Gender Inequity in Institutional Leadership Roles in US Academic Medical Centers

Key Points

Question

What is the current state of gender inequity in institutional leadership roles in US academic medical centers?

Findings

This systematic scoping review of 94 articles from 2019 to 2022 including 22 478 participants found that while there were more women in medicine than ever before, inequities in leadership attainment by women persisted in all roles, including deans, department chairs, division chiefs, and program directors.

Meaning

These findings suggest that organizational and systems-level changes are essential to recruit and retain diverse leaders in academic medicine.

This systematic scoping review evaluates the state of gender inequity in US institutional leadership roles in academic medicine, including deans, department chairs, and residency and fellowship program directors.

Abstract

Importance

Academic medical centers have focused their efforts on promoting gender equity in recent years, but the positive outcomes associated with those efforts remain to be seen in recruiting and retaining diverse institutional leadership.

Objective

To evaluate the current state of gender inequity in institutional leadership roles, such as deans, department chairs, and residency and fellowship program directors, at US academic medical centers.

Evidence Review

A search for articles published from January 1, 2019, to August 5, 2022, on gender inequity in institutional leadership roles at academic medical centers was performed using the PubMed, CINAHL, and ERIC databases. Studies were screened for inclusion by sets of 2 independent reviewers (with disagreements resolved by a third reviewer) and evaluated for risk of bias. The Methodological Expectations of Cochrane Intervention Reviews Standards were followed for conducting the review, and the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guideline was followed for reporting results.

Findings

A total of 8120 articles were retrieved, of which 6368 were screened by title and abstract, 6166 were excluded, and 202 underwent full-text review. Ultimately, 94 studies reported on institutional leadership roles, including deans (5 studies [5.3%]), department chairs (39 studies [41.5%]), division chiefs (25 studies [26.6%]), and program directors (67 studies [71.3%]), with some overlap. A total of 678 participants were deans (564 men [80.5%] and 132 women [19.5%]), 8518 were department chairs (7160 men [84.1%] and 1358 women [15.9%]), 3734 division chiefs (2997 men [80.3%] and 737 women [19.7%]), and 9548 program directors (7455 men [78.1%] and 2093 women [21.9%]). Even in specialties with 50% or more female faculty, none had equal representation of women as department chairs and division chiefs. Gender inequities were particularly pronounced in surgical specialties.

Conclusions and Relevance

This systematic scoping review suggests that even though emphasis has been placed on addressing gender inequities in academic medicine, considerable disparities remain at the leadership level. While certain positions and specialties have been observed to have more female leaders, niches of academic medicine almost or completely exclude women from their leadership ranks. Importantly, even female-dominated specialties, such as obstetrics and gynecology, have substantial inequity in leadership roles. It is past time for organizational and systems-level changes to ensure equitable gender representation in academic leadership.

Introduction

As of 2023, women represented the majority (55%) of US medical students, and 45% of all faculty.^1,2 However, only 25% of department chairs were women. While these figures reflect some improvement owing to recent efforts to increase gender equity and diversity in medicine, they do not reflect the barriers for women physicians to attain leadership positions.² The career path from medical student to resident to early career faculty member presents numerous circumstances for exposure to microaggressions, gender bias, and threats to career advancement, ultimately leading to fewer women who continue in academia.^3,4,5,6,7

An abundance of research has reported on gender disparities in academic rank. Only 43.8% of medical school faculty are women, and women represented only 41.2% of associate professors and 28.3% of full professors.⁸ Beyond representation, the differential trajectory by gender is crucial to recognize. In a study of women physicians over a 35-year period, women were less likely than men to be promoted to associate professor or full professor or to be appointed as a department chair.⁹ Notably, these gaps did not narrow over time, highlighting the need for continued deliberate efforts to promote gender equity. While these figures directly reflect academic rank, they indirectly impact the gender distribution of physicians available to fill institutional leadership roles, including deans, department chairs, and residency and fellowship program directors. Less work has directly focused on institutional leaders, who set a culture that either promotes and retains women as leaders or does not.

The inequitable environment of academia threatens the success of women and has led many to consider leaving academic medicine and/or medicine altogether. Among a cohort of academic physicians examined from 2014 to 2019, female physicians had an increased odds of leaving academic medicine compared with male physicians (odds ratio, 1.25; 95% CI, 1.23-1.28).⁴ Moreover, with a continued lack of advancement for women, these trends might persist and worsen over time, having detrimental impacts on not only workforce diversity but also patient care. In a cohort study of more than 1 million surgeries, patients treated by a female surgeon were less likely to die or experience hospital readmission or major medical complications at 90 days or 1 year after surgery.¹⁰ The study also showed that patient-surgeon gender concordance was associated with significantly lower mortality for female patients for elective procedures.¹⁰ Another national study of hospitalized Medicare beneficiaries found that patients treated by female physicians had significantly lower mortality and readmission rates compared with those cared for by male physicians within the same hospital.¹¹ Better outcomes across numerous quality-of-care indicators occur under the care of women physicians.^{12,13,14,15,16,17,18,19,20,21} Additionally, female authors are significantly more likely to include female participants in their research, and clinical trials led by women are significantly more likely to recruit more women as participants, underscoring the important role of women physicians in advancing health care.^22,23 Thus, interventions to recruit and retain women physicians, including in key leadership roles, are essential.^{12,13,14,15,16,17,18,19,20,21}

Although there has been measurable progress over time in the number of women attaining leadership positions within academic medicine, raw numbers alone do not accurately depict the underlying issue. In one review that included 40 studies published through 2019, the authors asserted that these numbers merely reflect a performance indicator rather than a marker of genuine improvement in leadership for female faculty.²⁴ Specifically, simply having women in leadership positions without providing necessary support does not provide equity in leadership roles. Ultimately, a fundamental shift in viewing women as leaders and a more inclusive culture may allow all to thrive and patients to receive better care. To identify opportunities for strategic intervention, it is necessary to understand the current state of gender inequity in leadership. The purpose of this study was to assess gender equity in impactful institutional leadership roles, including deans, department chairs, division chiefs, and residency and fellowship program directors.

Methods

Given the current state of the research field, we chose to conduct a systematic scoping review to assess gender equity in institutional leadership roles (deans, department chairs, division chiefs, and residency and fellowship program directors). As Tricco et al²⁵ stated, “Scoping reviews are useful for answering much broader questions,” allowing researchers to “summarize findings from a body of knowledge that is heterogeneous in methods or discipline,”^(p467) which is in alignment with our research goals. This study followed the Methodological Expectations of Cochrane Intervention Reviews Standards for conducting the review²⁶ and the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) reporting guideline for reporting results.²⁵

Search Strategy

We conducted a comprehensive search of the PubMed, CINAHL, and ERIC databases for articles published between January 1, 2019 (the last year included in the systematic review by Alwazzan and Al-Angari²⁴), and the final search date of August 5, 2022. The original search strategy was developed by a medical librarian (B.M.S.) in consultation with the research team (M.S.L., K.N.H., K.A.L., A.M., M.H.) and included keywords and subject headings corresponding to the concepts of (1) women/gender, (2) leadership, (3) academia, and (4) medicine. The eAppendix in Supplement 1 provides the full search strategy. In addition to applying a publication date limit from 2019 to 2022, we limited the results to articles published in English due to the focus on academic institutions in the US.

We found a total of 8119 articles across the databases. After removing duplicate studies using EndNote, version 20 (Clarivate) and Covidence,²⁷ 6367 unique publications remained. An additional 3 articles were added to this pool from other sources (eg, references in included articles) based on preliminary searching, for a total of 6370 unique articles. Sets of two independent reviewers (K.N.H., K.A.L., V.M., A.M., E.M., and R.D.) screened these articles in Covidence sequentially, first by title and abstract and then by full text, to select the articles ultimately used in this review. Articles were also assessed for quality during the review process by sets of 2 reviewers (K.N.H., K.A.L., V.M., A.M., E.M., and R.D.) using a checklist developed from the Joanna Briggs Institute criteria for scoping reviews.²⁸ A third reviewer (M.S.L.) resolved disagreements.

Inclusion and Exclusion Criteria

The inclusion criteria were a US academic medical center setting; focus on institutional leadership roles, including but not limited to program directors, department chairs, division chiefs, and/or deans; gender breakdown in roles reported; focus on physician leadership roles; and articles published in English. The exclusion criteria were studies set outside the US or in hospitals that are not academic medical centers; no institution-level leadership positions included; and articles published in a language other than English. An academic medical center was defined as a tertiary care hospital that is organizationally and administratively integrated with a medical school.²⁹ An additional exclusion criterion was if the study did not include quantitative data on the proportion of leaders by gender, such as qualitative research reports and commentaries, since our main objective was to quantify the proportion of women in institutional leadership roles.

Statistical Analysis

We calculated descriptive statistics for the articles included in the final analysis, including the gender composition of participants (men and women) in the defined roles of interest, scholarly and clinical productivity, demographics, and future directions. The analyses were performed using SPSS, version 29 (IBM Corp). The final analysis was conducted on January 28, 2025.

Results

Study Characteristics

Of the 6370 articles screened for eligibility, 202 underwent full-text screening, 108 were excluded because they did not report on the preidentified outcomes (77 articles), were commentaries (17 articles), or were not based in the US (14 articles). Ultimately, 94 articles including 22 478 participants (80.8% men and 19.2% women) were included in the final analysis (Figure 1).^{30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80,81,82,83,84,85,86,87,88,89,90,91,92,93,94,95,96,97,98,99,100,101,102,103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123} We grouped the studies by the types of institutional leadership roles reported and summarized the gender distribution for each role along with demographic factors and broad findings (Table 1). A total of 678 participants were deans (564 men [80.5%] and 132 women [19.5%]), 8518 were department chairs (7160 men [84.1%] and 1358 women [15.9%]), 3734 division chiefs (2997 men [80.3%] and 737 women [19.7%]), and 9548 program directors (7455 men [78.1%] and 2093 women [21.9%]).

Figure 1. Preferred Reporting of Items for Systematic Reviews and Meta-Analyses Flow Diagram for Identification of New Studies.

Table 1. Article Foci and Data Reported (N = 94).

Attribute	Articles reporting attribute, No. (%)
Roles
Deans	5 (5.3)
Department chairs	39 (41.5)
Division chiefs	25 (26.7)
Program directors	67 (71.3)
Scholarly and/or clinical productivity
Publication impact metricsa	53 (55.2)
Research outputb	33 (34.4)
Additional degree (PhD, MPH, MBA)	33 (34.4)
Grant funding	13 (13.5)
Academic rank	17 (17.7)
Demographics
Age	28 (29.2)
Race and ethnicity	36 (37.5)
Years of experience	44 (45.8)
Parental status	5 (5.2)
LGBTQAI+	3 (3.1)
Relationship status	3 (3.1)

Abbreviation: LGBTQAI+, lesbian, gay, bisexual, transgender, queer (or questioning), asexual (or allied), intersex, and all other sexual and gender identities not included in the acronym.

^a H index or impact factor of journals published in Altmetric (Altmetric Ltd).

^b Articles published per year.

The institutional leadership roles reported in the articles were deans (5 articles [5.3%]),^{30,31,32,97,118} department chairs (39 articles [41.5%]),^{33,34,35,37,39,40,42,43,46,52,60,62,64,66,67,69,70,71,81,83,84,87,89,91,92,93,94,95,99,101,102,106,109,110,112,116,117,120,121,122,123} division chiefs (25 articles [26.6%]),^{36,37,38,44,46,47,49,50,52,53,54,63,81,82,84,88,89,90,96,98,102,104,111,112,113} and program directors (67 articles [71.3%]),^{33,34,36,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,72,73,74,75,76,77,78,79,80,83,84,85,86,87,89,94,98,99,100,102,103,104,105,107,108,109,110,114,116,119,120,123} with some overlap. Studies also reported on measures of scholarly productivity, including publication metrics (53 articles [55.2%]),^{31,37,39,40,41,42,44,45,47,51,52,54,55,56,58,59,60,61,62,63,64,65,67,68,71,72,73,74,75,76,77,78,79,81,82,85,87,90,94,98,99,100,101,102,104,106,107,108,109,111,115,118,119} research output (32 articles [34.0%]),^{31,33,41,45,47,51,52,54,55,59,61,62,63,67,68,69,77,78,79,81,94,98,99,100,101,104,106,107,108,115,116,119} having an additional degree (32 articles [34.0%]),^{35,39,40,41,45,46,47,52,55,59,62,63,66,68,70,71,77,78,79,82,86,94,95,99,100,101,102,106,107,115,118,122} grant funding (12 articles [12.8%]),^{31,42,47,51,54,67,77,94,104,108,109,116} and academic rank (17 articles [17.7%]).^{33,40,51,52,60,64,66,70,85,90,101,102,107,109,111,116,122} Some studies also assessed measures of diversity, equity, inclusion, and accessibility in addition to gender, including age (28 articles [29.2%])^{37,41,45,51,52,55,58,59,61,62,64,65,68,70,72,73,74,75,76,78,79,86,100,106,107,113,116,119}; race and ethnicity (34 articles [36.2%])^{30,35,40,48,55,56,57,58,59,60,70,72,73,74,75,76,78,79,83,84,91,92,93,95,97,98,113,114,115,116,117,118,120,122}; years of experience (44 articles [45.8%])^{33,39,40,41,44,45,47,49,51,52,54,55,57,58,59,60,61,62,63,64,65,68,71,72,74,75,76,77,78,79,81,82,86,99,100,101,102,106,107,108,109,115,116,118}; parental status (5 articles [5.2%])^{42,69,104,115,116}; lesbian, gay, bisexual, transgender, queer (or questioning), asexual (or allied), intersex, and all other sexual and gender identities (2 articles [2.1%])^81,114; and relationship status (3 articles [3.1%]).^69,104,116 Among the included studies, the most common themes addressed as next steps were conduct more research on the reasons for these disparities (59 articles [62.8%]),^{31,32,33,34,35,36,38,40,41,42,44,47,48,49,50,51,52,53,54,60,64,65,66,68,69,71,72,73,74,77,78,79,80,81,84,85,86,89,93,94,95,99,100,102,103,104,105,106,107,108,110,111,112,114,115,119,121,122,123} provide mentorship (20 articles [21.3%]),^{39,43,45,46,48,54,63,70,76,88,97,98,101,106,108,109,112,113,116,120} and engage in intentional recruitment of women (33 [35.1%])^{30,35,37,39,44,45,48,55,56,57,58,59,61,62,63,68,72,75,76,78,80,82,83,87,90,91,92,97,101,114,117,118,122} (Figure 2).

Figure 2. Most Common Themes for Future Directions.

Allopathic Medical School Deans

As one of the highest levels of leadership, deanship of an allopathic medical school has largely been a role attainable for men, though some progress has been made from no female deans in 1977 to 21% in 2020 (Table 2).^30,31 Across physician deans, women only accounted for 38.4% (634 of 1649). Women remained underrepresented when stratified by tier of dean, representing only 43.3% of lower-tier deans (182 of 419); 39.1% of higher-tier deans (424 of 1084), including vice, senior associate, and associate deans; and 18.9% of medical school deans (28 of 148).³²

Table 2. Key Findings of Included Articles: Allopathic Medical School Deans (n = 5).

Year of data	Source	Sample size, No.	Representation of women as dean reported, No. (%)
2018	Larson,32 2019	148	28 (18.9)
2019	Nobles,97 2022	125	28 (22.4)
2019	Jacobson,118 2021	95	15 (15.8)
2020	Kamran,30 2022	153	28 (18.3)
2020	Nguyen,31 2022	157	33 (21.2)

Department Chairs and Division Chiefs

From 1977 to 2019, the percentage of women as department chairs increased from 2.1% to 17.8%.³⁰ Surgery and surgical subspecialties had the lowest female representation at less than 10% of chairs, including orthopedic surgery (2.6%), general surgery (5.1%), and plastic surgery (8.2%) (Table 3).^33,34,35 Division chief roles serve as a direct pipeline to department chair opportunities but have continued to have a low representation of women. In addition to surgical specialties, low representation of women as division chiefs was seen in procedural specialties such as cardiology (2.8%), pain medicine (7.1%), and gastroenterology (18.2%) (Table 3).^36,37,38

Table 3. Key Findings of Included Articles by Surgical, Medical, and Procedural Specialties (N = 91).

Specialty	Source	Sample size, No.	Representation of women, No. (%)
			Department chair	Division chief	Program director (residency and fellowship)
Surgical specialties
Cardiothoracic surgery	Singh et al,62 2021	149	3 of 72 (4.2)	NA	8 of 77 (10.4)
Neurosurgery	Donaldson et al,64 2021	218	3 of 109 (2.8)	NA	7 of 109 (6.4)
Neurosurgery	Feng et al,66 2021	270	4 of 137 (2.9)	NA	8 of 133 (6.0)
Neurosurgery	Kearns et al,39 2022	216	4 of 116 (3.4)	NA	8 of 100 (8.0)
Neurosurgery	Melnick et al,67 2021	232	6 of 116 (5.2)	NA	8 of 116 (6.9)
Neurosurgery	Parikh et al,55 2023	161	NA	NA	9 of 161 (5.6)
Neurosurgery (spinal); orthopedic surgery (spinal)	Agaronnik et al,63 2022	147	NA	2 of 60 (3.3)	3 of (2.0) Spinal surgery fellowship
Orthopedic surgery	Donnally et al,65 2020	103	NA	NA	4 of 103 (3.9)
Obstetrics and gynecology	Das et al,46 2022	1444	58 of 202 (28.7)	228 of 486 (46.9)	165 of 286 (57.7) Residency; 102 of 203 (50.2) fellowships
Obstetrics and gynecology	Foglia et al,89 2021	52	2 of 8 (25.0)	13 of 31 (41.9)	2 of 8 (25.0) Residency; 0 of 5 fellowship
Obstetrics and gynecology	Temkin et al,88 2020	98	NA	13 of 98 (13.3)	NA
Obstetrics and gynecology	Selter et al,90 2020	49	NA	15 of 49 (30.6)	NA
Obstetrics and gynecology	Winkelman et al,47 2020	48	NA	15 of 33 (45.5)	8 of 15 (53.3)
Ophthalmology	Gershoni et al,99 2021	215	14 of 106 (13.2)	NA	28 of 109 (25.7)
Ophthalmology	Kloosterboer et al,100 2020	116	NA	NA	32 of 116 (27.6)
Ophthalmology	Patel et al,61 2022	54	NA	NA	6 of 54 (11.1)
Orthopedic surgery	Belk et al,76 2021	90	NA	NA	3 of 90 (3.3)
Orthopedic surgery	Bi et al,33 2022	314	4 of 153 (2.6)	NA	18 of 161 (11.1)
Orthopedic surgery	Brisbin et al,77 2023	87	NA	NA	13 of 87 (15.0)
Orthopedic surgery	Hoof et al,81 2020	807	2 of 143 (1.4)	56 of 664 (8.3)	NA
Orthopedic surgery	Meadows et al,83 2022	566	5 of 122 (4.1)	NA	40 of 444 (9.0)
Orthopedic surgery (adult reconstruction)	Schiller et al,56 2020	94	NA	NA	0 of 94
Orthopedic surgery (foot and ankle)	Elahi et al,79 2021	47	NA	NA	3 of 47 (6.4)
Orthopedic surgery (hand)	Grandizio et al,80 2021	89	NA	NA	12 of 89 (13.5)
Orthopedic surgery and plastic surgery (hand)	Schiller et al,75 2023	90	NA	NA	9 of 72 (12.5) Orthopedic surgery; 3 of 18 (16.7) plastic surgery
Orthopedic surgery (musculoskeletal oncology)	Moore et al,59 2022	19	NA	NA	4 of 19 (21.1)
Orthopedic surgery (pediatric orthopedic)	Cohen et al,78 2021	55	NA	NA	6 of 55 (11.0)
Orthopedic surgery (should and elbow)	Sanders et al,73 2022	40	NA	NA	1 of 40 (2.5)
Orthopedic surgery (sports medicine)	Kamalapathy et al,58 2022	88	NA	NA	1 of 88 (1.1)
Orthopedic surgery (sports medicine)	Maqsoodi et al,82 2022	100	NA	4 of 100 (4.0)	NA
Orthopedic surgery (sports medicine)	Moore et al,57 2021	88	NA	NA	1 of 88 (1.1)
Orthopedic surgery (sports medicine)	Schiller et al,74 2021	82	NA	NA	2 of 82 (2.4)
Orthopedic surgery (orthopedic trauma)	Sama et al,72 2021	72	NA	NA	5 of 72 (6.9)
Otolaryngology	Epperson et al,60 2020	306	NA	NA	27 of 102 (26.5) Residency; 30 of 204 (14.7) fellowship
Otolaryngology	Tucker et al,86 2022	125	NA	NA	38 of 125 (30.4)
Otolaryngology	Uppal et al,87 2022	229	9 of 115 (7.8)	NA	34 of 114 (29.8)
Otolaryngology (head and neck)	Garstka et al,85 2019	35	NA	NA	6 of 35 (17.1)
Otolaryngology; surgery (plastic)	Landeen et al,44 2022	73	NA	NA	7 of 11 (63.6) Facial plastic surgery fellowship
Plastic surgery	Hughes et al,68 2022	82	NA	NA	15 of 82 (18.3)
Plastic surgery	Keane et al,342021	197	8 of 98 (8.2)	NA	13 of 99 (13.1)
Plastic surgery	Moeller et al,69 2021	101	NA	NA	4 of 20 (20.0) Fellowship; 14 of 81 (17.3) residency
Plastic surgery	Smith et al,70 2019	268	7 of 99 (7.1)	NA	9 of 65 (13.8) Fellowship; 14 of 104 (13.5) residency
Plastic surgery	Wenzinger et al,71 2019	94	5 of 94 (5.3)	NA	NA
Surgery	Battaglia et al,101 2020	178	17 of 178 (11.0)	NA	NA
Surgery	Kassam et al,84 2021	389	17 of 116 (14.7)	14 of 87 (16.1) Pediatric surgery; 12 of 68 (17.6) colorectal surgery	30 of 118 (25.4)
Surgery (neurosurgery, obstetric and gynecologic, ophthalmologic, orthopedic, otolaryngologic, interventional radiologic, plastic, thoracic, urologic, vascular)	Patel et al,45 2021	1571	NA	NA	68 of 332 (20.5) General surgery; 10 of 86 (11.6) interventional radiology; 7 of 119 (5.9) neurosurgery; 181 of 285 (63.5) obstetric and gynecologic surgery; 32 of 116 (27.6) ophthalmologic surgery; 19 of 196 (9.7) orthopedic surgery; 36 of 122 (29.5) ENT surgery; 17 of 81 (21.0) plastic surgery; 4 of 28 (14.3) thoracic surgery; 24 of 143 (16.8) urologic surgery; 8 of 63 (12.7) vascular surgery
Surgery (plastic)	Ngaage et al,102 2020	281	20 of 115 (8.7)	31 of 166 (18.7)	NA
Surgery (surgical critical care)	Ehrlich et al,103 2023	103	NA	NA	26 of 103 (25.2)
Surgery (academic)	Zhu et al,35 2021	375	19 of 375 (5.1)	NA	NA
Surgery (vascular)	Carnevale et al,104 2020	231	NA	12 of 118 (10.2)	13 of 113 (11.5)
Medical and procedural specialties
Anesthesiology	Bissing et al,42 2019	148	NA	NA	47 of 148 (32.0)
Anesthesiology (pain medicine)	Hagedorn et al,105 2019	44	NA	NA	17 of 44 (38.7)
Anesthesiology (pain medicine); physical medicine and rehabilitation (pain medicine)	Doshi et al, 202038	112	NA	4 of 56 (7.1)	16 of 56 (28.6)
Anesthesiology; emergency medicine; neurology; physical medicine and rehabilitation; psychiatry (chronic pain)	D’Souza et al,106 2022	87	17 of 87 (19.5)	NA	NA
Anesthesiology; neurology; physical medicine and rehabilitation; psychiatry (acute pain, chronic pain)	D’Souza et al,107 2021	146	NA	NA	35 of 111 (31.5) Chronic pain; 10 of 35 (28.6) acute pain
Anesthesiology; pulmonology (critical care)	Fahy et al,108 2021	117	NA	NA	26 of 117 (22.0)
Dermatology	Thompson et al,94 2021	219	31 of 94 (33.0)	NA	38 of 125 (30.4)
Dermatology	Xierali et al,93 2020	3675	694 of 3675 (18.9)	NA	NA
Emergency medicine	Parsons et al,43 2021	426	23 of 203 (11.2)	NA	77 of 223 (34.6)
Family medicine	Xierali et al,92 2022	407	119 of 407 (29.2)	NA	NA
Internal medicine	Herzke et al,109 2020	66	NA	NA	14 of 66 (21.2)
Internal medicine	Medepalli et al,110 2023	292	20 of 146 (13.4)	NA	58 of 146 (39.7)
Internal medicine (cardiology)	Coylewright et al,37 2022	398	NA	11 of 398 (2.8)	NA
Internal medicine (cardiology)	Khan et al,52 2019	652	NA	7 of 140 (5.0)	73 of 512 (14.3)
Internal medicine (gastroenterology)	John et al,111 2022	111	NA	7 of 111 (6.3)	NA
Internal medicine (gastroenterology)	Sethi et al,36 2021	313	NA	26 of 143 (18.0)	41 of 170 (24.0)
Internal medicine (hematology oncology)	Riaz et al,54 2020	196	NA	7 of 42 (16.7)	47 of 154 (30.5)
Internal medicine (medical oncology); radiation oncology; surgery (surgical oncology)	Chowdhary et al,112 2020	258	11 of 94 (11.7) Radiation oncology	30 of 138 (21.7) Medical oncology; 1 of 26 (3.8) surgical oncology	NA
Internal medicine (pulmonary and critical care medicine)	Olson et al,53 2022	477	25 of 162 (15.4)	21 of 140 (15.0)	50 of 175 (28.6)
Internal medicine (rheumatology)	Jorge et al,51 2021	117	NA	NA	53 of 117 (45.3)
Interventional radiology	Wadhwa et al,119 2020	174	NA	NA	21 of 174 (12.1)
Nuclear medicine	Cheng et al,98 2021	43	NA	7 of 23 (30.4)	5 of 23 (21.7)
Neurology	Saleem et al,120 2021	129	15 of 129 (11.6)	NA	NA
Pediatrics	Allan et al,50 2021	199	NA	80 of 146 (55.0)	35 of 53 (66.0)
Pediatrics	Horak et al,113 2022	79	NA	19 of 79 (24.0)	NA
Pediatrics	Saboor et al,91 2022	154	48 of 154 (31.2)	NA	NA
Pediatrics	Weller et al,121 2019	213	49 of 213 (23.0)	NA	NA
Pediatrics (pediatric critical care)	Maxwell et al,49 2019	326	NA	66 of 206 (32.0)	66 of 120 (55.0)
Pediatrics (pediatric gastroenterology)	Sanghavi et al,48 2021	119	NA	15 of 60 (25.0)	32 of 59 (54.2)
Pediatrics (pediatric hospital medicine)	Dixon et al,114 2021	57	NA	NA	40 of 57 (70.0)
Physical medicine and rehabilitation	Martinez et al,115 2022	49	15 of 49 (30.6)	NA	NA
Physical medicine and rehabilitation	Zhang et al,122 2021	65	11 of 65 (16.9)	NA	NA
Psychiatry	Chaudhary et al,95 2020	125	15 of 125 (19.6)	NA	NA
Psychiatry	Hosoda et al,96 2021	66	NA	21 of 66 (32.0)	NA
Radiation oncology	Beeler et al,116 2019	94	10 of 72 (13.9)	NA	3 of 22 (13.4)
Radiation oncology	McClelland et al,40 2022	97	6 of 51 (11.8)	NA	13 of 46 (28.3)
Radiation oncology	Vengaloor Thomas et al,123 2020	188	11 of 94 (11.7)	NA	19 of 94 (20.2)
Radiology	Niu et al,117 2020	224	39 of 224 (17.4)	NA	NA
Radiology	Purushothaman et al,41 2021	197	NA	NA	58 of 197 (29.4)

Abbreviations: ENT, ear, nose, and throat; NA, not applicable.

Graduate Medical Education

Residency

Among residency program directors, the lowest representation of women was within neurosurgery (4.7%).³⁹ Women represent 21.5% of neurosurgery residents and 9.6% of all practicing neurosurgical physicians.^124,125 Similarly, orthopedic surgery had 11.2% women as residency program directors. Women accounted for 18.3% of orthopedic residents and 5.9% of all practicing orthopedic surgeons.^33,124,125 Among nonsurgical specialties, radiation oncology had only 13.4% women program directors.¹¹⁶ Additionally, the percentage of women program directors was 24.9% in radiology, 31.8% in anesthesiology, and 34.6% in emergency medicine.^41,42,43

The highest representation of female residency program directors was within obstetrics and gynecology at 57.7%.⁴⁶ Within otolaryngology, women represented 40.3% of residents and 18.9% of practicing physicians.^124,125 Obstetrics and gynecology also reported high numbers of women-led residency programs, with 2 articles reporting 63.5% and 57.7%, respectively.^45,46 However, in stark contrast to other surgical specialties, women comprised 86.4% of obstetrics and gynecology residents and 60.5% of practicing physicians.^124,125

Fellowship

The highest representation of women fellowship directors was within urogynecology (in obstetrics and gynecology) (53.3%)⁴⁷ and pediatric subspecialties, with women making up the majority of fellowship directors of pediatric gastroenterology (54.2%), pediatric critical care (54.6%), and pediatric hospital medicine programs (66.0%).^48,49,50 For internal medicine fellowships, the percentage of women program directors was 45.3% in rheumatology, 30.5% in hematology oncology, 29.1% in gastroenterology, 28.6% in pulmonary and critical care medicine, and 14.3% in cardiology.^{36,51,52,53,54}

Surgical specialties had lower representation of women as fellowship directors. Women accounted for 11.5% of pediatric neurosurgery program directors, but were less represented among stereotactic (7.4%), endovascular (4.1%), and spine (0.04%) programs.⁵⁵ Orthopedic surgery showed similarly low female representation, ranging from none in adult reconstructive surgery and 1.1% in orthopedic sports medicine to a high of 21.1% in orthopedic oncology.^56,57,58,59 Only 14.7% of fellowship directors in otolaryngology, 10.4% in cardiothoracic surgery, and 11.1% in ophthalmology were women.^60,61,62

Specialty-Specific Trends

Surgical Specialties

Gender inequities were particularly pronounced in surgical specialties. In a study of gender equity in 11 different surgical specialties, all specialties other than obstetrics and gynecology had less than 50% female program directors and a lower percentage of female program directors than female residents across all 11 fields studied.⁴⁵ In neurosurgery,^{39,55,63,64,65,66,67} women comprised only 9.6% of practicing physicians, 8.7% of faculty, and 3.4% of department chairs.^8,64,66,125 They were also more likely to be assistant professors, while male neurosurgeons were more likely to be full professors, hold chair positions, and lead subspecialty divisions.³⁹ In plastic surgery,^{34,68,69,70,71} only 17.6% of all practicing physicians, 19.5% of faculty, and 10.8% of department chairs were women.^69,125 Plastic surgery departments with a female chair were significantly more likely to have a female program director (75% vs 7.5% male program directors; P < .001)³⁴ and a significantly higher proportion of female faculty (32.5% vs 18.5% male faculty; P = .02).⁷⁰ In orthopedic surgery,^{33,45,56,57,58,59,63,65,72,73,74,75,76,77,78,79,80,81,82,83} women represented only 5.9% of practicing physicians, 21.3% of faculty,⁸ and 4.1% of department chairs.^8,83,125 Of note, scholarly productivity for men and women in senior faculty positions and leadership positions in orthopedic surgery was similar.⁸¹

In general surgery, only 22.1% of all practicing physicians, 28.1% of faculty, and 14.1% of department chairs were women.^8,84,125 In otolaryngology (ear, nose, and throat), 18.9% of all practicing physicians, 36.6% of faculty, and 7.8% of chairs were women.^{8,44,60,85,86,87,125}

Specialties With Fifty Percent or More Women Faculty

In 5 specialties, including obstetrics and gynecology, pediatrics, family medicine, dermatology, and psychiatry, women represented more than 50% of all faculty, yet representation did not translate to department and division leadership. The field with the greatest representation of female faculty was obstetrics and gynecology.^{8,46,47,88,89,90} Departments of obstetrics and gynecology with a woman as chair were significantly more likely to have more than 50% women faculty compared with those with men as chairs (90.2% vs 9.8%; P < .01).⁸⁸ In 2020, only 28.7% of obstetrics and gynecology department chairs were women, and 47% of all division directors were women.⁴⁶ Among division directors, there was the least gender equity in oncology, where women held only 33% of roles.⁴⁶ Among leadership roles, women were significantly more likely than men to hold educational leadership positions, including clerkship directors, residency program directors, and fellowship program directors (56% vs 40%; P < .001), and men were significantly more likely than women to hold administrative leadership positions, including chairs, vice chairs, and division directors (68% vs 52%; P < .001).⁴⁶

In pediatrics, 61.1% of all faculty were women, but only 31.2% of department chairs, which represents some increase in representation from women holding only 10.1% of chair positions in 2007, but the increases were disproportionate to the number of women faculty in the specialty.^8,91 Women represented the majority of division director roles in pediatric hospital medicine at 55% but remained underrepresented in pediatric gastroenterology (29%) and pediatric critical care medicine (32%).⁵⁰

In family medicine, 54.4% of all faculty and 29.2% of department chairs were women.^8,92 Of note, family medicine had significantly more chairs who identified as underrepresented in medicine compared with all other fields (16.7% vs 9.1%; P < .001).⁹² In dermatology, 53.4% of all faculty were women, with 33.0% as department chairs.^8,93 Men were department chairs at 75% of the top 20 National Institutes of Health–funded departments in dermatology.⁹⁴ For program directors in dermatology, 32.8% were women.⁹⁴ In psychiatry, 55.8% of all faculty and 20.0% of department chairs were women.^8,95 Specifically in child and adolescent psychiatry, the majority of fellows (58.5%) and faculty (54.6%) were women, but only 31.8% were division directors.^96,124,126

Discussion

This systematic scoping review shows pervasive gender inequity in institutional leadership at academic institutions. Medical school deans play a vital role in developing the culture of their institution, and the lack of women leaders is at a critical point. For department chairs, leadership in male-dominated surgical specialties recapitulates inequity in the representation of women. Even in specialties that are women-dominated, the representation of women as leaders compared with all women in the field is disparate. In this scoping review, all articles clearly documented inequities in academic medicine leadership and consistently recommended increasing the representation of women in leadership roles.

Institutional leadership roles are a key consideration in the bigger picture of gender inequity in academic medicine. An institution that does not have substantial female representation in leadership is unlikely to promote a work culture that is inclusive and supportive of women, which may impact not only the daily experience of those already working and training at the institution but also the institution’s ability to recruit diverse talent. Deans shape the overall vision of their institutions. Department chairs play direct roles in the culture among faculty and trainees in their departments. Residency and fellowship program directors have a major influence on the experience of trainees and whether their programs are inclusive and supportive, and they are ultimately responsible for the formative training years of the next generation of clinicians in their specialty.

A lack of gender-diverse leadership in an institution may contribute to the sense of a lack of opportunity for advancement to leadership roles among junior faculty. Previous research has shown that women are more likely to leave academia than men at all stages of training.⁴ Attrition from academic medicine was associated with the perceived failure of the department chair to foster a climate of teaching, research, service, inclusiveness, respect, and open communication to support the growth and advancement of women.³ Additional factors associated with attrition included lack of professional development, lack of institutional recognition, support for excellence in teaching and clinical care, and more than 50% of professional time devoted to patient care.³ Many women leave academic medicine because of the lack of professional development opportunities; thus, it is crucial for institutions to improve the opportunities available to retain women faculty and solidify their leadership trajectory.

The diversity of leaders and faculty in different specialties at an institution may impact the culture as early as medical school. A paucity of women leaders or faculty in a specialty of interest is often a factor that may lead students to question whether a specific field would be a suitable choice. Not only do women feel reassured when seeing women faculty as role models in their chosen specialties but also they note which specialties feel like safe spaces vs hostile environments.¹²⁷ If the current climate of a field is not welcoming to women, it may be unlikely that the trajectory of women entering the field in the next generation would change. At the ground level, institutional leaders have a major influence on career choices and are very important to promoting and supporting diverse leaders across all levels of academia.

Addressing gender inequities in academic medicine is an elusive challenge that begins with systemic culture change that promotes the success of women in academia and the recognition that women are equally capable of being excellent leaders. Among the included studies, the most common themes addressed as next steps were conduct more research on the reasons for these disparities (62.8%), provide mentorship (36.2%), and engage in intentional recruitment of women (21.3%). Consistently, the articles reviewed highlighted the need to call attention to this topic and appoint more women for leadership roles, an approach that has not yet made a substantial impact on the leadership landscape for women in academic medicine. Some tangible factors that could enhance the academic portfolio of women, such as grant funding, mentorship, equitable salary, and professional development opportunities, may begin to bridge the gap but might not solve this problem on their own. Notably, in academic medicine gender equity studies, women were observed to be less likely to hold leadership roles despite equivalent or higher research productivity compared with their male counterparts in those positions.^5,128 Another topic to address is the gendered distribution of citizenship tasks, which are uncompensated work-related duties that require dedicated time, such as taking notes at meetings or serving as a diversity representative.¹²⁹ A survey of women physicians found that 50% felt obligated to volunteer for these tasks because of their gender, and 47% perceived spending more time on these tasks than men. Addressing the potential time- and compensation-related burdens for citizenship tasks is one way to improve equity. If we continue with the current standard of gender equity work within the guise of success and no clear trajectory for improvement, the disparities might continue to grow.

Limitations

One limitation of this work is that as a scoping review of previous studies, the quality of our work is contingent upon the quality of the articles included. However, studies were assessed for quality during the review process to mitigate this effect with the use of a checklist developed from the Joanna Briggs Institute criteria for scoping reviews.²⁸ Additionally, the data focused on representation, which may, at best, be a surrogate for the diversity and inclusivity of a field. Finally, there was the usual time lag between the time of initial data collection and the publication of the article, exacerbated by the time required for screening and reviewing the studies.

Conclusions

This systematic scoping review found that ultimately, current efforts to promote gender equity in institutional leadership at academic medical centers have been inadequate. Specific goals to increase female representation in leadership positions with a clearly defined trajectory, especially in fields comprising more than 50% women, should take priority, including mentoring and intentional recruitment of women.

Supplement 1.

eAppendix. Full Search Strategy

Supplement 2.

Data Sharing Statement