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Research Reports

Rank and Tenure Amongst Faculty at Academic Medical Centers: A Study of More Than 50 Years of Gender Disparities

Franks, Adam M. MD1; Calamur, Nandini MD2; Dobrian, Anca PhD3; Danielsen, Mark PhD4; Neumann, Serina A. PhD5; Cowan, Eileen MD6; Weiler, Tracey PhD7

Author Information
doi: 10.1097/ACM.0000000000004706

Abstract

Gender inequality is a problem facing the global workforce; the World Economic Forum recently estimated that it will take ~100 years to reach gender parity globally and ~150 years in North America. 1,2 In addition to injustice, gender inequality results in a loss of talent and profit. 3–5 Furthermore, decreased gender diversity can result in an undesirable increase in homogeneity of thought and action. 6 Manifestations of gender inequality include a significant wage gap, fewer females in leadership roles, and prolonged time to career advancement for females. 1,5 The cause is multifactorial: disproportionate responsibilities for caregiving (child and elder) and domestic duties, imposter syndrome, less sponsorship for females, and gender bias, amongst other factors. 1,3–5,7–10

Gender inequality is also an issue in academic medicine. The first American medical schools founded in the late 1700s accepted only males. 11 Therefore, females who wanted to be physicians trained through irregular apprenticeships. 12 Elizabeth Blackwell was the first woman to graduate from medical school in the United States in 1849. 13,14 In the late 19th century, philanthropic gifts eased financial pressures on institutions and facilitated females matriculating into medical schools. By the end of the 19th century, more than 7,000 females were practicing physicians and another 1,200 were in medical school. 12,13

The gender gap in medicine has since narrowed, and recently there have been more females than males entering medical school. 15–18 However, this recent trend toward equal numbers of males and females (gender parity) in medical school has not resulted in equal outcomes (gender equality) for faculty overall. 17,19 In 2019, 41% of all specific gender-identified, full-time faculty at academic medical centers (AMCs) were female, 16 while only 25% of full professors and 18% of department chairs and deans were female. 16–18,20–22 In basic science (BSc) departments in 2019, 58% of graduate students were female, yet only 40% of full-time faculty were female. 16,23 Furthermore, depending on specialty, there is a 16%–37% wage gap between females and males. 24 In addition, females are less likely than males to receive career development awards and grant funding. 25–28 In academic medicine, inherent gender bias manifests as impediments in compensation and authorship, exclusion as panel speakers, decreased membership on editorial boards, fewer successful awards and grants, and decreased promotion to advanced ranks and positions. 15–18,20–25,29–31

Gender inequality has also been observed in tenure acquisition. The earliest evidence for tenure in the United States dates back to 1721 with the creation of endowed chairs at Harvard, which essentially provided “tenure for life.” 32 Traditionally, tenure, controlled by male leadership, provided faculty with the academic freedom to teach and research whatever they wished without repercussion. 32–34 In 2004, the National Study of Postsecondary Faculty reported that the ratio of tenured females to males in health science faculty was less than 1:4. 35

In this report, we assess the historical trends toward gender parity using data from the Association of American Medical Colleges (AAMC) Faculty Roster and project the time to full gender parity. We contextualize the progress toward gender parity by considering external forces that may have shaped the evolution of academic medicine. For example, the size of the academic medicine faculty workforce nationally has dramatically expanded since the 1960s. Declining support for research from private philanthropy and the government in the 1980s created faculty dependence on clinical work to fund the academic enterprise. 36,37 In the 1990s, increased educational demands resulted in the development of the medical educator academic track. 36–40 We suggest that these external forces resulted in nonlinear changes in gender parity over the past half century. Understanding the magnitude of the forces that created these changes is necessary for implementing future policies aimed at strengthening gender equality.

Method

The AAMC Faculty Roster (https://www.aamc.org/data-reports/faculty-institutions/faculty-roster) is a database that describes the characteristics of full-time faculty at MD-granting medical schools in the United States. The database, initiated in 1966 with data from 88 (of 96, 91.67%) institutions, is updated annually. Institutions self-report their data. In 2019, 149 (of 153, 97.39%) medical schools were represented. The Faculty Roster captures the following descriptive data: academic rank, tenure status, year of appointment, promotion, race/ethnicity, degree, department, age, and sex. (The data field in the Faculty Roster is listed as “sex”; however, we opted to use the term “gender” throughout this report, except when directly referring to our search, as it was a more accurate description of the data.) Definitions for data fields, including a binary choice for gender, are defined by individual institutions.

We queried the Faculty Roster for “sex, tenure, & department” and “sex, rank, & department” each year from 1966 to 2019 for BSc and clinical science (CSc) departments. The data we received represented combined, national figures for the end of December each year. Faculty categorized as “instructor” or “other” represented 12.56% of the total database and were excluded from our analyses, owing to institutional heterogeneity in the definitions of these ranks. We also excluded part-time faculty, as they are not included in the Faculty Roster. We submitted a request to the AAMC for combined tenure status and academic rank data as these are not available through the publicly searchable Faculty Roster.

We received absolute numbers of females and males for the academic ranks of assistant, associate, and full professor, as well as for the following tenure statuses: tenured, tenure track, and non-tenure track. These terms were specific fields in the Faculty Roster; thus, we did not define them ourselves. In our analyses, we expressed these data as whole numbers and as percent female (total females per total faculty) and graphed them over time.

We conducted chi-square tests for gender versus academic rank and gender versus tenure status using SAS 9.4 software (SAS Institute, Cary, North Carolina). We also conducted trend analyses (ANOVA) using the R studio 4.0.3 software (R Studio, Boston, Massachusetts). We used the “tseries” package for trend analysis because of its well-established functions in time series analysis. 41 We used the “forecast” package for its appropriateness in univariate time series prediction analysis and automatic ARIMA modeling, which we adopted because of its capabilities to account for autocorrelation between neighboring periods in a time series with good predictive accuracy. 42 Finally, we used ANOVA testing to compare the difference between the slopes of the trend lines. Odds ratios (ORs) reported below represent gender differences in the comparison of 2 faculty groups. A P value of < .05 was considered significant for all statistical tests.

The Marshall University Institutional Review Board deemed this project exempt from review (#1529416-1).

Results

There was a 12-fold increase in the number of assistant, associate, and full professors from 13,022 in 1966 to 156,957 in 2019 (see Figure 1A). This change was driven by a 15-fold increase in CSc faculty from 9,180 (70.50% of 13,022 total faculty) to 139,151 (88.66% of 156,957 total faculty) and a nearly 5-fold increase in BSc faculty from 3,842 (29.50% of 13,022 total faculty) to 17,806 (11.34% of 156,957 total faculty) over this time period. The increase in the number of BSc faculty appears to be steady over the entire time frame (see Figure 1B); however, it is made up of 3 distinct trends: an increase of 492 faculty per year from 1966 to 1976 (R2 = 0.99; P < .001), an increase of 216 faculty per year from 1977 to 2015 (R2 = 0.98; P < .001), and an increase of 64 faculty per year from 2016 to 2019 (R2 = 0.89; P < .001). The increase in the number of CSc faculty was more varied. From 1966 to 2000, there was a steady growth of 1,944 faculty per year (R2 > 0.99; P < .001). That growth increased to 3,810 faculty per year (R2 = 0.99; P < .001) in 2001, then decreased to 1,268 faculty per year from 2017 to 2019.

F1
Figure 1:
Aggregated longitudinal data for number of faculty with appointments at academic medical centers (AMCs), number of AMCs, and number of medical students. The numbers of faculty overall, in basic science departments, and in clinical science departments were calculated based on yearly data, curated by the Association of American Medical Colleges Faculty Roster from 1966 to 2019 (Panel A). Significant differences were seen between basic science and clinical science faculty. Clinical science faculty had 2 significant slopes: 1966–2000 (increase of 1,944 per year; R2 > 0.99) and 2001–2016 (increase of 3,810 per year; R2 = 0.99), while the 2017–2019 slope (increase of 1,268 per year) did not meet significance. Basic science faculty had 3 distinct slopes: 1966–1976 (increase of 492 per year; R2 = 0.99), 1977–2015 (increase of 216 per year; R2 = 0.98), and 2016–2019 (increase of 64 per year; R2 = 0.89) (Panel B). Data include females and males, all tenure categories, and all academic ranks. The total number of Liaison Committee on Medical Education (LCME)-accredited AMCs in the continental United States was plotted over time (Panel C). Three distinct trends were seen: 1966–1977 (increase of 2.52 per year; R2 = 0.97), 1978–2005 (increase of 0.07 per year; R2 = 0.67), and 2006–2019 (increase of 1.72 per year; R2 = 0.97). The total number of medical students enrolled in medical schools (Panel D) had 2 distinct slopes: 1966–1977 (increase of 712 per year; R2 = 0.98) and 2006–2019 (increase of 410 per year; R2 = 0.99). The Pearson correlation coefficient for numbers of medical schools and medical students was 0.99.

Despite the 12-fold increase in the number of faculty from 1966 to 2019, the number of AMCs increased less than 2-fold over this time period, including a 28-year period (1978–2005) of minimal growth (see Figure 1C). The growth pattern of medical schools correlated with that of first-year medical students, which also plateaued between 1977 and 2006 (R2 = 0.99; P < .001) (see Figure 1D).

The total number of tenured faculty in 1966 was 2,944, which increased to a maximum of 25,263 by 2011 but remained relatively constant from 1994 to 2019 (see Figure 2A). From 189 (6.42% of 2,944) in 1966, the number of tenured females increased in a linear manner of 121 per year for the entire 54 years we studied (R2 = 0.99; P < .001). In the 1970s, the rapid increase in the number of tenured males outpaced the gradual increase in the number of tenured females, initially widening the gender gap. In the 1980s, the increase in the number of tenured males slowed and, by 2004, started to decrease, somewhat shrinking the gender gap. Yet, in 2019, females only made up one-quarter of the tenured workforce (6,265 females of 24,263 total faculty).

F2
Figure 2:
Total number of faculty at academic medical centers by gender and tenure category. The numbers of female and male faculty in the tenured, tenure track, and non-tenure track categories were obtained from the Association of American Medical Colleges Faculty Roster from 1966 to 2019. Tenured (Panel A) females exhibited 1 slope (increase of 121 per year; R2 = 0.99), while males had 4 distinct slopes: 1966–1980 (increase of 920 per year; R2 = 0.97), 1981–1994 (increase of 332 per year; R2 = 0.99), 1995–2004 (increase of 61 per year; R2 = 0.61), and 2005–2019 (decrease of 169 per year; R2 = 0.96). Tenure track (Panel B) females also exhibited 1 slope (increase of 174 per year; R2 = 0.99), while males had 4 distinct slopes: 1966–1980 (increase of 626 per year; R2 = 0.96), 1981–1994 (increase of 140 per year; R2 = 0.77), 1995–1999 (decrease of 169 per year; R2 = 0.86), and 2000–2004 (increase of 494 per year; R2 = 0.99). Males also had a nonsignificant slope from 2005 to 2019 (increase of 6 per year). Both non-tenure track (Panel C) females and males had 2 distinct slopes with transition points in 2000: increase of 463 per year (R2 = 0.92) and 2,189 per year (R2 = 0.99) for females and increase of 905 per year (R2 = 0.98) and 1,982 per year (R2 = 0.99) for males.

The pattern for female tenure track faculty is similarly consistent, increasing at a rate of 174 faculty per year for 54 years (R2 = 0.99; P < .001) (see Figure 2B). The number of tenure track males initially rose sharply then plateaued in 2004. As a result, the percent female of tenure track faculty rose continuously (12.71%, 305 females of 2,400 total faculty, in 1966 to 42.12%, 9,299 females of 22,075 total faculty, in 2019). In contrast to the number of tenured faculty, the number of tenure track faculty continued to increase.

A 106-fold increase in the number of non-tenure track faculty occurred from 1966 to 2019 (1,150 to 121,729). This reflects an almost 248-fold increase in the number of females (225 to 55,768) and a more than 71-fold increase in the number of males (925 to 65,961) (see Figure 2C). In contrast, the numbers of tenured and tenure track faculty only showed an 8-fold and 9-fold increase, respectively. The year 2000 was a transition point for non-tenure track faculty of both genders, with males experiencing a faster rate of increase than females before 2000 (905 per year vs 463 per year) and females experiencing a slightly faster rate after 2000 (1,982 per year vs 2,189 per year).

We calculated ORs for females to be in specific positions relative to their male peers. In 2019, the OR for female BSc faculty to be in tenure track versus non-tenure track positions compared with males was 0.83 (confidence interval [CI] 0.76–0.90) (see Figure 3A). Parity was seen for female CSc faculty (OR 0.98; CI 0.95–1.01) (see Figure 3B). The odds were lower for female BSc and CSc faculty to be in tenured versus tenure track positions compared with males: 0.63 (CI 0.58–0.68) and 0.44 (CI 0.42–0.46), respectively (see Figures 3C and 3D). Similarly, small ORs were observed for female full professors versus associate and assistant professors in both BSc and CSc departments compared with males: 0.55 (CI 0.52–0.59) and 0.42 (CI 0.41–0.43), respectively (see Figures 3E and 3F). Our academic rank and tenure status component groups subanalysis often revealed gender parity and even an overrepresentation of females when total numbers were small, such as in assistant professors with tenure and full professors on a tenure track (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B258).

F3
Figure 3:
Odds of female faculty being in each tenure category and at each academic rank relative to male faculty. Odds ratios with 95% confidence intervals (CIs) were calculated from data from the Association of American Medical Colleges Faculty Roster. The odds that females were on a tenure track versus non-tenure track relative to males were 0.86 (CI 0.52–1.40) in 1966 and 0.83 (CI 0.76–0.90) in 2019 for basic science faculty (Panel A) and 1.10 (CI 0.84–1.45) in 1966 and 0.98 (CI 0.95–1.01) in 2019 for clinical science faculty (Panel B). The odds that females were tenured versus on a tenure track compared with males were 0.45 (CI 0.31–0.66) in 1966 and 0.63 (CI 0.58–0.68) in 2019 for basic science faculty (Panel C) and 0.59 (CI 0.46–0.76) in 1966 and 0.44 (CI 0.42–0.46) in 2019 for clinical science faculty (Panel D). The odds that females would achieve full professor rank versus associate or assistant professor rank compared with males for basic science faculty were 0.24 (CI 0.15–0.36) in 1966 and 0.55 (CI 0.52–0.59) in 2019 (Panel E) and for clinical science faculty were 0.22 (CI 0.17–0.30) in 1966 and 0.42 (CI 0.41–0.43) in 2019 (Panel F).

We constructed a percent female trend line with 95% CI to predict gender parity. For BSc/CSc assistant, associate, and full professors, we predicted gender parity will be achieved in 2034/2023, 2047/2033, and 2065/2053, respectively (see Figure 4). We predicted faculty on a non-tenure track will achieve gender parity first, usually followed by those on a tenure track then those who are tenured, within each academic rank group (see Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/B258).

F4
Figure 4:
The percent female faculty in basic science and clinical science departments, by academic rank, and the projected time needed to reach gender parity. Numbers of female and male faculty were obtained from the Association of American Medical Colleges Faculty Roster from 1966 to 2019. Analysis was done individually for each academic rank and type of department (basic science: Panels A–C, clinical science: Panels D–F). Data were expressed as the average percent of the faculty who were female. The calculated model of the best-fit line was used to extrapolate the trajectory to predict when gender parity will be achieved with a 95% confidence interval. The years at which gender parity was predicted are shown.

For all ranks within both BSc and CSc departments, the percent female faculty was initially very low in 1966: BSc assistant ~18%, associate ~10%, full professor ~4%; CSc assistant ~17%, associate ~9%, full professor ~4% (see Figure 5). In BSc departments, the percent female faculty at the assistant and associate professor ranks consistently increased by 0.53%–0.54% per year from 1966 to 2019 (R2 = 0.99). In contrast, a consistent increase of 0.23% per year for BSc full professors was observed until 1986 (R2 = 0.97), after which the rate increased to 0.57% per year (R2 > 0.99), which was similar to that of other BSc faculty ranks. This rate then remained constant (P < .001) for the next 34 years.

F5
Figure 5:
The percent female faculty rate of change in basic science and clinical science departments. Numbers of female and male faculty were obtained from the Association of American Medical Colleges Faculty Roster from 1966 to 2019. The average percent female faculty in basic science and clinical science departments was plotted in yearly increments for each academic rank. Piecewise linear regression fits were applied for individual graphs. The slopes of the linear functions, corresponding with the rates of change in percent female, are shown. Goodness of fit for basic science assistant professors was R2 = 0.99 (Panel A) and for associate professors was R2 = 0.99 (Panel B). Basic science full professors had 2 distinct slopes: R2 = 0.97 from 1966 to 1986 and R2 > 0.99 from 1987 to 2019 (Panel C). Clinical science assistant professors did not have a distinct slope until 1977, after which 2 consistent slopes emerged, from 1978 to 1994 (R2 > 0.99) and 1995 to 2019 (R2 > 0.99) (Panel D). Clinical science associate professors (Panel E) displayed consistent slopes from 1966 to 1985 (R2 = 0.96) and 1986 to 2019 (R2 > 0.99). Clinical science full professors had 3 distinct slopes: 1966–1980 (R2 = 0.96), 1981–1994 (R2 > 0.99), and 1995–2019 (R2 > 0.99) (Panel F). The years separating independent linearly fit segments were significant (P < .001) and are indicated on the graphs.

We observed long-term linear increases in the percent female faculty in CSc departments (P < .001): 0.93% per year from 1978 to 1994 (R2 > 0.99) and 0.62% per year from 1995 to 2019 for assistant professors (R2 > 0.99), 0.71% per year from 1985 to 2019 for associate professors (R2 > 0.99), and 0.66% per year from 1994 to 2019 for full professors (R2 > 0.99). These rates at times exceeded those for faculty in BSc departments.

In 2019, a small percent of assistant professors (3.65%), a larger percent of associate professors (58.85%), and almost all full professors (86.26%) in BSc departments held tenured positions. In CSc departments, non-tenure track faculty dominated the assistant (72.24%) and associate (56.38%) professor ranks, while both tenured (59.85%) and non-tenure track (34.96%) faculty comprised most full professor positions (see Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/B258).

Discussion

The importance of gender equality within all parts of the economy has been well established. In academic medicine, in 2020, the AAMC Board of Directors and Leadership Team reaffirmed gender equality as a priority. 43 Our analysis of full-time faculty can lead to an improved understanding of gender representation in academic medicine and inform the implementation of new policies to improve gender equality.

Trends in number of faculty positions

Our analysis of the overall change in the number of faculty over time provides context for understanding promotion and tenure. The 12-fold increase in the number of faculty from 1966 to 2019 (see Figure 1) cannot be explained solely by the increase in the number of medical students (more than 2-fold) or medical schools (more than 1-fold). Although both have increased proportionately, their magnitude and pattern of increase are different from those of faculty. Specifically, from 1978 to 2005, the number of medical students and medical schools plateaued, while the number of faculty increased by more than 2-fold.

In addition, changes in faculty numbers differed between department types. While the number of total BSc faculty increased by almost 5-fold, the rate of increase decreased twice (1976 and 2015), resulting in a decrease in the percent of BSc faculty among total faculty, from ~30% in 1966 to ~13% in 2019. In BSc departments, the faculty-to-student ratio nearly doubled over the time period we studied, implying that factors other than student numbers contributed to the increase in the number of BSc faculty. At most AMCs, BSc faculty responsibilities include obtaining grants for research and educating both graduate and preclinical medical students. More recently, additional faculty effort has been required to successfully compete for limited research funding 44 and manage the complexity of medical pedagogy, evaluation methods, and maintaining and expanding accreditation. 33,45 These factors may have contributed to the need for additional BSc faculty, as we observed over the time period we studied.

In contrast, the 15-fold increase in the number of CSc faculty far exceeded the increase in medical student enrollment, suggesting that other forces were driving this expansion. Starting in the 1960s, direct payments to hospitals, defraying the costs of overhead and resident salaries, led to a growth in graduate medical education. 46 However, these payments were capped with the Balanced Budget Act of 1997. 38,46 As a result, many medical schools became affiliated with health systems, integrating the health system’s physicians as CSc faculty, as a way to generate clinical revenue. 39,47 This shift may have contributed to the large increase in the number of CSc faculty we observed.

Trends in tenure-related positions

The total number of tenured faculty positions remained relatively constant from 2005 to 2019 (see Figure 2). In contrast, the numbers of tenure track and non-tenure track faculty positions increased at rates of ~1% and ~7% per year, respectively. Previous reports described that this growing number of non-tenure track faculty positions led to a decrease in the percent of tenured positions among all positions. 38,39,48,49 Our data confirmed that this trend was due to a sustained increase in the percent of non-tenure track positions from 18% of all positions in 1966 to 72% in 2019.

Tenure is awarded to faculty who are deemed valuable to their institution. Therefore, an institution’s tenure decisions reveal the faculty characteristics that that institution values. 44,50 Similarly, national data illustrate the faculty characteristics that are valued across AMCs. We observed that males predominated in all 3 tenure categories. We identified large increases in the numbers of males in tenured (see Figure 2A) and tenure track (see Figure 2B) positions in the late 1960s and early 1970s, widening the gender gap. However, from 2004 to 2019, the number of males in tenured positions declined and the number in tenure track positions plateaued, while the number of females in tenured and tenure track positions continued to increase at regular rates (121 per year and 174 per year, respectively). This consistent slope indicates that external forces did not greatly affect the number of females in these positions. Recent changes in the gender makeup of faculty likely reflect the retirement of predominately male, senior-level faculty and the repopulation of these desired academic positions with increased percentages of females. The overall effect is an increase in the percent of females in both tenured and tenure track positions for BSc full professors and CSc assistant, associate, and full professors.

The numbers of females and males in non-tenure track positions exhibited similar trajectories, with the number of females lagging behind that of males by 10–15 years (see Figure 2C). The delayed increase in the number of non-tenure track positions relative to the number of tenured and tenure track positions cannot be fully explained by the increase in the number of AMCs. The difference likely represents financial stressors driving the hiring of non-tenure track clinicians, whose primary role is to generate clinical revenue, as mentioned above. 38,39,44,47,49,50 This strategy to increase an institution’s budget through additional clinical revenue likely afforded female clinical faculty greater academic opportunities, as we observed increases in the percent of females in assistant, associate, and full professor positions in CSc departments. The limited opportunities for BSc faculty to make significant financial contributions to their AMCs resulted in fewer hires than for CSc faculty, mirroring the hiring practices of faculty to higher education institutions generally. 44,49,50

ORs demonstrated that, compared with male faculty, BSc female faculty were historically less likely to be in tenure track positions than in non-tenure track positions (OR 0.81–0.90), with numbers trending in favor of tenure track positions from the 1970s to the 1990s before returning to pre-1970 levels (see Figure 3A). ORs for CSc female faculty were higher (0.94–1.10), at times achieving parity, and numbers trended toward more non-tenure track positions before the 1990s and more tenure track positions afterward (see Figure 3B). These ORs were largely impacted by incoming faculty, so the changes were reflected in assistant professor OR trends. Females were less likely to be tenured than on a tenure track, compared with males. ORs for BSc faculty increased from 1966 (0.45) to 2019 (0.63) (see Figure 3C), while ORs for CSc faculty decreased from 1966 (0.59) to 2019 (0.44) (see Figure 3D). The increase in ORs for BSc faculty after the 1990s denoted an increase in the number of females in tenured positions, compared with males. A decrease in the number of females in tenured positions was seen in the ORs for CSc faculty through the 1990s, before increasing relative to males afterward. Our subanalysis revealed that these tenure changes were mirrored in assistant and associate professor numbers (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B258).

Trends in female representation

Our analysis of historical percent female trends revealed that the assistant and associate professor ranks should reach gender parity faster than full professors (see Figure 4). While some gaps were smaller than others, no tenure option within an academic rank demonstrated parity. Notably, assistant and associate professors in BSc departments will take nearly 4-fold and 2-fold longer, respectively, to reach parity than their CSc department counterparts. Shockingly, academic medicine will need 3 to 4 decades to achieve gender parity at the full professor rank for both BSc and CSc departments, as the ORs for female full professors relative to males were far from parity in 2019 (0.55 and 0.42, respectively, see Figures 3E and 3F). These trends for full professors were reflected in the changes in non-tenure track and tenured faculty (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B258).

When we analyzed the percent female rates of change in detail (see Figure 5), we observed consistent rates of increase, with some notable transition points. It is reasonable to assume that these transition points represent periods of substantial and additive changes in national hiring, promotion, retention, and retirement practices. Understanding these forces may inform interventions aiming to expedite the journey toward gender parity.

Effects of rapid expansion in AMCs

In the 1960s, new faculty positions were likely created to staff the rapidly increasing number of new AMCs (see Figure 1). The pool of newly trained physicians, containing a greater percentage of females than in the past, filled these positions, while current assistant professors were promoted. 16 This created a consistent linear increase in the percent female for BSc assistant and associate professors from 1966 onward (see Figures 5A and 5B). We observed a more gradual slope in the percent female before 1971 for assistant professors and before 1968 for associate professors; however, the duration of this increase was too short to make a significant impact on the gender makeup of faculty. A more distant effect of AMC expansion appeared at the full professor rank in 1986, 8 years after AMC expansion plateaued (see Figure 5C). This effect can be seen in percent female increases across all tenure options. The time lag aligns with improved ORs for female full professors in non-tenure track and tenure track positions (see Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/B258) and in promotion and tenure trends in the late 1960s and early 1970s, when the average time for faculty promotion was more than 5 years in BSc departments. 51 Notably, no significant rate changes occurred for BSc faculty past this 0.53%–0.57% per year increase, meaning the impact of positive and negative forces remained constant.

After the first period of AMC expansion ended in 1977, the percent female consistently increased for CSc assistant professors across all tenure options (see Figure 5D). This change occurred after a similar change in BSc assistant professors, perhaps representing the importance of first building a strong BSc faculty when creating a new AMC. Decreases in female tenure ORs in the 1970s to 1980s can be explained by an increase in the number of female tenure track assistant professors. The downstream effects of AMC expansion can be seen in later years, with the CSc associate professor (1985) transition point occurring 8 years after the assistant professor (1977) transition point and the full professor (1994) transition point occurring 9 years after that (see Figures 5D-5F). This delayed change in percent female, observed across all tenure options, was consistent with the more than 5-year average time to promotion for CSc faculty in the 1970s and 1980s. 46 This change was seen primarily in non-tenure track faculty and also somewhat in tenured faculty. The other transition point for CSc full professors in 1980, which occurred 3 years after the first period of AMC expansion, can be explained by the natural promotion of existing associate professors, as only tenure track percentages did not increase at that time. Interestingly, we observed no transition points in academic ranks during the second period of AMC expansion from 2005 to 2016, when 20 new medical schools were created. We believe that larger numbers of faculty and higher percentages of females, especially in junior ranks, at the start of this period of expansion made change more difficult to achieve during the early 2000s compared with the early 1970s.

Effects of changes in medical education

Another set of transition points occurred in 1994, when there was a 0.31% per year blunting of the CSc assistant professor percent female rate of change (from 0.93% to 0.62%, see Figure 5D) and a 0.37% per year increase in the CSc full professor percent female rate of change (from 0.29% to 0.66%, see Figure 5F). The timing of these transition points suggests that changes to medical education contributed to these rate shifts. For example, the development and implementation of more sophisticated instructional and evaluation processes resulted in the need for specialized clinician–educators. 45 These faculty (~80% clinical and ~20% education/scholarship) became so prevalent by 2001 that 91 institutions had specific medical educator tracks. 39,45,52 This shift toward hiring and promoting medical educator track faculty likely benefited females, who disproportionately populate clinician–educator positions. 53 Next, the promotion of CSc assistant professors to higher academic ranks can explain the blunting of the percent female rate of change in this category, as the promotion of both non-tenure and tenure track females from assistant to associate professor outstripped the hiring of new female faculty. However, the associate professor percent female rate remained constant over this time (0.71% per year), as proportionate numbers of tenure track faculty were promoted to tenured professor. Significant increases in the ORs for both BSc and CSc tenured full professors (see Figures 3C–3F) also showed the effects of changes in medical education.

Effects of changes in financial models

While AMC expansion in the 1970s and changes to medical education in the 1990s can be tied to CSc percent female transition points, we suggest that the financial pressures we mentioned above compounded these changes. An example of the compounded effect of financial pressures can be seen at the 1977 transition point for the assistant professor rank (see Figure 5D), as the percent female rate of change rose from a flat trend to 0.93% per year, driven predominately by increases in the percent female rate of change of non-tenure and tenure track faculty. Eight years later, we observed an abrupt transition in the percent female rate of change of associate professors, from 0.27% to 0.71% per year (see Figure 5E). Nine years after that, the percent female rate of change of full professors increased from 0.29% to 0.66% per year (see Figure 5F). These associate and full professor changes were reflected in all tenure categories and can be seen in changes to CSc ORs that indicate preferential hiring of non-tenure track assistant and associate professors over tenure track faculty after the 1980s (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B258). The compounding effect of financial pressures allowed the magnitude of CSc faculty increases to surpass that of BSc faculty (0.53%–0.57% per year).

Limitations

The data collection instrument used in this study, the AAMC Faculty Roster, has inherent limitations. While the data are handled by reliable sources, including institutional and AAMC staff, they are subject to the rigor of the participating institutions. Potential human errors aside, informational diversity can also lead to heterogeneity, both in institutional reporting practices and in institutional definitions of rank and tenure. The large numbers reported mitigated some of this heterogeneity. In addition, many forces drive gender parity; the effects are only seen if positive and negative forces create a net change over time. Institutional forces are likely to be small and have limited effects on compiled national data. Future research should focus on the retention and attrition of faculty. The specific institutional values that support successful navigation of the promotion and tenure system by female faculty, applied widely throughout the United States, may be the key to uncovering the next impactful trend to accelerate gender equality.

Conclusions

Our findings indicated that gender parity within academic ranks and tenure categories will not be reached for decades. As improving gender equality is crucial for the future of academic medicine, the current rate of change must be accelerated. Our analysis suggested that large historical changes in AMC expansion, medical education, and economics have shifted the curves at all academic ranks. As these shifts addressed a volume-based necessity, the role of value-based forces remains to be analyzed. Our projections revealed that the current rates of increase will not quickly compensate for past gender disparity and a need to further accelerate this trajectory remains.

Critical solutions, such as improved hiring and promotion and tenure practices, based on the value of female faculty, independent of volume, as well as better retention practices may help accelerate current rates. Future research in this area should move from “what” national trends exist to “how” to create best practices that facilitate gender parity and equality. In addition, specific institutional characteristics improving gender parity and equality need to be identified and applied widely. Furthermore, similar analysis should be applied to other underrepresented groups to also address racial and ethnic disparities.

Acknowledgments:

The authors would like to thank Eric Weissman and Alex Bolt of the Council of Faculty and Academic Societies (CFAS) at the Association of American Medical Colleges (AAMC), who provided organizational support for and facilitated this research. CFAS and the AAMC provided a collaboration of diverse faculty through national meetings that were invaluable to this work. The authors also appreciate the statistical analysis of Jing Tian, MD, Marshall University.

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