The Road to an Academic Medicine Career

Abstract

The authors analyzed full-time faculty appointments among 66,889 US medical school graduates from 1998 to 2004, followed through July 2009. Women had higher odds of appointment than men, and one or more years of research during graduate medical education showed a positive association with appointments for both men and women. Men and women entering faculty positions had different levels of research experience and debt, and the authors suggested these differences could influence their subsequent career trajectories.

Background

US medical schools have established programs to support the recruitment and career advancement of female faculty. Women accounted for 48% of graduates from Liaison Committee for Medical Education (LCME)-accredited medical schools, 46% of participants in Accreditation Council for Graduate Medical Education (ACGME)-accredited residency programs, and 33% of physicians serving as faculty.

The authors hypothesized that women in recent graduating cohorts would be more likely than men to receive full-time faculty appointments. Given gender differences in career intentions and specialty choices, they also expected the associations of research experience and specialty choice with appointments to differ between men and women. The study examined the relationship between experiences gained from medical school entry through residency and subsequent full-time faculty appointments in a national cohort.

Method

The study was conducted from June 2011 to March 2012 and received institutional review board approval from the Washington University School of Medicine. The authors selected graduates who entered US LCME-accredited medical schools in 1994–2000 and graduated in 1998–2004. Matriculation questionnaires before 1994 lacked the required variables. Restricting the sample to those who graduated by 2004 allowed at least five years to complete residency training.

The study used the Association of American Medical Colleges (AAMC) Student Record System, Matriculating Student Questionnaire (MSQ), Graduation Questionnaire (GQ), GME Track, and Faculty Roster. These sources were combined with examination data from the National Board of Medical Examiners (NBME) and data from the American Medical Association (AMA) Physician Masterfile. The authors linked de-identified individual records using unique identification numbers and defined the outcome as ever having held a full-time faculty appointment by July 2009.

MD-PhD graduates were excluded because their career intentions differed. Graduates still in residency at follow-up were excluded because they did not meet the Faculty Roster definition of full-time faculty. Demographic variables included sex, race/ethnicity, and graduation year. Underrepresented minorities in medicine (URM) included Black, Hispanic, and American Indian/Alaska Native individuals.

Research-related variables included participation in college laboratory research, intention to pursue a research career at medical school entry, matriculation at a research-intensive medical school, medical school research electives, authorship/co-authorship of submitted manuscripts, and one or more years of research during graduate medical education (GME). Research-intensive medical schools were defined as the top 40 institutions by National Institutes of Health (NIH) funding. The cumulative number of research experiences across college, medical school, and GME ranged from 0 to 3.

Professional development variables included passing USMLE Step 1 on the first attempt, participation in health education electives, 12 categories of specialty choice, 4 categories of career intention at graduation, and 5 categories of debt. The authors used chi-square tests to examine associations between categorical variables and analysis of variance to examine relationships between continuous and categorical variables. They fitted multivariable logistic regression models for the full cohort and separately for men and women using SPSS 17.0.3. Statistical significance was defined as a two-sided P < .05.

Results

Of 113,522 entrants, 103,597 graduated during the study period. After excluding 1,232 MD-PhD graduates, 1 graduate with missing degree information, 17,122 still in training, and 207 with missing training status, 85,035 remained. An additional 17,611 with incomplete survey responses and 535 with other missing data were excluded. The final sample consisted of 66,889 individuals, representing 78.7% of the eligible population.

Within the final sample, 12,038 (18.0%) had held a full-time faculty appointment, and the adjusted odds ratio for women compared with men was 1.21. The appointment rate in the excluded group was 16.1%, lower than in the included group (P < .001). The proportion of women was 43.1% in the excluded group and 46.2% in the included group (P < .001).

Table 3 from the original article presents adjusted odds ratios (aOR) and 95% confidence intervals (CI).

Variable	Total, aOR (95% CI)	P value	Men, aOR (95% CI)	P value	Women, aOR (95% CI)	P value
Sex
Men	1.00 (Reference)		N/A		N/A
Women	1.21 (1.16–1.26)	<.001	N/A		N/A
Race/ethnicity
White	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Other/Unknown	0.89 (0.72–1.10)	.268	1.08 (0.83–1.40)	.575	0.65 (0.46–0.93)	.017
Asian/Pacific Islander	0.86 (0.81–0.91)	<.001	0.89 (0.83–0.96)	.003	0.82 (0.76–0.89)	<.001
URM	0.76 (0.72–0.82)	<.001	0.81 (0.73–0.89)	<.001	0.73 (0.66–0.79)	<.001
Graduation year, 1-year increase	0.90 (0.89–0.91)	<.001	0.91 (0.89–0.92)	<.001	0.90 (0.88–0.91)	<.001
College laboratory research participation
No	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Yes	1.07 (1.03–1.12)	.002	1.08 (1.02–1.14)	.014	1.06 (1.00–1.13)	.053
Intention for a research career at medical school entry	1.05 (1.02–1.08)	<.001	1.08 (1.04–1.12)	<.001	1.02 (0.98–1.07)	.293
Matriculation at a research-intensive medical school
No	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Yes	1.18 (1.13–1.23)	<.001	1.21 (1.14–1.28)	<.001	1.15 (1.08–1.22)	<.001
Medical school research elective
No	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Yes	1.05 (1.00–1.10)	.055	1.04 (0.97–1.12)	.267	1.06 (0.99–1.14)	.090
Authorship/co-authorship during medical school
No	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Yes	1.09 (1.04–1.15)	.001	1.12 (1.05–1.21)	.001	1.05 (0.98–1.13)	.177
≥1 year of research during GME
No	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Yes	1.65 (1.55–1.76)	<.001	1.53 (1.40–1.67)	<.001	1.79 (1.63–1.97)	<.001
USMLE Step 1 first attempt
Fail	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Pass	1.41 (1.25–1.59)	<.001	1.55 (1.27–1.88)	<.001	1.33 (1.14–1.55)	<.001
Medical school health education elective
No	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Yes	1.11 (1.06–1.16)	<.001	1.07 (1.01–1.14)	.019	1.15 (1.08–1.22)	<.001
Specialty choice
Internal medicine	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Undecided	0.80 (0.73–0.88)	<.001	0.90 (0.78–1.04)	.144	0.72 (0.63–0.82)	<.001
Radiology	1.06 (0.96–1.19)	.261	1.12 (0.97–1.29)	.127	1.06 (0.89–1.27)	.496
Internal medicine subspecialty	0.95 (0.87–1.04)	.302	0.97 (0.85–1.10)	.604	0.99 (0.86–1.13)	.874
Family medicine	0.34 (0.31–0.39)	<.001	0.39 (0.33–0.46)	<.001	0.30 (0.26–0.36)	<.001
Pediatrics	0.97 (0.89–1.07)	.587	1.29 (1.10–1.51)	.002	0.82 (0.73–0.93)	.001
Pediatrics subspecialty	1.21 (1.06–1.37)	.003	1.65 (1.37–1.99)	<.001	0.95 (0.80–1.13)	.568
Other specialty	1.00 (0.92–1.08)	.908	1.08 (0.96–1.20)	.199	0.93 (0.83–1.05)	.240
Surgery/Surgical subspecialty	0.62 (0.57–0.68)	<.001	0.65 (0.58–0.74)	<.001	0.64 (0.56–0.75)	<.001
Dermatology	0.61 (0.52–0.71)	<.001	0.69 (0.53–0.89)	.004	0.56 (0.46–0.68)	<.001
Obstetrics and gynecology	0.77 (0.69–0.85)	<.001	1.01 (0.83–1.23)	.909	0.67 (0.59–0.76)	<.001
Psychiatry	1.01 (0.90–1.14)	.863	1.30 (1.08–1.54)	.004	0.82 (0.69–0.96)	.016
Career intention at graduation
Full-time faculty	1.00 (Reference)		1.00 (Reference)		1.00 (Reference)
Undecided	0.61 (0.58–0.65)	<.001	0.61 (0.56–0.67)	<.001	0.62 (0.57–0.68)	<.001
Other	0.42 (0.38–0.47)	<.001	0.34 (0.30–0.39)	<.001	0.52 (0.46–0.60)	<.001
Clinical practice	0.43 (0.41–0.45)	<.001	0.41 (0.38–0.44)	<.001	0.46 (0.42–0.49)	<.001
Total debt at graduation	0.99 (0.97–1.00)	.092	0.96 (0.94–0.98)	.001	1.01 (0.98–1.03)	.460

Total N = 66,889, Men n = 35,975, Women n = 30,914. All models were adjusted for the variables presented in the table. The estimate for intention to pursue a research career represents a 1-unit increase, and the estimate for debt represents a $50,000 increase. N/A means not applicable. The Hosmer–Lemeshow goodness-of-fit test yielded P > .05 for all three models.

Matriculation at a research-intensive medical school, research during GME, passing Step 1, and participation in health education electives were positively associated with appointments for both men and women. College research participation, research intentions at entry, and medical school authorship experience were significantly associated with appointments only in the model for men. Higher debt was associated with lower odds of appointment only among men.

Among 35,146 participants in research electives, 60.3% (12,299/20,380) of men and 51.9% (7,669/14,766) of women had authorship experience (P < .001). Among those appointed to faculty, 63.5% of men and 54.2% of women had participated in research electives, while 44.1% of men and 33.6% of women had authorship experience (all P < .001). Health education electives were taken by 61.9% of women and 51.0% of men (P < .001). Female faculty had higher debt at graduation (P = .014).

Discussion

The 17.6% appointment rate among all graduates eligible for analysis was higher than the 9.3% reported in a previous study that tracked 1979–1993 graduates until 1997. Given that the annual number of graduates remained relatively constant, the authors interpreted this increase as partly reflecting an expansion of the clinical faculty workforce.

The authors suggested that URM and Asian/Pacific Islander graduates might have become less interested in academic careers during training or received fewer appointment offers aligned with their personal and professional goals.

The authors suggested that early interest in a research career might have played a larger role for men, whereas becoming more competitive for medical school admission might have been more salient for women. They noted that medical school research electives vary in duration and scope, so participation alone provides limited information about the nature of the experience. Differences in research quality and scope, as well as in how mentors acknowledge contributions, could contribute to the disparity in authorship.

One or more years of research during GME predicted appointment in both groups, and the estimated odds ratio was larger for women. The authors viewed residency and fellowship as key periods in women’s decisions about academic careers. Male faculty had accumulated more research and authorship experience. The authors discussed how disparities in research readiness at the time of appointment could contribute to subsequent gaps in productivity and promotion.

The positive relationship between participation in health education electives and appointment may reflect an interest in teaching. The relationship between the intention to pursue a faculty career at graduation and subsequent appointment was consistent with the view that intentions predict behavior. The authors believed that adding academic career guidance to the AAMC Careers in Medicine could assist students with their career decisions.

The authors explained that both research interest and the distribution of faculty positions could contribute to the lower odds of appointment in family medicine. While family medicine accounted for approximately 10% of all specialists, it represented 3.9% of clinical faculty appointments. The direction of the associations for pediatrics and psychiatry differed between men and women. The authors suggested that this might partly reflect efforts to recruit men in specialties with large numbers of female trainees.

Obstetrics and gynecology was chosen by 10.1% of female faculty and 2.8% of male faculty. Citing previous studies that reported lower retention rates in obstetrics and gynecology, the authors recommended considering specialty and clinical department in studies of gender and careers. They speculated that, even if debt did not deter women from accepting faculty appointments, it could affect subsequent retention when combined with the lower compensation of female faculty.

The use of national data on MD graduates and records of actual appointments is a strength of the study. The observational design supports an associational interpretation, and the higher inclusion rates for women and those with appointment histories leave open the possibility of selection bias. The results are not generalizable to MD-PhDs, osteopathic or international medical graduates, or PhD holders. The influence of mentors and role models was not measured. A short follow-up period might have contributed to the lower odds of appointment for recent graduates.

Conclusions

Women in this cohort were more likely than men to have held a full-time faculty appointment. Men and women entered academia with different research experiences, debt levels, and preferences for professional activities.

Reading notes

Among research elective participants, 60.3% of men and 51.9% of women had experience as authors or co-authors. Because elective participation was measured as a binary variable, these proportions encompass research experiences of varying durations and scopes. From a career development perspective in HRD, this finding raises a further question about how opportunities to participate in research and recognition of contributions through authorship relate to later entry into academia.

The adjusted odds ratio of 1.21 for women’s appointment to full-time faculty was based on whether an individual had ever been appointed by July 2009. This figure is an indicator of entry into a faculty role rather than a measure of retention or promotion. Interpretation of this relationship should account for the higher proportions of women and individuals with appointments in the included group than in the excluded group.

References

Andriole, D. A., & Jeffe, D. B. (2012). The road to an academic medicine career. Academic Medicine, 87(12), 1722–1733. https://doi.org/10.1097/ACM.0b013e318271e57b