The proportion of all practicing physicians in the United States who are women ranges from 23% in Utah to 40% in Massachusetts.1 Compared with other specialties, a higher proportion of obstetrician–gynecologists (ob-gyns) are women, ranging from 36% in Alabama to 65% in New Hampshire.1 Physicians tend to practice in the state where they were trained; 39% and 47% practice in the state of their undergraduate and graduate medical education, respectively.1 When physicians complete both undergraduate and graduate education in the same state, two thirds remain there to practice.1 Among ob-gyns, 47% practice in the state where they completed graduate medical education.2 Because geographic mobility is positively associated with career advancement,3 and women tend to move less than men as they get older or reach later career stages,4 location of training has implications for practice location and potentially for career advancement.
Sociologists have noted regional differences in the United States in attitudes toward gender roles with particular differences seen between southern and northern regions.5 Given that these attitudes may affect women's career advancement, either negatively or positively, our objective was to describe and compare regional differences in the representation of women in obstetrics and gynecology department-based leadership roles across American Congress of Obstetricians and Gynecologists (ACOG) districts and U.S. Census Bureau regions. We chose to include both ACOG districts and Census Bureau regions because local leadership roles are often a route to national leadership. However, ACOG districts do not easily cluster into geographic regions (where we hypothesized culture may differ); thus, we also stratified by Census Bureau regions. With representation ratios, we can meaningfully compare women's representation in leadership roles in each area by accounting for the proportion of women in the practicing obstetrics and gynecology base.
MATERIALS AND METHODS
This was a cross-sectional observational study of the gender and geography of department-based leaders relative to practicing ob-gyns in U.S. academic departments of obstetrics and gynecology in the 11 ACOG districts (the Armed Services District was excluded because no data on gender are available) and U.S. Census Bureau regions. The institutional review board at Beth Israel Deaconess Medical Center approved this project. The methods of this study are described in detail elsewhere.6,7 Briefly, a department was included if it had a residency program accredited in 2012–2013 by the Accreditation Council for Graduate Medical Education. We searched departmental websites between November 2012 to October 2013 to determine the gender of individuals in each major department-based leadership role (chair, vice chair, and division director) as well as in the department-based educational leadership roles of fellowship director (maternal-fetal medicine, reproductive endocrinology and infertility, female pelvic medicine and reconstructive surgery, gynecologic oncology, family planning, and minimally invasive gynecologic surgery), residency program director, associate residency program director, and medical student clerkship director. We calculated the proportion of women in each of these roles for each ACOG district and for each district's corresponding U.S. Census Bureau region8 to compare geographic differences in women's representation in these roles. We then used Association of American Medical Colleges Physician Workforce data from 2013 to determine the proportion of practicing ob-gyns who were women in each ACOG district and the corresponding four U.S. Census Bureau regions—Northeast, Midwest, South, and West.8
We used a previously reported innovative methodology, the representation ratio, to meaningfully compare geographic differences in women's representation in department-based leadership roles in a way that accounted for the proportion of women in the practicing obstetrics and gynecology base.7 To calculate each geographic area's representation ratio for women in leadership roles, we divided the proportion of department-based leaders in that area in 2013 who were women by the proportion of practicing ob-gyns in that area in 2013 who were women. We calculated representation ratios for the three major department-based leadership roles and these three roles combined as well as for each of the four department-based educational leadership roles in each ACOG district and corresponding U.S. Census Bureau region. We did not calculate a representation ratio for the four educational leadership roles combined, because previous research suggested that women were underrepresented in the fellowship director role in contrast to the residency and medical student educational leadership roles where women had achieved parity or were overrepresented, and combining them would obscure the observed differences for each individual role.6,7
A representation ratio of 1.0 indicates that women were represented as leaders in the same proportion in which they were present in the practicing obstetrics and gynecology base, whereas a ratio less than 1.0 indicates that women were underrepresented, and a ratio greater than 1.0 indicates that women were overrepresented. Ratios are presented with 95% CIs, which were calculated by treating the representation ratio as a risk ratio. In instances in which both bounds of the 95% CI were below or above 1.0, we concluded that women were underrepresented or overrepresented, respectively, in leadership roles relative to the proportion of women in the base. All data were analyzed using Stata 9.0, and figures were created using GraphPad Prism 6.05 for Windows.
In 2013 in the United States, 50% of practicing ob-gyns were women. ACOG District I (Northeast) had the highest proportion of ob-gyns in the practicing base who were women (59%), whereas District XII (South) had the lowest proportion (40%). Table 1 shows the states within each district and corresponding U.S. Census Bureau region (Fig. 1) along with the number of departments and the proportion of women in the practicing obstetrics and gynecology base in each district.
Overall, women comprised 28% of major department-based leadership roles. ACOG District IX (West; 47%) and District VI (Midwest; 42%) had the highest proportion of women in the three major department-based leadership roles combined, whereas district VII (South; 13%) and district III (Northeast; 15%) had the lowest proportions. ACOG District VIII (West; 40%) had the highest proportion of women in the chair role, whereas District XI (South; 7%) had the lowest. Maps with the proportion of women in major department-based leadership roles (combined, chair, vice chair, division director) for each ACOG district are shown in Figure 2.
ACOG District VIII (West; 45%) had the highest proportion of women in the fellowship director role, whereas District XII (South; 0%) had the lowest. For the residency program director role, ACOG District I (Northeast; 75%) had the highest proportion of women, whereas District III (Northeast; 32%) had the lowest. ACOG District I (Northeast; 100%) had the highest proportion of women in the medical student clerkship director role, whereas District VII (South; 42%) had the lowest. Figure 3 shows maps with the proportion of women in each ACOG district in each department-based educational leadership role.
Nationally, the representation ratios for women in major department-based leadership roles were significantly less than 1.0 for department chair, vice chair, division director, and for all three roles combined. This indicates that women were underrepresented nationally in major department-based leadership roles relative to the proportion of practicing ob-gyns who were women. In individual ACOG districts, women were significantly underrepresented in major departmental leadership roles in every district except Districts IX (West) and XII (South) (Fig. 4A). In the department chair role, representation ratios were less than 1.0 in every ACOG district; however, in Districts VI (Midwest), VIII (West), IX (West), and XII (South), this underrepresentation was not statistically significant (Fig. 4B). In the vice chair role, representation ratios in individual districts were generally higher than for the chair role with several districts achieving representation ratios that indicated proportionate representation of women and with CIs crossing 1.0 in every district (Fig. 4C). Representation ratios for women in the division director role were less than 1.0 in all districts except District IX (West). However, this underrepresentation was not statistically significant in Districts VI (Midwest), XI (South), and XII (South) (Fig. 4D).
When we compared representation ratios for major department-based leadership roles across U.S. Census Bureau regions, for the three major department-based leadership roles combined (chair, vice chair, division director), women were significantly underrepresented in all four census regions (Fig. 4A). Although women were underrepresented in major department-based leadership throughout the country, there was significantly higher women's representation in major department-based leadership roles in the West (ratio 0.82, 95% CI 0.68–0.99) compared with the Northeast (ratio 0.50, 95% CI 0.42–0.59) and South (ratio 0.45, 95% CI 0.36–0.57). Similarly, in the division director role, the West (ratio 0.85. 95% CI 0.68–1.1) had significantly higher representation of women compared with the Northeast (ratio 0.50, 95% CI 0.40–0.62) (Fig. 4D). Representation ratios for women in major department-based leadership roles relative to the practicing obstetrics and gynecology base in each ACOG district and corresponding U.S. Census Bureau regions are shown in Figure 4.
In educational leadership, overall the representation ratio for women in the fellowship director role was significantly less than 1.0, indicating that women were underrepresented nationally as fellowship directors. The representation ratios for women in fellowship director roles were less than 1.0 in all individual ACOG districts, although this underrepresentation was only significant in District XII (South), where there were no women in the role (Fig. 5A). In the residency and associate residency program director roles, the national representation ratios indicated that women were proportionately represented (Fig. 5B and C). In the medical student clerkship director role, the national representation ratio demonstrated that women were significantly overrepresented. The representation ratios for women in medical student clerkship director roles exceeded 1.0 in all but District VII (South), and five districts had significant overrepresentation of women in this role (Fig. 5D).
When comparing representation ratios across U.S. Census Bureau regions, we observed that women were significantly underrepresented in the fellowship program director role in all areas except the West. Women were significantly overrepresented in the West as associate residency program directors and in the Northeast as medical student clerkship directors. Although there were no statistically significant differences among Census Bureau regions across educational leadership roles, representation ratios tended to be higher in the West compared with other regions. Representation ratios for department-based educational leadership roles (fellowship director, residency program director, associate residency program director, medical student clerkship director) and corresponding U.S. Census Bureau regions are shown in Figure 5.
We used a previously reported innovative representation ratio7 to meaningfully compare the proportion of women in department-based leadership roles relative to the proportion of women in the practicing obstetrics and gynecology base in ACOG districts and U.S. Census Bureau regions. Representation ratios for women in major department-based leadership roles were higher in the West. However, throughout the United States, women were underrepresented in all major department-based leadership roles relative to women in the practicing obstetrics and gynecology base—even in the West.
Similar to previous findings,6,7 women were significantly underrepresented as fellowship directors—nationally and in the Northeast, Midwest, and South. We speculate this underrepresentation may be related to fewer women entering subspecialties.9 In contrast, representation ratios for women in residency program director roles showed proportionate representation, and women were actually overrepresented as medical student clerkship directors. This may reflect the cultural bias of women becoming teachers,10 and it is not clear whether being a residency program or medical student clerkship director is a route to major leadership roles. Some have perceived that leadership roles progress from medical student to residency to fellowship, but our data dispute this, because the majority of medical student clerkship and residency program directors are generalists.6
Representation ratios in our study suggest that women were more likely to advance to the department-based leadership roles of chair, vice chair, or division director in the West. Representation ratios may better quantify progress in women advancing as leaders. Evaluating proportions of women in leadership roles without accounting for proportions of women in the practicing base may falsely suggest that women are promoted in some regions more than others simply because there are more women practicing in those regions. In a previous study that compared women in department leadership roles across different specialties, obstetrics and gynecology had the largest proportion of leaders who were women, which made it appear that obstetrics and gynecology promoted a higher proportion of women to leadership roles than other specialties. However, comparing progress of women as leaders across specialties using a representation ratio that accounted for the proportion of women entering each field 20 years prior showed there was greater gender parity in anesthesia and radiology. Contrary to common perceptions of advancement of women as leaders, obstetrics and gynecology was similar to general surgery and internal medicine in promoting women to leadership roles.7
Our results suggest that the culture in certain geographic regions in the United States can affect leadership opportunities. Perhaps this finding should factor into the decision of where to train, given that training locations often are where physicians ultimately practice, and there may be limitations to future geographic mobility.1,2 One study found that women were less likely to relocate than men, and the effect of family further dampened women's willingness to relocate to achieve higher career status.11 A study of medical school faculty who were women and attended the Executive Leadership in Academic Medicine program demonstrated a positive association between geographic mobility and career advancement.3 The culture and leaders of academic departments may be influenced by regional attitudes toward gender roles, and this in turn may influence faculty satisfaction, success, and advancement. Regardless of geography, departments that promote equal access to opportunities and resources, work–life integration, freedom from bias, and supportive leadership are conducive to women's academic success.12,13 It is possible that academic culture varies by geography, which may, in part, explain the progress of women in the West Census Bureau region in achieving department-based leadership roles.
Our analysis was limited by small sample sizes of leaders in some districts. In District XII, for example, there were wide CIs for every role and only 47 total leaders compared with a range of 102–229 leaders in other districts.
Representation ratios can measure pipeline progress in achieving diversity in workforce gender, race, ethnicity, and childhood socioeconomic position as well as lesbian, gay, bisexual, transgender, and queer faculty. Inclusive attitudes and behaviors of leaders can enable advancement of underrepresented faculty by leveraging varied perspectives from those around them.14 Being transparent with measurements such as representation ratios can inspire meaningful progress in achieving leadership diversity.15,16 Diverse leadership in academic medicine is both a moral imperative and a strategic advantage as a source of innovation and creativity.
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