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Abstract
Background Previous studies demonstrate female under-representation in top medical school leadership and dermatology departments, although separately. Here, we investigate the extent and interplay of gender disparity between these two bodies.
Objective To compare the extent of gender disparity among top 15 US medical schools with affiliated dermatology programmes.
Methods Cross-sectional study conducted in 2022. Faculty gender, academic rank, leadership position and membership of medical school leadership or affiliated dermatology department were extracted from public institutional sources. Research metrics (h-index, citations, publication span and publication counts) were collated using Elsevier’s SCOPUS tool.
Results From 1243 individuals (31.7% women), 840 held medical school leadership positions and 403 were affiliated dermatology faculty. Rank biserial correlation indicated a significant relationship of male gender with higher academic rank (r=−0.305, p<0.001), leadership position (r=0.095, p=0.004) and scholarly metrics. More medical leadership individuals had higher academic rank than dermatology faculty; we, therefore, hypothesise a pipelining of rising departmental faculty into leadership positions.
Limitations Public faculty listings seldomly reported leadership appointment age and length, career duration and mid-career breaks.
Conclusion Continued diversity efforts are recommended to improve female under-representation in medical school leadership and affiliated dermatology faculties.
- career development
- career path
- clinical leadership
- medical leadership
Data availability statement
Data are available upon reasonable request.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Women are under-represented in top medical school leadership and dermatology department ranks. However, it is controversial how the extents of disparity compare between these two bodies.
WHAT THIS STUDY ADDS
This study compares gender-based differences between top medical school leadership and affiliated dermatology departments, which have been investigated separately. Results suggest the pipelining of faculty from departmental to higher leadership positions.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Further diversity efforts are indicated as current departmental disparities project an unfavourable outlook of female under-representation in medical school leadership.
Introduction
Despite efforts to mitigate gender inequity in academic medicine, women are still under-represented in leadership positions.1 2 Though representing half of the population, women account for only 41.2% and 32.6% of the Canadian and American physician workforce, respectively.3 4 Prevailing attitudes on gender roles have imposed social and family responsibilities onto female physicians, who report working fewer hours than their male counterparts.5 Especially in the careers of young women, these social restraints may stunt their leadership prospects in academic medicine.6 While women have already achieved parity with men with respect to medical school admission rates, women only account for 16% of medical school deans, 21% of professorship appointments and 15% of department chair positions.7 8 Additionally, women are represented in dermatology societies such as the American Academy of Dermatology, but they are under-represented in receiving societal recognition awards that promote career advancement.9 The lasting gender gap in academic leadership may also be attributed to an impartial selection of candidates on account of their gender. Despite leadership aptitude being independent of gender, unconscious biases due to entrenched social attitudes may disfavour women as leaders in the selection process.10 11
Current evidence has demonstrated a significant correlation between a physician’s research metrics and their likelihood of attaining academic appointments, grant funding and career advancement.12 13 Regretfully, societal restraints imposed on young female physicians have created a gender gap in research productivity. Not only do women have fewer academic authorships across medical specialties, but they are also less likely than men to be credited as first author on their published works.14–16 Further, a recent systematic review and meta-analysis found that across most specialties, women had lower h-indices than men despite adjusting for confounding factors.17 Ingrained gender biases within peer review committees may also discriminate against submissions from female physicians. As evidenced by one study, through the blinding of peer-reviewers, the acceptance rates of publications with a female first author significantly increased.18 As publication output and h-index are frequent measures used in qualifying academic promotions, women are further inhibited in attaining academic leadership appointments.
Among medical specialties, the dermatology workforce has a relatively high proportion of female-identifying physicians. Within the last decade, it has been estimated that women comprise 49.1% and 44.7% of dermatologists in Canada and the USA, respectively.3 4 However, despite these tremendous strides towards equitable gender representation, women are still under-represented in academic dermatology leadership positions.19 In a 2018 cross-sectional study on North American dermatology programmes, only 26.1% of department heads were women.19 The extent of gender inequity in academic dermatology and medical school leadership has been previously elucidated by Shah et al 19 and Abdellatif et al.20 We hypothesise the existence of a pipeline effect where leaders in academic dermatology faculties eventually feed into higher-level leadership positions, such as within the medical school. Indeed, one study of medical school deans of medicine found that the most common pathway to reaching this pinnacle position was prior service as a specialty department chair, thus indicating a need for diverse departmental leadership to eventually feed forward into broader medical school ranks.21 Hence, we expect that the extent of gender inequality in medical school versus dermatology leadership is interdependent. That is, inequity in medical school leadership will be a time-lagged reflection of that found in specialty departments ranks. For example, a high degree of inequity in current departmental ranks may reflect a congruent extent of future inequity in the associated medical school leadership cohort. The rationale for our hypothesis arises from newer evidence for a pipeline effect that has been elucidated in a limited number of specialties such as plastic surgery and radiology.22 23 However, current evidence does not discern whether gender disparity in academic dermatology departments transfers into medical school leadership; therefore, we aimed to compare the disparities at these two levels.
Methods
As data were synthesised from publicly available data, approval from our institutional review board was not required.
In the USA, there are 156 and 37 allopathic and osteopathic medical institutions, respectively.24 25 The top 15 medical schools were identified using the US News Ranking, which employs a robust scoring criteria consisting of scientific excellence, research impact and regional/global reputation.26 Once these schools were identified, data extraction was conducted in several steps. First, official websites for each school were extracted for information on medical school leadership. Leadership rank was stratified into four levels consisting of dean, vice dean, department chair and director. Individuals were excluded if they did not have a leadership rank within any of these categories (eg, administrative personnel). The academic rank of each medical school leader was also abstracted, and categorised as professor, associate professor or assistant professor.
Subsequently, affiliated dermatology programmes for each school were identified through the Fellowship and Residency Electronic Interactive Database for American medical residency and fellowships. Official websites for these programmes were then examined for department faculty listings, from which all faculty members were recorded. Leadership appointment and academic rank for faculty were noted and categorised.
Gender identification was performed systematically. Official website biographies were first examined for personal pronouns that affirmed an individual’s gender affiliation. If official website biographies were unavailable, profiles on auxiliary websites such as LinkedIn or Doximity were consulted. Second, if no biography was found, combinations of their first name and website photo were used to determine gender. For ambiguous cases, gender application programming interface software was used to determine the most statistically likely gender based on first name. Although gender exists on a spectrum, a binary approach to gender identification was used. While this method does not represent the diversity of gender, this method has been previously validated in the literature.2 6 14
Elsevier’s SCOPUS tool was used to collect data on author metrics including number of publications, number of citations and h-index. The SCOPUS tool was selected as it most accurately reports h-indices due to its proficiency at distinguishing authors.27
The rank biserial correlation was computed to assess relationships between affiliation/gender and academic rank/leadership position. A lack of data normality for the continuous variables was confirmed using the Shapiro-Wilk’s test. Scholarly metrics (h-index, publications and citations) were compared between gender/affiliation groups using the Mann-Whitney U test. Statistical analysis was performed using IBM SPSS Statistics V.25. An alpha of 0.05 was set as the significance cut-off.
Results
General characteristics
A total of 1243 individuals across 15 institutions were included in the analysis. Online supplemental table S1 depicts the included institutions in this work. Of the total number of physicians, 840 (67.6%) individuals had medical school leadership positions, while the remaining 403 (32.4%) individuals were from affiliated dermatology departments. This sample comprised 394 (31.7%) women and 848 (68.2%) men. Table 1 presents a breakdown of academic rank and leadership positions for medical leadership versus dermatology faculty, and for male versus female gender, respectively. Of note, while there were 1243 individuals included in the study (from medical leadership and dermatology faculty), table 1 does not include all 1243 individuals. Rather, for academic rank, we analyse the 1168 individuals (795 from medical leadership; 373 from dermatology faculty leadership) who possessed an academic rank, which therefore excluded those who had roles such as lecturer or instructor. As well, for leadership roles, we analyse the 898 individuals (840 from medical school leadership; 58 from dermatology faculty leadership) who possessed a leadership role (dean, vice dean, department chair or director).
Supplemental material
Academic rank and leadership position breakdown by medical leadership and dermatology faculty
Academic rank
The majority of medical leadership faculty held the position of professor (n=756, 95.1%). Comparatively, assistant professor was the most common academic rank among dermatology faculty (n=178, 47.7%). A rank biserial correlation identified a significant, strong relationship between academic rank and affiliation (ie, medical leadership vs dermatology faculty) (r=0.701, p<0.001). This finding suggests that the academic rank of medical leadership faculty tended to be higher than dermatology faculty counterparts.
A greater number and proportion of men (n=670, 82.9%) held the position of professor than female faculty (n=196, 54.4%). Rank biserial correlation indicated a significant, moderate relationship between academic rank and gender (r=−0.305, p<0.001), with male gender being associated with higher academic rank. Figure 1 illustrates an increasing gender disparity at higher academic ranks, which is a consistent finding in both medical leadership and dermatology faculty subgroups.
Female and male proportions by academic rank in medical leadership and dermatology faculty. Height of the data bars represents percentages. Males and females in medical leadership are denoted in grey and yellow, respectively. Males and females in dermatology are illustrated in green and purple, respectively.
Leadership positions
The most common leadership positions were department chair for medical leadership faculty (n=402, 47.9%) and director for dermatology faculty (n=32, 55.2%). A rank biserial correlation identified a significant, weak–moderate relationship between position and affiliation (r=0.207, p<0.001). This finding suggests that the position of medical leadership faculty tended to be higher than dermatology counterparts.
Men had a 2.1 times higher proportion of holding the position of dean than women. Comparatively, the greater proportion of women held the position of vice dean (n=89, 40.3%). There was a very weak, significant correlation observed between position and gender (r=0.095, p=0.004). Given the proximity of this rank biserial correlation to zero, this result was interpreted as representing minimal differences between male and female genders.
Comparison of scholarly metrics
Tables 2 and 3 show the distributions of publication metrics by affiliation and gender, respectively. Medical leadership faculty had significantly higher h-index (p<0.001), number of publications (p<0.001) and number of citations (p<0.001) than dermatology faculty. Males had significantly higher h-index (p<0.001), number of publications (p<0.001) and number of citations (p<0.001) than female counterparts.
Publication metrics breakdown by medical leadership and dermatology faculty
Publication metrics by gender
Discussion
Our findings revealed the prevailing extent of gender disparity in North American academic dermatology programmes. Analysis revealed a significant, moderate relationship between male gender and achieving higher academic rank, with men dominating the highest academic rank of full professor. This finding is consistent with a 2016 study, which concluded that women were under-represented among senior academic dermatology ranks due to having significantly lower h-indices than men.28 Indeed, the present study coincidingly determined that men in academic dermatology have significantly higher h-index, publication output and number of citations than women.
Although a significant near-zero relationship was found between gender and leadership hierarchy position, our findings indicate that a greater number and proportion of men were represented in the highest leadership position of dean. Further, women tended to inhabit lower-level roles, with vice dean comprising the largest proportion of women. As fewer women were found to progress to the highest levels of leadership, this study illustrated the glass-ceiling effect, which has been affirmed in a recent meta-analysis on appointments to medical leadership positions.29
Finally, the rank biserial analysis found that medical leadership faculty tended to reach higher research metrics, academic rank and leadership positions than their affiliated dermatology faculty counterparts. The higher proportion of higher academic rank in medical leadership supports the hypothesised pipeline effect, whereby affiliated specialty departments (eg, dermatology) feed their rising faculty into medical leadership at top medical schools. The current pipeline may therefore project future gender representation in top medical school leadership. When paired with the study findings that women are currently under-represented across both medical leadership and affiliated dermatology faculties, the outlook for future gender parity in both bodies remains bleak. However, while the current state of the pipeline is not optimal, there is newer encouraging evidence of improved gender representation. In one report of dermatology residency leadership, women comprised nearly 40% of chair leader positions, and were represented as most paediatric dermatology fellowship programme directors.30 Nonetheless, gender disparity persists in the subspecialty areas of surgical dermatology and dermatopathology fellowship leadership.30 Altogether, despite a currently non-optimal pipeline, there is much optimism given the increasing number of women graduating from dermatology residency, all with the potential to compose future leaders in academic dermatology and eventually into medical school leadership.31
Still after many decades, women disproportionately face obstacles to career development in medicine. Prevailing social attitudes remain a contributing factor, as evidenced by one study, where 78% of female physician respondents reported career delays due to childrearing.32 Additionally, when compared with their male colleagues, female physicians were more likely to be balancing professional and domestic roles.33 34 These marital and parental pressures explain the current evidence of female physicians spending significantly fewer hours at work and on career development.5 Indeed, one study reported that female family physicians work fewer overall hours across all age groups.35 This trend appears to extend to other specialties. For instance, female academic dermatologists in another study describe part-time work as a remedy to balancing parental roles.36 Current evidence shows that both male and female medical graduates prefer specialties with controllable work–life balance, which is an attributable reason for graduates pursuing dermatology.37 38 However, while women are better represented in the dermatology clinical workforce, it should be addressed that male clinicians continue to dominate the academic positions in this field.3 4
The marital and parental pressures on female physicians also inhibit career advancement. Starting a young family typically coincides with the start of one’s young academic career. One report indicates that female physician scientists face early delays to research productivity; a measure for which they only surpass their male colleagues by mid-career.6 As research metrics such as h-index are referenced as qualifications for academic leadership promotion, women are therefore disadvantaged in career advancement. A desire for work–life balance to uphold additional family and domestic responsibilities is also suggested as a major contributor to female under-representation in academic leadership positions.39
As female physicians face deeply rooted social impediments to career advancement,40 implementing more equitable institutional structures may reduce the negative impact of these barriers. For example, promoting paternity leave in medical training and practice may balance non-professional responsibilities among the male and female physicians,41 which can improve female research productivity and leadership representation. Evidence also suggests that appointing female role models to leadership positions may increase empowerment among women aspiring to these positions.42 Likewise, one study found that women with mentors report greater time spent on research with associated increases in research productivity.43 As women in medicine face other barriers including harassment and pay inequity,44 implementing measures against sex-based discrimination may improve career outcomes for female physicians.
Due to its cross-sectional nature, one limitation of this study is that it is an indirect assessment of the leadership pipeline effect in dermatology. With that being said, Jacobson et al confirmed the direct phenomenon of departmental leadership feeding into higher medical school ranks across medical schools in the USA.21 However, we welcome the potential for future study to longitudinally monitor the progression of individuals from affiliated departments to higher medical school leadership. Another potential limitation of our study is that dermatology programmes may not continually update their publicly available faculty listings. Additionally, faculty listings seldom report variables such as age at leadership appointment, length of leadership term, family situation and total career duration. Another limitation is that because SCOPUS measures years of research activity as the time between one’s first and last publication, it does not account for mid-career breaks taken for family responsibilities. Thus, female physicians’ years of active research may be overestimated. Further, in this work, the quantity of individuals with leadership positions was smaller than that of academic rank, which precluded stratification of the former by gender and affiliation. For this reason, our conclusions on gender disparity are largely applicable to the analysis by academic rank. Finally, as research articles are tied to an author’s surname at the time of publication, those that undergo marital name changes during their academic career may have underestimated research measures.
Conclusion
Gender disparities persist in academic dermatology as women continue to face substantial social pressures to career advancement. Leadership promotion practices also seldom consider the burdensome social responsibilities carried by women female physicians. Additional initiatives toward gender parity may improve the proportion of female representation in North American dermatology faculties.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors JD and FK the authors responsible for the overall content as the guarantors. JD contributed to conceptualisation, methodology, software, formal analysis, investigation, data curation, writing—original draft, writing—review and edition, visualisation, project administration. BT contributed to conceptualisation, methodology, validation, investigation, data curation, writing—original draft, writing—review and edition, project administration. MJ contributed to conceptualisation, methodology, writing—original draft, writing—review and edition, supervision, project administration. SC contributed to validation, investigation, data curation, writing—original draft, writing—review and edition. WA contributed to validation, investigation, data curation. FK contributed to conceptualisation, methodology, validation, resources, writing—original draft, writing—review and edition, supervision, project administration. Funding acquisition: N/A.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. The authors did not have any relationship with organizations or individuals that may have influenced this study. Dr. FK is the recipient of the Michael Smith Health Research BC Award (2023-2028); Don Rix Physician Leadership Lifetime Achievement Award (2022); BC Achievement Foundation – Mitchell Award of Distinction (2022); University of British Columbia – Distinguished Achievement Award for Equity, Diversity & Inclusion (2022) and Vancouver Medical Dental & Allied Staff Association – Equity, Diversity & Inclusion Award (2022).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Author note IRB approval status: This study was exempt from institutional review board approval as the data was extracted in its entirety from publicly available resources. The dissemination of results will not identify any individual or generate new forms of identifiable information.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.