Women and minorities historically have been underrepresented in medicine. Although women make up 50.8% of the US population,a they comprise only 38% of the US medical school faculty.b Similarly, underrepresented minorities, which are defined as racial or ethnic groups that have been historically underrepresented in medicine (ie, African American/black, Hispanic/Latino, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander),c comprise 32% of the US populationa and only represent 8.9% of the medical workforce.d Both women and minorities struggle to advance in academic medicine.b,1–5 Specifically, women and minorities are less likely to be promoted to the rank of associate or full professor,b,1,3,6,7 obtain funding from the National Institutes of Health,5,6 or obtain leadership positions in academic or organized medicine.1,2,4
Every decade, the US Department of Health and Human Services establishes 10-year national objectives for improving the health of all Americans. One goal for Healthy People 2020 is to establish health equity by eliminating health disparities; this includes disparities by gender, as well as race/ethnicity.e Disparities have been well documented in medicine and persist despite significant advances in medicine and public health over the last quarter century.8 Women have a lower prevalence of coronary heart disease and myocardial infarction than men yet are more likely to experience mortality from both.9 Minority patients are less likely to receive appropriate preventative care, more likely to receive lower quality hospital care, and more likely to have morbidity and mortality associated with certain medical conditions than nonminority white patients.8,10–17 Minority women may be particularly vulnerable to disparities.18 Several studies have documented racial and ethnic disparities in pain management among minority women.19–22
Although many potential solutions for reducing disparities exist, the Institute of Medicine proposed increasing the diversity of the health care workforce as one possible strategy to eliminate disparities.23 It has been argued that diversity in the health care workforce promotes and improves the quality of health care delivered to minority groups.24 The Sullivan Commission on Diversity in the health care workforce was established in 2003 to address the Institute of Medicine’s recommendations on workforce diversity.f The commission emphasized the importance of minority faculty entering leadership positions, as leadership diversity leads to organizational cultural competence.f
The American Society of Anesthesiologists is the only general anesthesiology organization that represents physician anesthesiologists in the United States. It is an educational, research, and advocacy organization whose mission is to advance the practice and secure the future of anesthesiology.g The American Society of Anesthesiologists is one of the leading patient safety organizations in medicine. At a national level, the American Society of Anesthesiologists creates and approves clinical guidelines, major educational initiatives for its members, and supports foundations such as the Foundation for Anesthesia Education and Research and the Anesthesia Patient Safety Foundation. The American Society of Anesthesiologists House of Delegates (HOD) is its primary legislative and governing body, and it is comprised of leadership from individual states, anesthesia subspecialty societies, and other key stakeholders, most of whom are elected to their positions. The leadership determines and represents the priorities of the American Society of Anesthesiologists. The extent to which minorities or women are represented in the leadership of the American Society of Anesthesiologists is unknown. Therefore, the objective of this study was to evaluate the demographic composition (gender, race/ethnicity, and age) of the leadership of the American Society of Anesthesiologists. We hypothesized that the percentage of women and underrepresented minorities is less than that of their representation in the general physician workforce.
METHODS
Study Design
The study was approved by the Northwestern University IRB. Two authors (P.T. and C.W.) developed a 3-question survey. The survey questions asked about age, gender, and race/ethnicity. Race/ethnicity categories were classified by the US Census and Office of Management and Budget standards.h The final survey was reviewed by all authors for face validity (Supplemental Digital Content 1, https://links.lww.com/AA/B602).
Study Population
A list of the members of the 2014 American Society of Anesthesiologists HOD, and state society officers who were not members of the HOD, was generated through a Web search (March 2015). The email contact information for each member was obtained through the American Society of Anesthesiologists member directory, state society website, or through a Google search.
All participants with a valid email address were sent an invitation to complete the electronic survey (N = 595) via SurveyMonkey. Nonresponders received 3 follow-up email reminders at 2-week intervals. Survey completion implied consent for the study participation. Although the survey was anonymous, SurveyMonkey does collect the IP addresses of respondent computer. IP addresses were not used during data analysis. The survey was conducted between March and April 2015.
Sample Size Calculation
An a priori sample size was not calculated, as this was a census survey of the leadership of the American Society of Anesthesiologists. The current sample size has 96% power to detect a 10% difference from the proportion of females in the general physician workforce (38%) using a 2-sample t test with a .05 significance level.
Statistical Analysis
The primary outcome was the comparison of the percentage of women and underrepresented minorities in the American Society of Anesthesiologists leadership to the corresponding percentages in the medical workforce.b,d Underrepresented minorities were defined as racial or ethnic groups that have been historically underrepresented in medicine: African American/black, Hispanic/Latino, American Indian/Alaska Native, or Native Hawaiian/Pacific Islander.i A 1-sample t test was used to compare the characteristics of the respondents to that of the hypothesized means of 38.0% for women and 8.9% for underrepresented minorities.b,d In addition, the demographic characteristics of the American Society of Anesthesiologists leadership were compared with the gender and racial/ethnic diversity of the membership of the American Society of Anesthesiologists,j the demographics of the anesthesia workforce in the United States,d and the US population.a
Univariate statistics were used to characterize survey respondents. Age was assessed for normal distribution. The gender for nonrespondents was generated via the methodology used by Wong and Stock.7 Gender was assigned based on inspection of first names. If the gender was not apparent by inspection of the first name, a Web search was used to identify photos of the individual. If no photograph could be found, gender was assigned by study investigators who are also members of the HOD (J.A. and P.T.). The gender for respondents and nonrespondents was compared with a 2-tailed t test. Probability distributions were generated by use of the binomial distribution. Two-sided 95% confidence intervals (CIs) are reported. P values were adjusted based on Bonferroni correction. P < .0125 was considered significant for comparison of women and P < .016 for comparison of underrepresented minorities. Data were analyzed using Stata SE (Version 12, StataCorp LP, College Station, TX).
RESULTS
Surveys were delivered to 556 valid email addresses. A total of 299 responses were received (54% response rate). The demographic characteristics of the respondents are shown in Table 1. There were no differences in female gender between survey responders and nonresponders (21.1% vs 16.7%, respectively, P = .20).
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Table 1.: Demographic Characteristics of Survey Respondents
A total of 21.1% (95% CI, 16.4%–25.7%) of respondents were women and 6.0% (95% CI, 3.3%–8.7%) were underrepresented minorities. Among the underrepresented minority respondents, 6 were women (1.1%, 95% CI, 0.2%–1.9%). The median age was 54 years.
Table 2.: Demographic Characteristics of Survey Respondents and Comparison With Demographics of Other Groups
The proportion of women in the American Society of Anesthesiologists leadership was lower than the general medical workforce and the US population; the proportion of underrepresented minorities was lower than the US population (Table 2). The composition of the American Society of Anesthesiologists leadership was no different than the membership of the American Society of Anesthesiologists (gender only), or that of the anesthesia workforce (gender and race/ethnicity).
DISCUSSION
The important finding of this study is that women and minorities are underrepresented in the leadership of the American Society of Anesthesiologists. Specifically, women are underrepresented relative to their respective proportions in the medical workforce, as well as in the general population. In addition, our study found that the leadership of the American Society of Anesthesiologists is comprised of mid- to late-career anesthesiologists.
Although women were underrepresented relative to the general physician workforce and the general population, they were not underrepresented relative to their respective proportions in the anesthesia workforce or relative to the composition of the American Society of Anesthesiologists membership. Because the American Society of Anesthesiologists does not maintain data on the race/ethnicity of its members, the closest appropriate comparison is likely the demographic composition of the anesthesia workforce as estimated by the American Association of Medical Colleges. Although we did not find a statistically significant difference, the confidence interval was wide and neared significance (3.3%–8.7%, P = .06); therefore, it is possible that a difference exists and the study was simply underpowered to detect such a difference.
Representation at the leadership level is significant, as the American Society of Anesthesiologists HOD is the decision-making body of the organization. Although the composition of American Society of Anesthesiologists leadership reflects that of the anesthesia workforce, the anesthesia workforce, similar to many other medical specialties, lacks diversity compared with the general population of the United States. At a national level, there has been increasing awareness and attention given to increasing diversity in the medical workforce. It is generally accepted that more diversity is needed both in the workforce, as well as in the leadership,b,d,f as increased diversity in the physician workforce contributed to better patient outcomes,24 and improved access to care.25 In addition, racially concordant care is associated with better patient-provider communication and improved patient satisfaction.26 In the business world, companies with increased diversity (ie, gender and racial/ethnic diversity) perform better than less-diverse companies.k It is unclear how underrepresentation affects the cultural competence of the organization and specifically, the decisions made by the HOD.
The results of this study are consistent with those of many other American studies that have evaluated the role of women and minorities in leadership positions within medicine. Obstetrics and gynecology has one of the greatest proportions of women faculty (57%),l yet women comprised only 20.4% of chair positions, 36.1% of vice chair positions, and 29.6% of division director positions in 2013.4 In a retrospective, cross-sectional analysis of data on faculty in US medical schools (1997–2008) from the Association of American Medical Colleges, there was a similarly a low percentage of women in leadership positions.1 Women represented only 9.2% of all chairpersons and 9.3% of all medical school deans. Minorities were similarly underrepresented. Only 6.0% of chairs and 7.8% of deans were underrepresented minorities.1 The Society for Vascular Surgery evaluated the composition of the leadership of their society over an 8-year period. Between 2004 and 2012, the percentage of board members who were non-Hispanic white varied between 88.2% and 100%, and the percentage of council members who were non-Hispanic white was greater than 91% in all years analyzed.2 Representation by minorities was even lower in a regional vascular society (Midwestern Vascular Surgical Society). During a 30-year period, white men comprised 89.4% of all officer positions and 94.2% of all senior positions within the society.27
The American Society of Anesthesiologists Committee on Professional Diversity was established in the early 1990s to increase the representation of women in anesthesiology. The mission of the committee has evolved; its current mission is to promote membership and support members of diverse backgrounds including gender, race, ethnicity, sexual orientation, and disability.m During the past 15 years, there has been a 7% increase in the proportion of women American Society of Anesthesiologists members; in contrast, there has been no increase in the proportion of women in the American Society of Anesthesiologists HOD.28 Despite the lack of increase in the overall number of women in the HOD; however, there has been a doubling of the number of women American Society of Anesthesiologists officers in the past 5 years.28 The Committee on Professional Diversity tried to help overcome the lack of role models by creating a mentoring program in 2009. The goal of the program is to provide a structural framework for mentees from diverse background to learn about the administrative, executive, educational and political components, and processes of the American Society of Anesthesiologists with the goal to increase their involvement in the American Society of Anesthesiologists. Although individual success stories from the mentoring program have been reported,29 measuring the effect of the committee’s work on racial/ethnic diversity is hampered by a lack of data as the American Society of Anesthesiologists does not collect membership race/ethnicity data.
There are several possible explanations for why there are not more women or minorities represented in the American Society of Anesthesiologists leadership. Contributing factors might include a lack of role models or mentors.30–34 Women and minorities may lack relationships or a sense of inclusion that would help them achieve leadership positions.35 Family, responsibilities (eg, childcare, elder parent care) also may make women less likely to assume leadership roles.36,37 Women, in particular, may view obtaining leadership positions as less desirable than men38 and feel less self-efficacious of their ability to assume a leadership role.36
Bias also may be a contributing factor to the underrepresentation. The Implicit Association Test is a validated computerized test that measures implicit attitudes toward different social categories.39,40 The test measures the ease by which concepts are sorted by an individual. The underlying assumption is that similar concepts will be sorted faster than less associated concepts. Differences in reaction times are used to derive implicit preferences for one group over another. Although the majority of physicians do not endorse explicit racial/ethnic bias, studies have shown that both medical students and practicing physicians have an implicit preference for white or European Americans versus black or African Americans.41,42 This bias may be perceived by women or minorities and be a barrier to pursing leadership positions. In a national survey of US medical school faculty, nearly half of underrepresented minority faculty reported experiencing bias or discrimination by a superior or colleague.43 Similar results were found among trainees in obstetrics and gynecology.30
We acknowledge that our study has limitations. Our sample was limited by our response rate of 54%. The possibility of responder bias exists. Respondents who were women and minorities may have been more likely to respond to the survey, and thus may be overrepresented in the sample. Furthermore, our survey assessed gender, and the survey listed only 2 options (male and female). No transgender option was available. Although the number of transgender persons in the population is estimated to be <0.5%,44 the estimated number is likely to increase given increasing awareness and measurement of transgender options in population-based surveys. We did not find a difference in the gender of respondents and nonrespondents when the gender for nonrespondents was assigned using the methodology used by Wong and Stock.7 We realize, however, that by using names and photographs, we were evaluating the gender and not the sex of nonrespondents, and we did not assess transgender status.
An additional limitation is that our study population was limited to members of the 2014 HOD; therefore, we were unable to evaluate change in demographics over time. Although we collected information on demographic variables, we did not survey women or minorities to further understand the factors contributing to their reason to serve in the American Society of Anesthesiologists leadership. Similarly, we did not survey American Society of Anesthesiologists members who wish to serve in the HOD but were not chosen to do so by their state or subspecialty society.
The population of the United States is becoming increasingly diverse, and many organizations have called for increased workforce diversity. Increased workforce diversity has been identified as a key step toward improving organizational cultural competence and reducing health care disparities.45 To our knowledge, this is the first study to evaluate the demographic characteristics of the American Society of Anesthesiologists leadership. We believe that identifying a gap in representation is an important first step for developing a plan to address that gap. Ensuring that the leadership of the American Society of Anesthesiologists represents and promotes diversity may be 1 step toward encouraging more women and underrepresented minorities to consider anesthesiology as a career, as well as assume leadership positions. As such, the American Society of Anesthesiologists should consider collecting data on self-identified race/ethnicity, in addition to gender, as part of its member demographics. Other international medical organizations collect and report on the diversity of its physician workforce,n,o and use these data to track the growth of underrepresented physician groups (eg, physicians with indigenous backgrounds).p Future work should evaluate whether programs, such as the American Society of Anesthesiologists Committee on Professional Diversity mentoring program, have an effect on women and minorities obtaining leadership roles within the American Society of Anesthesiologists.
DISCLOSURES
Name: Paloma Toledo, MD, MPH.
Contribution: This author helped conceive and design the study, collect, analyze, and interpret the data, and draft the article.
Name: Lorent Duce, MD.
Contribution: This author helped conceive and design the study, collect, analyze, and interpret the data, and draft the article.
Name: Jerome Adams, MD, MPH.
Contribution: This author helped conceive and design the study, analyze and interpret the data, and draft the article.
Name: Vernon H. Ross, MD.
Contribution: This author helped conceive and design the study, collect, analyze, and interpret the data, and draft the article.
Name: Kelli M. Thompson, MD.
Contribution: This author helped analyze and interpret the data, and draft the article.
Name: Cynthia A. Wong, MD.
Contribution: This author helped conceive and design the study, collect, analyze, and interpret the data, and draft the article.
This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.
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