URM faculty (black, not of Hispanic origin; Mexican American, Puerto Rican); and other-minority faculty (Asian and other Hispanic groups).
We used principal-component analysis to assess the internal reliability of the career satisfaction scale (Cronbach alpha = 0.87). Chi-square tests were used to compare proportions between the ethnic/racial groups. We used analysis of covariance to compare career satisfaction scores between majority, URM, and other-minority faculty, adjusting for gender, medical school, department, rank, presence of a mentor, compensation, hours worked per week, and proportion of time spent in clinical and research activities. Analysis of covariance was also used to determine the adjusted compensation among the three ethnic/racial groups, controlling for gender, medical school, department, rank, years as faculty member, proportion of time spent in clinical activities, and average hours worked per week. We used least-significant difference to test for significant differences in pairwise comparisons of the continuous outcome variables. Analyses were performed using SAS statistical software (version 6.11).
Of 3,013 eligible faculty who received the questionnaire, 1,807 (60%) returned it. Our yield of URM respondents was somewhat lower than that for other faculty: URM faculty received 15.5% of the questionnaires, but comprised only 10.8% of the respondents. Despite over-sampling URM faculty, we received completed questionnaires from 1,463 majority faculty, but from only 195 URM faculty and 149 other-minority faculty.
Compared with majority faculty, URM faculty were less likely to be women (Table 1). Other-minority faculty were less likely to have been born in the United States than were majority faculty. Majority and other-minority faculty were more likely than URM faculty to have a professional father (>62% versus 47%; p = .001). Compared with majority faculty, fewer URM faculty were board certified or had a PhD. Only 11% of URM faculty were in a basic science department. Compared with majority faculty, a larger proportion of URM faculty were in medical specialties; they also spent more time in patient care and the less time in research activities. There was no difference between majority, URM, and other-minority faculty in the proportions of those groups practicing in primary care specialties.
There was no significant difference in the adjusted mean compensations for majority, URM, and other-minority faculty. However, a greater percentage of URM faculty reported needing supplementary income and felt that financial considerations had affected their professional career development choices. They also had significantly lower adjusted career satisfaction scores and more often reported that they were considering leaving academic medicine within five years.
We found that most URM faculty were in primary care and medical specialties. The proportion of URM faculty in basic sciences (11.6%) was similar to that reported in the AAMC Faculty Roster (10.0%). 1 One study examining the specialty selection among 1987 U.S. medical school graduates by race and ethnicity found that URM students were more likely than were their majority and other-minority peers to select a primary care specialty as their first choice. 5 However, recent data show an increasing proportion of URM medical students pursuing non-generalist careers. 10
The socioeconomic background of URM faculty respondents also may have been less advantaged than those of the other groups; fewer URM faculty came from households with professional fathers. Kassenbaum and colleagues 11 found that a greater number of URM medical graduates had a higher debt burden (over $75,000) after medical school than did majority graduates (26% versus 20%); the gap was even more striking in graduates of private medical schools (45% of URM students versus 35% of majority students). They also noted that, in the pool of graduates with that level of debt, URM medical students were less interested than their majority peers in primary care and more likely to pursue medical specialties, and they were more likely than their peers to cite indebtedness as a major influence on specialty choice. Economic pressure on URM students may reduce the likelihood of their pursuing PhDs or careers in research or basic science, as these choices generally lead to lower compensation. However, other studies have shown small or nonsignificant relationships between indebtedness and specialty selection. 12–15 It is likely that debt load is but one of many factors that influence career choice. Despite similar compensation, more URM faculty in our study still felt pressed to moonlight and were more likely than other faculty to report that finances had affected their professional career development choices.
The URM faculty's lower career satisfaction scores are of concern, as this group is also more likely to leave academic medicine. This finding persisted despite adjustments for rank, compensation, department, and professional time allocation. This is particularly worrisome given the relatively low numbers of URM medical school faculty and their enrollment in U.S. medical schools. 16
In summary, we found that URM faculty may come from less advantaged backgrounds, have more clinical responsibilities and less research time, and, despite receiving compensation similar to that of majority and other-minority faculty, need to supplement their incomes. It is notable that URM faculty are less satisfied with their careers and are more likely to leave academic medicine, further reducing their numbers. Deans and department heads need to address the issues raised here because URM faculty play an important role in training medical professionals to meet the needs of an ever-more-diverse U.S. population.
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