Surgeon Intersectionality and Academic Promotion and Retention in the US

This cohort study investigates the association of academic surgeon sex and race and ethnicity with career trajectory.

Key Points

Question

Is the intersection of race and ethnicity and sex associated with the career trajectory of academic surgeons?

Findings

In this cohort analysis including 31 045 faculty, female surgeons who are also underrepresented in medicine were the least likely to be promoted and the most likely to leave academia.

Meaning

In academic surgery, race and ethnicity and sex have combined associations with the diversity of faculty.

Abstract

Introduction

Efforts have been made to increase the number of women and physicians who are underrepresented in medicine (UIM). However, surgery has been slow to diversify, and there are limited data surrounding the impact of intersectionality.

Objective

To assess the combined association of race and ethnicity and sex with rates of promotion and attrition among US academic medical department of surgery faculty.

Design, Setting, and Participants

This was a retrospective cohort study using faculty roster data from the Association of American Medical Colleges. All full-time academic department of surgery faculty with an appointment any time from January 1, 2005, to December 31, 2020, were included. Study data were analyzed from September 2022 to February 2023.

Exposures

Full-time academic faculty in a department of surgery with a documented self-reported race, ethnicity, and sex within the designated categories of the faculty roster of Association of American Medical Colleges.

Main Outcomes and Measures

Trends in race and ethnicity and sex, rates of promotion, and rates attrition from 2010 to 2020 were assessed with Kaplan-Meier and Cox time-to-event analyses.

Results

A total of 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 institutions were included. The mean (SD) program percentage of UIM male faculty increased from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty members increased from 2.3% (2.6%) to 3.3% (2.5%) over the 10-year period (P < .001). The mean program percentage of non-UIM females increased at every rank (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all P < .001). There was no change in the mean program percentage of UIM female instructors or full professors. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%) and 1.6% (3.2%) to 2.2% (3.4%), respectively (P =.002). There was no change in the mean program percentage of UIM male instructors, associate, or full professors. Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). Non-UIM males had the shortest median (IQR) time to promotion, whereas non-UIM females had the longest (6.9 [6.8-7.0] years vs 7.2 [7.0-7.6] years, respectively; P < .001). After 10 years, 79% of non-UIM males (13 202 of 16 299), 71% of non-UIM females (3784 of 5330), 68% of UIM males (1738 of 2538), and 63% of UIM females (625 of 999) remained on the faculty. UIM females had a higher risk of attrition compared with non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001) and UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .05). The mean (SE) time to attrition was shortest for UIM females and longest for non-UIM males (8.2 [0.14] years vs 9.0 [0.02] years, respectively; P < .001).

Conclusion and Relevance

Results of this cohort study suggest that intersectionality was associated with promotion and attrition, with UIM females least likely to be promoted and at highest risk for attrition. Further efforts to understand these vulnerabilities are essential.

Introduction

Despite increased diversity in the US and efforts to achieve equity in the physician workforce, racial and ethnic minority individuals and women continue to be underrepresented among academic surgeons. Those who identify as American Indian or Alaska Native, Black, Hispanic or Latinx, or Native Hawaiian or Other Pacific Islander comprise 36% of the US population, yet are less than 10% of academic surgery faculty in 2022.^1,2 Recent trends have shown an increase in the number of Hispanic or Latinx surgery faculty but no corresponding increase in their overall percentage.³ In the case of Black surgeons, there has been little improvement in representation dating back over 30 years.⁴ American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander surgeons are less than 1% of surgery faculty and have had no recent changes in representation.⁵ Although some progress has been made toward increasing the number of women surgeons, they are still less likely to be promoted or receive research funding and are more likely to experience harassment than their male counterparts.^6,7,8

Racial, ethnic, and gender diversity is essential to achieving equity in health care. Physicians who are underrepresented in medicine (UIM) are more likely to work in underserved or rural communities.^9,10 At the county level, an increase in the percentage Black physicians has been demonstrated to decrease disparities in mortality between Black and White patients.¹¹ Physician and patient gender concordance has been associated with improved outcomes in surgical care.¹² However, the field of surgery has been slow to diversify, and understanding how intersectionality impacts academic retention and promotion is poorly understood.

UIM and female surgeons are most underrepresented in departmental leadership positions and at the full professor level.⁵ Unfortunately, junior surgery faculty who are UIM are less likely to be promoted and are more likely to leave academia.¹³ Most research about diversity of surgery faculty lacks data that allow for an in-depth analysis of the intersectionality between race and ethnicity and sex.^5,14 Recent studies have demonstrated significant differences between the trends in percentage of surgeons, at every academic rank, who identify as UIM male or UIM female.⁵ UIM females receive fewer grants and less grant funding compared with males and non-UIM surgery faculty.⁷ However, to date there are almost no data about the effect of intersectionality on the career trajectory of surgical faculty. As a result, we sought to use Association of American Medical Colleges (AAMC) data regarding both sex and race and ethnicity to evaluate trends in retention and promotion of general surgery faculty members with a focus on intersectionality.

Methods

A secondary analysis was performed using deidentified data from the AAMC faculty and resident roster with data from 2005 to 2020. Written informed consent was waived as this cohort analysis involved no more than minimal risk to participants. This study was approved by the institutional review board at Weill Cornell Medicine and the University of California San Francisco. To be included in the study, individuals must have held a full-time faculty appointment in a department of surgery. Faculty members had individual records that allowed data to be tracked across multiple institutions to account for individuals who changed academic affiliations. There were 7 programs excluded from the analysis, each with a percentage of UIM faculty that ranged from 70% to 100%, representing in some cases, a 10-fold increase in UIM faculty compared with all other programs. We excluded these programs under the assumption that they likely have a focus on minority surgeons and our concern that they would skew findings compared with other programs.^15,16 In addition, faculty without documented sex and/or race and ethnicity assignment were excluded from the study cohort. Analysis was focused on 2010 to 2020 to ensure adequate follow-up. The overall percentage change of faculty demographic metrics, rates of promotion, and rates of faculty leaving academic medicine were evaluated. The race and ethnicity categories used in this study are derived from the AAMC Faculty Roster, which has self-reported race, ethnicity, and sex information and coincides with the minimum requirements of the Office of Management and Budget standards. Race and ethnicity categories included American Indian or Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, Hispanic or Latinx, White, or other, which indicates any race or ethnicity not otherwise designated by the AAMC. The category of faculty sex was limited to the binary options of either male or female, per the AAMC data that was collected during the time period.

Statistical Analysis

Individual- and program-level sample characteristics were described using frequencies and summary statistics, as appropriate. Linear regression was used to assess linear trends of program-level characteristics over time. Pearson correlation coefficients were used to assess associations between program-level UIM and female percentages. Program-level demographic characteristic rates were dichotomized at the 75th percentile, as there is no established cutoff from prior literature, and promotion and retention rates were tested for differences between these groups using t tests. Kaplan-Meier and Cox proportional hazards regression time-to-event analyses were performed to assess promotion and retention rates by 10 years and their associations with demographic characteristics. Hypothesis tests were 2-sided, and the significance threshold was set to .05. Statistical analyses were performed using SAS, version 9.4 (SAS Institute). Study data were analyzed from September 2022 to February 2023.

Results

Demographics of Overall Cohort

There were 31 045 faculty members (23 092 male [74%]; 7953 female [26%]) from 138 department of surgery programs in our study cohort, and the mean (SD) follow-up was 12.4 (10.9) years (Figure and Table 1). Surgeons identified with the following race and ethnicity categories: 131 American Indian or Alaska Native (<1%), 6158 Asian (20%), 1175 Black (4%), 1708 Hispanic or Latinx (6%), 215 Native Hawaiian or Other Pacific Islander (<1%), 22 486 White (73%), and 605 other race or ethnicity (2%). The cohort was composed of 20 554 non-UIM males (66%), 6954 non-UIM females (22%), 2538 UIM males (8%), and 999 UIM females (3%). The mean (SD) number of faculty members at each program increased from 99 (78) in 2010 to 126 (143) in 2020. A total of 80% of faculty were employed at only 1 academic institution during the 15-year study period.

Figure. Data Source.

These programs, representing 4.8% of eligible academic institutions, each had 70% or more faculty who were underrepresented in medicine (UIM). A total of 736 female faculty were missing data on UIM status, and 1010 male faculty were missing data on UIM status. AAMC indicates Association of American Medical Colleges.

Table 1. Individual Faculty Demographics by Self-Identified Race and Ethnicity (N = 31 045).

Variable	No. (%)
	Overall	Male	Female
Follow-up time, mean (SD) [median], y	12.4 (10.9) [8.8]	NA	NA
UIM status
Non-UIM	27 508 (88.6)	20 554 (66.2)	6954 (22.4)
UIM	3537 (11.4)	2538 (8.2)	999 (3.2)
Race
American Indian or Alaska Native	131 (0.4)	89 (0.3)	42 (0.1)
Asian	6158 (19.8)	4469 (14.3)	1689 (5.4)
Black	1175 (3.8)	770 (2.5)	405 (1.3)
Native Hawaiian or Other Pacific Islander	215 (0.7)	164 (0.5)	51 (0.2)
White	22 486 (72.4)	16 902 (54.4)	5584 (18.0)
Other	605 (1.9)	459 (1.5%)	146 (0.5)
Ethnicity
Hispanic or Latinx	1708 (5.5)	1281 (4.1)	427 (1.4)

Abbreviations: NA, not applicable; UIM, underrepresented in medicine.

Overall UIM Faculty Trends

Between 2010 to 2020, the mean (SD) program percentage of UIM faculty increased from 11% (6.8%) to 12% (7.3%; P = .005). The mean (SD) program percentage of UIM male faculty increased slightly from 8.4% (5.5%) in 2010 to 8.5% (6.2%) in 2020 (P < .001), whereas UIM female faculty increased from 2.3% (2.0%) to 3.3% (2.5%; P < .001). Over the 10-year period, the mean (SD) percentage of Black surgeons across all programs was unchanged (4.0% [3.8%] vs 4.0% [3.1%]). The mean (SD) percentage of Hispanic or Latinx surgeons increased from 4.9% (4.9%) to 6.0% (5.7%; P < .001). The mean (SD) percentage of Native Hawaiian or Other Pacific Islanders decreased from 0.6% (2.2%) to 0.4% (1.2%; P < .001), as did the percentage of American Indian or Alaska Native surgeons (from 0.4% [0.7%] to 0.3% [0.6%]; P < .001).

Trends in Faculty by Rank, Sex, and UIM Status

The mean program percentage of non-UIM females increased at every rank over the study period (percentage point increase per year from 2010 to 2020 in instructor: 1.1; 95% CI, 0.73-1.5; assistant professor: 1.1; 95% CI, 0.93-1.3; associate professor: 0.55; 95% CI, 0.49-0.61; professor: 0.50; 95% CI, 0.41-0.60; all with P < .001). There was no significant change in the mean program percentage of UIM female instructors or full professors from 2010 to 2020. The mean (SD) percentage of UIM female assistant and associate professors increased from 3.0% (4.1%) to 5.0% (4.0%; P < .001) and 1.6% (3.2%) to 2.2% (3.4%; P = .002), respectively, from 2010 to 2020.

There was no significant change in the mean program percentage of UIM male instructors, associate professors, or full professors between 2010 and 2020. The mean (SD) program percentage of UIM male assistant professors decreased from 10% (11%) to 8.7% (7.5%; P = .004). The mean program percentage of Hispanic or Latinx faculty increased at every professorship level, whereas the percentage of Black faculty increased only at the associate and full professor levels. The percentage of Black faculty decreased at the instructor and assistant levels. The percentage of American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander professors remained relatively unchanged at less than 1% at each faculty level during the study period.

Program Level Rates of Promotion

The mean (SD) percentage of surgeons promoted within 10 years of starting at their programs was 79% (16.4%). After 10 years from their initial start date, 82% of non-UIM males (16 672 of 20 406), 77% of non-UIM females (5309 of 6884), 81% of UIM males (1252 of 1542) and 75% of UIM females (490 of 657) were promoted (P <.001). The median (IQR) time to promotion within 10 years was 7 (7.0-7.7) years for all surgeons. Non-UIM males had the shortest median (IQR) time to promotion at 6.9 (6.8-7.0) years, whereas UIM males had a median (IQR) time to promotion of 7 (6.8-7.2) years, UIM females were promoted in 7.1 (6.7-7.8) years, and non-UIM females were promoted in 7.2 (7.0-7.6) years (P < .001). Compared with non-Hispanic White males, Hispanic females were 32% less likely to be promoted within 10 years (hazard ratio [HR], 0.68; 95% CI, 0.54-0.86; P <.001), non-Hispanic White females were 25% less likely (HR, 0.75; 95% CI, 0.71-0.78; P <.001), Hispanic males were 15% less likely (HR, 0.85; 95% CI, 0.76-0.96; P =.007), and Asian females were 12% less likely (HR, 0.88; 95% CI, 0.80-0.96; P =.03). There was no difference in the rate of promotion between non-Hispanic White males and Black faculty or Native Hawaiian or Other Pacific Islander faculty (Table 2 and eFigure 1 in Supplement 1).

Table 2. Cox-Adjusted Model for Faculty Promotion Over 10 Years.

Groupa	Compared with non-Hispanic White male (n = 16 299)
	Hazard ratio (95% CI)	P value
American Indian or Alaska Native female (n = 22)	0.53 (0.25-1.11)	.09
American Indian or Alaska Native male (n = 50)	0.73 (0.45-1.17)	.19
Asian female (n = 1554)	0.88 (0.80-0.96)	.003
Asian male (n = 4107)	1.01 (0.96-1.07)	.59
Black female (n = 378)	0.87 (0.73-1.04)	.13
Black male (n = 725)	0.96 (0.86-1.07)	.48
Hispanic female (n = 247)	0.68 (0.54-0.86)	<.001
Hispanic male (n = 732)	0.85 (0.76-0.96)	.007
Native Hawaiian or Other Pacific Islander female (n = 10)	0.26 (0.07-1.07)	.06
Native Hawaiian or Other Pacific Islander male (n = 35)	0.78 (0.44-1.37)	.38
White female (n = 5330)	0.75 (0.71-0.78)	<.001
Other female (n = 50)	0.96 (0.53-1.73)	.88
Other male (n = 182)	1.08 (0.83-1.40)	.56

^a Race categories included American Indian or Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, and other (which indicates any race or ethnicity not otherwise designated by the AAMC); groups shown do not include participants who indicated more than 1 race; Hispanic male and female only indicated Hispanic on demographics form; and groups with less than 10 participants were not analyzed. This model was adjusted for faculty rank and department (surgery vs nonsurgery) at baseline.

Rate of Faculty Attrition

After 10 years, 79% of non-UIM males (16 141 of 20 406), 71% of non-UIM females (4838 of 6884), 68% of UIM males (1056 of 1542), and 63% of UIM females (411 of 657) remained on faculty. Compared with non-UIM males, non-UIM females were 1.5 times (95% CI, 1.4-1.6) more likely to leave academia, UIM males were 1.6 times (95% CI, 1.5-1.8) more likely, and UIM females were 2.0 times (95% CI, 1.7-2.3) more likely (P < .001 for each comparison). UIM females had a higher risk of attrition over 10 years compared with non-UIM females, with 10-year rates of attrition at 37% for UIM females vs 30% for non-UIM females (HR, 1.3; 95% CI, 1.1-1.5; P = .001). UIM females also had a higher risk of attrition vs UIM males (HR, 1.2; 95% CI, 1.0-1.4; P = .04). The mean (SE) time to attrition was shortest for UIM females at 8.2 (0.14) years and was longest for non-UIM males at 9.0 (0.02) years. The mean (SE) time to attrition for UIM males was 8.3 (0.08) years and for non-UIM females was 8.5 (0.05) years.

Overall, non-White faculty had a higher risk of attrition compared with White faculty (HR, 1.6; 95% CI, 1.5-1.7; P < .001). Compared with non-Black faculty, Black faculty had 1.6 times the risk of attrition (HR, 1.6; 95% CI, 1.4-1.8; P < .001), and compared with non–American Indian or Alaska Native faculty, American Indian or Alaska Native faculty had 1.8 times the risk of attrition (HR, 1.8; 95% CI, 1.2-2.6; P = .003). All other dichotomized race group comparisons examined had lower HRs. Native Hawaiian or Other Pacific Islander faculty had the highest rates of attrition compared with non-Hispanic White males (Table 3 and eFigure 2 in Supplement 1).

Table 3. Cox-Adjusted Model for Faculty Attrition Over 10 Years.

Groupa	Compared with non-Hispanic White male (n = 16 299)
	Hazard ratio (95% CI)	P value
American Indian or Alaska Native female (n = 22)	1.62 (0.52-5.02)	.40
American Indian or Alaska Native male (n = 50)	2.34 (1.38-4.10)	.002
Asian female (n = 1554)	1.83 (1.60-2.09)	<.001
Asian male (n = 4107)	1.64 (1.50-1.78)	<.001
Black female (n = 378)	2.33 (1.84-2.95)	<.001
Black male (n = 725)	1.76 (1.49-2.07)	<.001
Hispanic female (n = 247)	2.43 (1.85-3.20)	<.001
Hispanic male (n = 732)	1.98 (1.68-2.33)	<.001
Native Hawaiian or Other Pacific Islander female (n = 10)	4.41 (1.98-9.84)	<.001
Native Hawaiian or Other Pacific Islander male (n = 35)	4.44 (2.79-7.06)	<.001
White female (n = 5330)	1.53 (1.41-1.66)	<.001
Other female (n = 50)	2.38 (0.89-6.35)	.08
Other male (n = 182)	3.16 (2.24-4.45)	<.001

^a Race categories included American Indian or Alaska Native, Asian, Black, Native Hawaiian or Other Pacific Islander, White, and other (which indicates any race or ethnicity not otherwise designated by the AAMC); groups shown do not include participants who indicated more than 1 race; Hispanic male and female only indicated Hispanic on demographics form; and groups with less than 10 participants were not analyzed. This model was adjusted for faculty rank and department (surgery vs nonsurgery) at baseline.

High-Outlier Programs

The first to third quartiles (Q1-Q3) for the percentage of UIM faculty per department of surgery program were 8% to 14%. High-outlier programs were designated as having 14% or more UIM faculty (≥75th percentile). There were 34 high-outlier programs of the 138 programs studied. The mean (SD) percentage of UIM faculty promoted within 10 years was lower at programs with the highest percentages of UIM faculty in the upper quartile compared with programs with fewer UIM faculty in the lower 3 quartiles (73% [27%] vs 85% [16%]; P = .02). There was no significant difference in the rates of attrition among UIM faculty between these groups of programs. Q1 to Q3 for the percentage of female faculty per program were 20% to 26%, with 35 programs having 26% or more female faculty (≥75th percentile). There was no significant difference in the rates of promotion or attrition between programs with the highest percentages of female faculty in the upper quartile compared with programs with fewer female faculty in the lower 3 quartiles.

Discussion

Over the past decade, despite an increase in numbers, the overall percentage of UIM surgery faculty has remained relatively unchanged. Our findings suggest that trends in representation and rates of promotion and attrition differ significantly between UIM males, UIM females, and between specific racial and ethnic categories of UIM faculty, with UIM faculty doing worse across the board. UIM females had the lowest rates of promotion, were most likely to leave academia, and had the shortest time to attrition.

Gender disparities in surgery are well documented. Women surgical trainees experience higher rates of mistreatment, including gender-based discrimination and sexual harassment.⁸ Evidence also suggests that UIM female surgeons have fewer opportunities for leadership and research funding. At the faculty level, a recent study by Riner et al⁵ showed that women are underrepresented in leadership positions, such as among department chairs and deans. Disparities extend beyond academic medical center leadership. In 2019, only 2 of 42 editors-in-chief (4.8%) of surgical journals were women.¹⁷ Leadership positions in national surgical societies have been less diverse than the overall demographics of academic surgeons despite evidence that many women and UIM surgeons have comparable academic and clinical achievement with non-UIM male candidates.¹⁸ A recent study on research funding from the National Institutes of Health reported that 13 Hispanic male and 7 Black male surgeons received R-01–equivalent funding compared with no Black or Hispanic female surgeons in 2019.⁷ Bias based on sex and race and ethnicity contributes to disparate levels of academic and leadership opportunities for UIM female surgeons that may significantly affect career trajectory. In our dataset, UIM female faculty had the lowest rate of promotion and the highest rate of attrition, along with the shortest time to leaving academia.

American Indian or Alaska Native, Black, and Native Hawaiian or Other Pacific Islander surgical faculty have remained underrepresented with little to no change in numbers at every faculty rank. In our study, representation among these groups on surgery faculties either remained the same or (more troubling) fell, as was the case for Black junior faculty. In their study on trends in UIM faculty, Lett et al¹⁹ reported that Black and Hispanic or Latinx faculty were more underrepresented in medicine in 2016 than in 1990. Over the last 30 years, the fields of surgery and family medicine have experienced the smallest relative increases in the proportion of Black professors.⁴ In a recent study of general surgery residents, Keshinro and colleagues¹⁴ reported a decrease in the matriculation to and graduation from general surgery residency programs for Black men as well as an unchanged graduation rate for Black women. The study also found that both male and female Hispanic or Latinx medical students submitted more applications to general surgery residency programs every year from 2005 to 2018.¹⁴ Although our data suggest that Hispanic or Latinx faculty were the only UIM group to experience an increase in representation across all faculty ranks from 2010 to 2020, these same surgeons were the only UIM group to have a significantly lower likelihood of promotion compared with non-Hispanic White males. If these trends continue, there could be even fewer senior faculty who are Hispanic or Latinx surgeons in the future, with potential ramifications for mentorship and sponsorship for more junior colleagues. Overall, there has been a disappointing lack of improvement in the percentage of UIM faculty in surgery in the past decade despite increasing efforts to remediate these trends.

Programs that performed in the upper quartile for percentage of UIM on faculty promoted their UIM faculty significantly less often than programs with fewer UIMs. There was no significant difference in promotion or retention between programs that had more or less female faculty. Efforts to recruit UIM and/or female faculty alone have not been enough to improve the percentage of these faculty at higher levels. In a study of a structured hiring process to improve faculty diversity in a department of surgery, Dossett et al²⁰ found that efforts to increase recruitment of UIM and female surgeons revealed institutional knowledge gaps related to objectively evaluating candidates for faculty positions. These gaps included having no objective standards for determining a candidate’s clinical skills, teaching acumen, or research productivity.²⁰ Guevara et al,²¹ in an analysis of AAMC faculty roster data from 2000 to 2010 that included 124 US medical schools, found no change in the rate of promotion of UIM faculty at medical schools where minority faculty development programs were implemented. These studies, along with our findings, suggest that increasing the representation alone of UIM and/or female surgeons is not enough and well might not lead to better rates of promotion and retention.

It will likely take additional policies and interventions to change the current trends in representation and career trajectory of UIM surgeons. Efforts to increase diversity in the pipeline to an academic surgical career are still needed. Increased recruitment of trainees will also need to be supplemented with longitudinal support. One such program is the Diverse Surgeons Initiative, sponsored by the Society of Black Academic Surgeons and Ethicon, which has assisted UIM surgical residents in pursuing academic careers and obtaining professional leadership positions through technical training and longitudinal mentorship.²² Further studies are needed to investigate the characteristics and initiatives that have made certain institutions more successful at both promoting and retaining UIM faculty.

Limitations

This study has some limitations. Five percent of faculty at the 138 institutions included in our study had either missing data for race and ethnicity or sex; as a result, these faculty could not be analyzed as part of our analysis. The AAMC faculty roster has self-reported data on sex rather than gender, which is not binary. Therefore, we cannot account for the specific effect of gender on our outcomes. The cohort includes all faculty with a full-time faculty position in surgery; therefore, they may include some nonphysicians and nonclinical faculty. At the same time, general surgery subspecialties could not be elicited from the roster, and so our study findings may not be equally relevant to all subspecialties.

Conclusions

To our knowledge, this was the first national study to investigate intersectionality among academic surgical faculty and its potential association with career trajectory. Due to the large cohort, we were able to evaluate smaller racial groups without a risk of losing confidentiality. The intersection of race and ethnicity and sex was associated with time to promotion and rates of attrition. Results suggest that UIM females on surgical faculties experience the highest rate of attrition and lowest rate of academic promotion within 10 years. Surprisingly, institutions with higher percentages of female or UIM surgeons did not have better rates of promotion or attrition than programs with fewer female or UIM surgeons. In the past decade, the percentage of UIM surgeons in academic surgery has remained low and relatively unchanged. The percentage of American Indian or Alaska Native and Native Hawaiian or Other Pacific Islander surgeons continues to be less than 1%, and the percentage of Black junior faculty has fallen. Understanding these vulnerabilities is essential for informing more targeted interventions that will diversify our surgical workforce. Better data, transparency, and accountability are needed to effect meaningful change.

Supplement 1.

eFigure 1. Kaplan-Meier Survival Plot for Time to Promotion by 10 Years

eFigure 2. Kaplan-Meier Survival Plot for Time to Attrition by 10 Years

Supplement 2.

Data Sharing Statement.