Abstract
Background
Although the number of women entering medical school and emergency medicine (EM) residencies has increased, female physicians are still proportionally underrepresented in EM. The goal of this study was to determine if there was a relationship between resident gender and program leadership gender.
Methods
A survey of residency leadership and residents was completed, and multivariate factor analysis was performed.
Results
It was found that 31% of program directors (PDs) were women, along with 42% of associate PDs, 48% of assistant PDs, 36% of residents, and 48% of chief residents. The strongest correlation between female residents and program leadership was between female residents and female assistant PDs (0.25). Female residents were also strongly correlated with female chief residents (0.40).
Conclusions
Although we cannot determine the direction of causation, moving forward, programs looking to increase their female resident cohort should consider focusing efforts around increasing representation at the program leadership and chief resident level.
INTRODUCTION
Gender disparities exist in medicine and medical training. 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, females made up the majority of medical students at U.S. medical schools.2 The importance of female representation in the medical field has also been bolstered by recent studies. A 2017 study examining hospitalized Medicare beneficiaries found that female physicians had both lower mortality rates and lower readmission rates in comparison to those in the care of a male physician.3 Another study of Florida heart attack patients found that female patients had better outcomes when there was a higher percentage of female physicians in that emergency department, no matter whether they were treated by a female physician or a male physician.4
While women entering medical school have increased, female physicians remain proportionally underrepresented in EM. In U.S. emergency medicine (EM) residencies, women comprised 33.6% of EM residents in 2018,5 down from 37.5% in 2013.6 Furthermore, according to the AAMC, female physicians make up only 28.3% of all EM physicians.7 As of the 2018 to 2019 academic year, female faculty comprised 11.2% of chairs, 34.6% of program directors (PDs), 40.5% of associate/assistant PDs, and 46.5% of clerkship directors in U.S. EM residency programs.8 In addition to EM faculty, prior studies have examined EM resident and chief resident gender distribution. The EM GIRLS study of residency leadership found that female EM residents accounted for 37% of all EM residents and 42.2% of EM chief residents.9 Adding on to the previously established literature, the goal of this study was to examine if there was a relationship between resident gender and program leadership gender.
METHODS
A survey was completed of residency leadership of all ACGME EM residencies in the United States from May 20 to August 1, 2020. A survey of residents was also completed from July 15 to August 1, 2020. Residency leadership and residents were determined by accessing each residency's website or by contacting the program coordinator if the website did not show current leadership. As established in previous gender‐based publications, gender was determined via listed pronouns or by first name and photographic masculine or feminine cues.10
Statistics were performed using GraphPad Prism. Differences in observed versus expected ratios of men and women in residency leadership roles were determined by chi‐square. Multivariate factor analysis was performed using a correlation matrix. Variables with significant correlation were evaluated by their coefficients by both positive or negative association as well as strength of association by magnitude of the coefficient.
RESULTS
Of the 268 EM programs, data were collected on leadership for 93% of programs (248/268), residents for 78% of programs (209/268), and chief residents for 29% (77/268) of programs. Women comprised 40.5% of total residency leadership roles (Figure 1). Female PDs made up 31% of all the PDs included in this study. Associate PDs were composed of 42% women, and assistant PDs were composed of 48% women in the programs reviewed. Thirty‐six percent of residents and 48% of chief residents were women. Upon analyses by chi‐square, women in residency leadership roles were different than expected (p = 0.046), but resident women did not differ significantly from expected.
FIGURE 1.
Percentage of men and women that comprise emergency medicine assistant program directors (PDs), associate PDs, PDs, chief residents, and all residents.
A multivariate correlation factor analysis was performed with the goal of noting which factors were associated with a more equitable distribution of female residents. We evaluated the correlation between percentage of female residents and percentage of female PDs (–0.026), female associate PDs (0.0995), and female assistant PDs (0.25). We also evaluated the correlation between female chief residents with female assistant PDs (0.26) and percentage of female residents (0.40). Finally, the correlation between percentage of female residents and total female leadership was 0.24.
DISCUSSION
EM is continuing to increase the percentage of female physicians in training and in practice. According to a 2020 AAMC report, 2,885 of the 8,029 (35.9%) active EM residents were female.11 Our data suggest a correlation between female residents and total female leadership. Most notably, female residents were most strongly correlated with female assistant PDs. Previous studies have found that female emergency physicians hold the role of assistant PD at a higher‐than‐anticipated rate compared with the current number of women in EM but in proportion to the current number of female EM residents.8 Because the assistant PD positions are often filled by early‐career emergency physicians, this may explain why these figures more closely mirror the percentage of women in EM training.
A recent study showed a higher‐than‐expected ratio of female chief residents compared to the total number of female EM residents.9 Adding to the literature, we found that programs with a higher percentage of female residents have a strongly positive correlation with female chief residents.
These findings are suggestive of a gender diversity snowball effect; a similar phenomenon was described by the Highland EM residency program in 2006.12 At Highland, they were focused on underrepresented minority physicians, but we have found similar findings when examining the gender of program leadership, chief residents, and residents.
Although we cannot determine the direction of causation, moving forward, programs looking to increase their female resident cohort should consider focusing efforts around increasing representation at the program leadership and chief resident level. Strategies such as including female physicians during the residency interview might help improve female resident recruitment. Additionally, programs looking to increase their female representation in program leadership should consider increasing their female resident and chief resident cohort.
LIMITATIONS
Gender is nonbinary and self‐determined. In this study, we often determined gender based on gender expression (photograph, name) and not gender identity, because pronouns were often not listed on residency websites. Given the constraints, we were unable to ask each participant to share how they self‐identify. One of the main limitations of the study was low response rate for some areas studied, particularly 29% in the area of chief residents. This makes it more difficult to generalize our findings. However, achieving 93% for the main outcome was very robust and exceeds what most surveys often achieve. Given that most of the information was obtained from the residency website, the chance of it being outdated or incorrect is a possibility with some of the results. Additionally, our data collection overlapped the 2019 to 2020 and 2020 to 2021 academic years. The faculty data were collected during 2019 to 2020; the resident data were collected during the 2020 to 2021 academic year. This overlapping data collection may have impacted the overall percentage of EM residents, but is unlikely to have impacted the faculty data. Finally, due to our cross‐sectional study design, we were unable to determine causation in this study. The focus of this study was to determine factors that could help increase the percentage of female residents. However, it remains unclear whether increasing the amount of female residency leaders increases the number of female residents, increasing the amount of female residents increases the number of female residency leaders, or some combination of the two.
CONCLUSIONS
Women are not highly represented in top emergency medicine residency leadership positions, but become more prevalent with junior positions. Residency programs were found to have a larger percentage of female residents when the assistant program director is a woman.
CONFLICT OF INTEREST
The authors have no potential conflicts to disclose.
AUTHOR CONTRIBUTIONS
Julia C. Saak: study concept and design, acquisition of data, analysis and interpretation of data, drafting of manuscript, revision of manuscript. Alexandra Mannix: analysis and interpretation of data, drafting of manuscript, revision of manuscript. Julie Stilley: analysis and interpretation of data, drafting of manuscript, revision of manuscript. Christopher Sampson: study concept and design, analysis and interpretation of data, drafting of manuscript, revision of manuscript.
Saak JC, Mannix A, Stilley J, Sampson C. Diversity begets diversity: Factors contributing to emergency medicine residency gender diversity. AEM Educ Train. 2021;5(Suppl. 1):S73–S75. 10.1002/aet2.10676
Presented at the University of Missouri Health Sciences Research Day, Columbia, MO, November 6, 2020; and the Council of Residency Directors in Emergency Medicine Academic Assembly Webinar, April 12, 2021.
Supervising Editor: Teresa Y. Smith, MD.
REFERENCES
- 1.Bickel J. Gender equity in undergraduate medical education: a status report. J Womens Health Gend Based Med. 2001;10(3):261‐270. [DOI] [PubMed] [Google Scholar]
- 2.Glicksman E A first: women outnumber men in 2017 entering medical school class. Association of American Medical Colleges. 2017. Accessed December 22, 2020. https://news.aamc.org/medical‐education/article/first‐women‐outnumber‐men‐2017‐entering‐medical‐s/
- 3.Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206‐213. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Greenwood BN, Carnahan S, Huang L. Patient‐physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018;115(34):8569‐8577. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Table B3: number of active residents, by type of medical school, GME specialty, and sex: 2017‐18 active residents. Association of American Medical Colleges. 2018. Accessed September 23, 2019. https://www.aamc.org/data‐reports/students‐residents/interactive‐data/table‐b3‐number‐active‐residents‐type‐medical‐school‐gme‐specialty‐and‐sex
- 6.2014 physician specialty data book. Association of American Medical Colleges; 2015.
- 7.Active Physicians by Sex and Specialty, 2019. Association of American Medical Colleges. c2021. Accessed August 29, 2019. https://www.aamc.org/data‐reports/workforce/interactive‐data/active‐physicians‐sex‐and‐specialty‐2019
- 8.Parsons M, Krzyzaniak S, Mannix A, Rocca N, Chan TM, Gottlieb M. Peek at the glass ceiling: gender distribution of leadership among emergency medicine residency programs. Emerg Med J. 2021;38(5):381‐386. [DOI] [PubMed] [Google Scholar]
- 9.Mannix A, Parsons M, Krzyzaniak SM, et al. Emergency Medicine Gender in Resident Leadership Study (EM GIRLS): the gender distribution among chief residents. AEM Educ Train. 2020;4(3):262‐265. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Gottlieb M, Krzyzaniak SM, Mannix A, et al. Sex distribution of editorial board members among emergency medicine journals. Ann Emerg Med. 2021;77(1):117‐123. [DOI] [PubMed] [Google Scholar]
- 11.Table B3. Number of active residents, by type of medical school, GME specialty, and sex: 2019‐20 active residents. Association of American Medical Colleges. 2020. Accessed May 16, 2020. https://www.aamc.org/data‐reports/students‐residents/interactive‐data/report‐residents/2020/table‐b3‐number‐active‐residents‐type‐medical‐school‐gme‐specialty‐and‐sex
- 12.Garrick JF, Perez B, Anaebere TC, Craine P, Lyons C, Lee T. The diversity snowball effect: the quest to increase diversity in emergency medicine: a case study of Highland’s emergency medicine residency program. Ann Emerg Med. 2019;73(6):639‐647. [DOI] [PubMed] [Google Scholar]