Emergency Medicine Gender in Resident Leadership Study (EM GIRLS): The Gender Distribution Among Chief Residents

Abstract

Objectives

The goal of this research was to determine the gender distribution of chief residents in emergency medicine (EM) residencies in the United States to explore whether the gender leadership gap is present at the resident level in EM.

Methods

The investigators compiled a list of EM residency programs accredited by the Accreditation Council for Graduate Medical Education. Investigators reached out to the programs using established best practices in survey distribution collecting the following: program name, program location, program length, total number of residents, total number of female residents, total number of chief residents, and the total number of female chief residents.

Results

Of the 223 programs contacted 194 programs responded and 182 programs were included in the study (a response rate of 82%). As of the 2019 to 2020 academic year, female EM residents account for 37.0% (2,459/6,718) of all EM residents and female EM chief residents account for 42.2% (250/593) of EM chief residents. The proportion of female EM chief residents was significantly higher than the proportion of both female EM residents (42.2% vs. 37%, p = 0.007) and female EM attending physicians (42.2% vs. 27.5%, p < 0.001). When comparing proportions of female residents based on duration of program, female physicians comprised 35.0% (1,652/4,720) of residents at 3‐year programs and 40.4% (807/1998) of residents at 4‐year programs (p < 0.01).

Conclusions

While the proportion of female EM residents remains significantly lower than the proportion of male residents, females and males are similarly represented at the chief resident role.

Gender disparities exist in medicine. Factors such as implicit bias may lead to challenges in female physicians obtaining leadership positions in academia and hospital administration. Efforts to increase female representation in medicine in the United States have been effective, with women comprising at least 40% of all medical school matriculants for almost 30 years.1 As of 2017, there were more female (50.7%) than male medical students matriculating in U.S. medical schools.2 Similarly in U.S. EM residencies, female representation has seen an upward trend, comprising 33.6% in 2018,3 up from 25.5% in 20134 according to the Association of American Medical Colleges (AAMC) data.

While gender composition in medical school has reached parity and female representation in EM residencies continue to increase, the increased representation of women at the undergraduate and graduate medical education levels has not yet closed the gap gender in female faculty promotion and leadership appointments.

Beyond residency training, women make up 32% of associate professors, 20% of full professors, 14% of department chairs, and 11% of deans at U.S. medical schools.5, 6 Similarly, female physicians are underrepresented among residency program directors in the 10 largest specialties albeit a trend up in EM.7 There is a dearth of literature around gender representation in the chief resident role in any specialty including EM. The goal of this research was to determine the gender distribution of chief residents in EM residencies in the United States to better understand overall gender leadership gap in academic medicine.

Methods

Study Design

We performed an observational survey study regarding female EM residents and EM chief residents in the United States. We compiled a list on December 11, 2018, of all EM residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) according to their website.8 A data extraction tool was developed to identify and categorize program‐level data. The following information was collected: program name, program location, region, program length, and primary type of residency (i.e., allopathic or osteopathic). The tool was piloted independently by three investigators. This study was granted an exemption by the institutional review board from the parent institution.

Study Population

All ACGME‐accredited EM programs from the ACGME website were included in the study population.8

Study Protocol

Between May 23, 2019, and August 9, 2019, investigators reached out to the programs using established best practices in survey distribution.9 Programs were contacted a minimum of three times with no more than one e‐mail per week. Program leaders (i.e., chair, program directors, and assistant/associate program directors) were contacted to obtain the information. If no response was obtained after three e‐mails, investigators reached out to other available program contacts (e.g., program coordinator, other faculty members). If there was still no response or no further contacts were available, the program was excluded from the study.

Outcome Measurements

Our e‐mail survey collected the following information: total number of residents, total number of female residents, total number of chief residents, and the total number of female chief residents. National data regarding the number of female attending physicians and resident physicians were obtained from the open access AAMC.10, 11

Data Analysis

Categorical variables were summarized using counts and percentages and analyzed using Pearson’s chi‐square tests. We used program reported data for comparisons of proportions of female residents and female chief residents by length of training program. The AAMC data were used for comparisons of female residents to national demographics for female EM attending physicians.2, 3

Results

Of the 223 programs contacted, 194 programs responded. Of those, 11 programs did not have chief residents, and one program declined to participate, for an overall response rate of 182/223 programs (82% response rate). Of the included 182 programs, data regarding the total number of residents, total number of female residents, total number of chief residents, and the total number of female chief residents were available from all of the programs.

Across EM residency programs, we found that the average number of all EM residents is 36.6 residents per program and the average number of female EM residents is 13.8 residents per program. Additionally, we found that the average number of all EM chief residents is 3.2 per program and the average number of female EM chief residents is 1.4 per program.

As of the 2019 to 2020 academic year, female EM residents account for 37.0% (2,459/6,718) of current EM residents and female EM chief residents account for 42.2% (250/593) of current EM chief residents in our study sample. Compared to the proportion of female EM attending physicians at 27.5% (11,658/42,315) there are significantly more female EM residents (27.5% vs 37.0%, p < 0.001). The proportion of female EM chief residents was also significantly higher than the proportion of both female EM residents (42.2% vs 37.0%, p = 0.007) and female EM attending physicians (42.2% vs 27.5%, p < 0.001).

The data were then separated into 3‐year versus 4‐year programs to see if there were differences in gender representation. The percentage of female EM residents was significantly higher in 4‐year (807/1,998, 40.4%) programs compared to 3‐year (1,652/4,720, 35.0%) programs (p < 0.01). There were no significant differences in the proportion of female EM chief residents in 4‐year programs (72/151, 47.7%) compared to 3‐year programs (178/442, 40.3%, p = 0.11).

Discussion

Our study finds that female residents are represented at rate that is slightly higher than the percentage of females in U.S. EM residency programs. Chief residents are considered to be resident leaders, and the position is often regarded as a stepping stone into an academic career. The increased numbers of female chief residents across the country may help influence leadership roles in future careers and may even help close the well‐established leadership gap in academic EM in the future.

Emergency medicine is continuing to increase the percentage of female physicians in the field. As of 2017, the AAMC calculated that 35.5% of EM residents were female; however, our data suggest an even higher percentage (37%) in the 2019 to 2020 academic year. Our data suggest that in the past decade, we have seen an increase in the percentage of female chief residents.12

The factors contributing to the variation in distribution of female residents according to training duration remains unclear. However our study shows that females have increased representation in 4‐year programs. Efforts should be made to explore why 4‐year programs have more female residents to improve representation across all programs.

Limitations

It is important to consider several limitations with respect to this study. First, gender is nonbinary and self‐determined. While it would have been preferable to ask each individual resident to self‐identify their gender, this was not feasible due to limited contact and concerns regarding response rate. Consequently, it is possible that our results may not reflect an individual’s gender identity in select cases. Additionally, while we followed best practices9 and attempted to obtain information from all programs, we were only able to obtain responses from 82% of programs. While there remained 18% of programs that we were unable to obtain information on gender distribution of residents and chief residents, we believe that this is unlikely to significantly alter the findings of this study. Further, this study only included ACGME‐affiliated resident programs and may not reflect the distribution among non‐ACGME programs. Another limitation is the lack of information regarding EM chief resident qualifications (e.g., publications, oral presentations, national leadership positions, in‐training examination scores), which may impact chief resident selection. Finally, this study was only conducted among EM residency programs and may not reflect the gender distribution in other fields.

Conclusion

The study determined the gender distribution of chief residents in emergency medicine residencies in the United States to be similar between male and female residents. While the proportion of female residents remains significantly lower than the proportion of male residents, females and males are similarly represented at the chief resident role. Female chief residents are represented at a higher than expected ratio when compared to the total number of female EM residents.

AEM Education and Training 2020;4:262–265