Key Points
Question
What are the sex, racial and ethnic, and sexual orientation diversity and career goals of medical students pursuing dermatology compared with those pursuing other specialties?
Findings
This cross-sectional study of 58 077 graduating medical students, there was limited racial and ethnic and sexual orientation diversity among students pursuing dermatology, particularly among female students, and they were less likely than students pursuing other specialties to intend to pursue underserved care or public health but more likely to pursue research in their careers.
Meaning
These findings suggest that efforts are needed to increase interest in dermatology among students from underrepresented racial and ethnic and sexual minority backgrounds and overall interest in underserved care and public health among students pursuing dermatology.
This cross-sectional study examines the demographic characteristics and intended career goals of graduating US allopathic medical students pursuing careers in dermatology compared with those pursuing other specialties and whether these differ by sex, race and ethnicity, and/or sexual orientation.
Abstract
Importance
Dermatology is one of the least diverse specialties, while patients from minority racial and ethnic groups and other underserved populations continue to face numerous dermatology-specific health and health care access disparities in the US.
Objectives
To examine the demographic characteristics and intended career goals of graduating US allopathic medical students pursuing careers in dermatology compared with those pursuing other specialties and whether these differ by sex, race and ethnicity, and/or sexual orientation.
Design, Setting, and Participants
This secondary analysis of a repeated cross-sectional study included 58 077 graduating allopathic medical students using data from the 2016 to 2019 Association of American Medical Colleges Graduation Questionnaires.
Main Outcomes and Measures
The proportion of female students, students from racial and ethnic groups underrepresented in medicine (URM), and sexual minority (SM) students pursuing dermatology vs pursuing other specialties. The proportions and multivariable-adjusted odds of intended career goals between students pursuing dermatology and those pursuing other specialties and by sex, race and ethnicity, and sexual orientation among students pursuing dermatology.
Results
A total of 58 077 graduating students were included, with 28 489 (49.0%) female students, 8447 (14.5%) URM students, and 3641 (6.3%) SM students. Female students pursuing dermatology were less likely than female students pursuing other specialties to identify as URM (96 of 829 [11.6%] vs 4760 of 27 660 [17.2%]; P < .001) or SM (16 [1.9%] vs 1564 [5.7%]; P < .001). In multivariable-adjusted analyses, students pursuing dermatology compared with other specialties had decreased odds of intending to care for underserved populations (247 of 1350 [18.3%] vs 19 142 of 56 343 [34.0%]; adjusted odd ratio [aOR], 0.40; 95% CI, 0.35-0.47; P < .001), practice in underserved areas (172 [12.7%] vs 14 570 [25.9%]; aOR, 0.40; 95% CI, 0.34-0.47; P < .001), and practice public health (230 [17.0%] vs 17 028 [30.2%]; aOR, 0.44; 95% CI, 0.38-0.51; P < .001) but increased odds of pursuing research (874 [64.7%] vs 29 121 [51.7%]; aOR, 1.76; 95% CI, 1.57-1.97; P < .001) in their careers. Among students pursuing dermatology, female, URM, and SM identities were independently associated with increased odds of caring for underserved populations (eg, URM: aOR, 4.05; 95% CI, 2.83-5.80) and practicing public health (eg, SM: aOR, 2.55; 95% CI, 1.51-4.31). URM students compared with non-URM students pursuing dermatology had increased odds of intending to practice in underserved areas (aOR, 3.93; 95% CI, 2.66-5.80), and SM students compared with heterosexual students pursuing dermatology had increased odds of intending to become medical school faculty (aOR, 1.60; 95% CI, 1.01-2.57), to pursue administrative roles (aOR, 1.60; 95% CI, 1.01-2.59), and to conduct research (aOR, 1.73; 95% CI, 1.01-2.98).
Conclusions and Relevance
The findings of this cross-sectional study suggest that diversity gaps continue to exist in the dermatology workforce pipeline. Efforts are needed to increase racial and ethnic and sexual orientation diversity and interest in careers focused on underserved care and public health among students pursuing dermatology.
Introduction
Diversity includes, but is not limited to, individual differences based on age, sex, gender identity, race and ethnicity, sexual orientation, socioeconomic status, and/or disability.1 Issues related to workforce diversity, equity, and inclusion in medicine remain at the forefront of a larger national discussion on diversity in the US. While female representation among US dermatologists has increased substantially over the last few decades—in 2017, approximately 48.9% and 64.5% of practicing dermatologists and dermatology residents, respectively, were female2—the lack of diversity among dermatologists in other dimensions is becoming increasingly recognized as a dire concern.3
Underrepresented in medicine (URM), as defined by the Association of American Medical Colleges (AAMC), describes racial and ethnic minority groups that are underrepresented among physicians relative to their numbers in the general population.4 While approximately 13% of the US population is Black and 18% Hispanic, only 3% of dermatologists in the US are Black and 4.2% are Hispanic, and this discordance is growing.1 Dermatology has the second lowest percentage of physicians from URM backgrounds.5 Several potential causes, many of which are systemic in nature, have been implicated, including unconscious bias, racism, inadequate exposure to dermatology during medical school,1 scarcity of URM students in medical schools,6 emphasis on test scores and scientific publications,3 and lack of mentorship.7
Female physicians who identify as lesbian, gay, bisexual, and transgender (LGBT) are also underrepresented among US dermatologists. Only 1.0% of female dermatologists identify as LGBT, compared with an estimated 6.9% of females in the general population.8,9 While the specific factors contributing to this are not well-studied, LGBT physicians face unique professional hurdles related to mistreatment, bias, and discrimination10,11 and are less likely to pursue competitive specialties and/or those with lower perceived inclusivity toward LGBT people.12
A diverse physician workforce has been shown to reduce health care disparities, enhance patient satisfaction, improve population health, reduce health care costs, and improve the well-being of clinicians.13 Several calls to action have been proposed to address the lack of diversity in dermatology and its detrimental consequences.1,3,5,6 However, few comprehensive data exist on the diversity within the dermatology workforce training pipeline and the association of diverse identities with the intended career goals of trainees. This study examined sex, racial and ethnic, and sexual orientation diversity and their associations with the intended career goals of graduating medical students pursuing careers in dermatology compared with those pursuing other specialties.
Methods
We conducted a secondary analysis of a repeated cross-sectional study using data from the 2016 to 2019 AAMC Graduation Questionnaires (GQs). The GQ is a national survey distributed annually to all graduating medical students attending an accredited allopathic medical school in the US with response rates of 80.5%, 81.1%, 83.0%, and 83.6% in 2016, 2017, 2018, and 2019, respectively.14 Survey participation is voluntary and confidential. Individuals with missing data on sex, sexual orientation, race and ethnicity, or intended specialty and those either undecided about their intended specialty or not planning to practice medicine were excluded. This study was deemed exempt from institutional review board review and the requirement for informed consent at the University of Minnesota, as it uses previously collected, deidentified data. The study followed the American Association for Public Opinion Research (AAPOR) reporting guidelines.
Participant Characteristics
Intended specialty choice was based on participants’ response to the question, “When thinking about your career, what is your intended area of practice?” Participants were categorized as students pursuing dermatology if they selected dermatology as their intended area of practice or students pursuing other specialties if they selected any other specialty. Sex was classified as either male or female and populated from previously collected AAMC data sources such as the American Medical College Application Service. Data on sex assigned at birth and gender identity were not available. URM was defined per AAMC’s definition as participants selecting American Indian or Alaska Native; Black or African American; Hispanic, Latino, or of Spanish origin; or Native Hawaiian or other Pacific Islander. Participants selecting more than 1 race and ethnicity were classified as URM if 1 of their responses fell within these categories. Sexual minority students were defined as participants selecting bisexual or gay or lesbian, and heterosexual students were defined as those selecting heterosexual or straight in response to the question, “How do you self-identify?” The MD combined degree program participants were defined as those in an MD and MPH, MPA, dental, BA, BS, MA, MS, JD, PhD, MBA, or another combined program. Total educational debt was summed from self-reported premedical and medical educational debts, excluding noneducational debt.
Primary Outcomes
Diversity in the dermatology workforce pipeline was assessed as the relative representation of female, URM, and SM students. Intended career goals included (1) “caring for underserved populations,” (2) “working in an underserved area,” (3) “public health,” (4) “teaching,” (5) “medical school faculty,” (6) “administrative roles [e.g., department chair, dean],” or (7) “research.” Individuals were categorized as intending to pursue a specific goal if they answered yes to the question: “In which of the following activities do you plan to participate during your career? Select all that apply.” Those selecting no or undecided were categorized as not pursuing that specific goal.
Statistical Analysis
First, demographic characteristics were compared between students pursuing dermatology and those pursing other specialties, including sex-stratified analyses, and by sex, race and ethnicity, and sexual orientation in a subpopulation analysis of students pursuing dermatology. For bivariate comparisons, Pearson χ2 tests (categorical variables), t tests (continuous variables), and Wilcoxon-type trend tests (ordered categorical variables) were used. Next, the proportion of students indicating specific intended career goals were compared, and logistic regression analyses were used to calculate odds ratios (ORs) between students pursuing dermatology and those pursuing other specialties, and by sex, race and ethnicity, and sexual orientation in a subpopulation analysis of students pursuing dermatology. For multivariable logistic regression analyses, a model adjusted only for age (age-adjusted) and a model additionally adjusted for sex, race and ethnicity, and sexual orientation (fully adjusted) were used. As secondary outcomes, intended career goals were compared between students pursuing dermatology and those pursuing other specialties in multivariable analyses stratified by sex (male and female), race and ethnicity (non-URM and URM), and sexual orientation (heterosexual and SM). Individuals with missing data on one or more career goals were excluded from multivariable analyses. All analyses were conducted using Stata version 16.1 (StataCorp) with a 2-sided α = .05.
Results
Demographic Characteristics Between Students Pursuing Dermatology and Other Specialties
Among 63 718 total respondents, 5641 (8.9%) were excluded, resulting in 58 077 study participants, with 28 489 (49.0%) female students, 8447 (14.5%) URM students, and 3641 (6.3%) SM students. Students pursuing dermatology (n = 1361), compared with those pursuing other specialties (n = 56 716), were more likely to be younger, female, and in an MD combined degree program, but less likely to be URM (146 [11.2%] vs 8301 [15.2%]; P < .001) and with lower mean (SE) total educational debt ($115 890 [$3382] vs $148 898 [$529]; P < .001). Female students pursuing dermatology compared with other specialties were less likely to identify as URM (96 of 829 [11.6%] vs 4760 of 27 660 [17.2%]; P < .001) or SM (16 [1.9%] vs 1564 [5.7%]; P < .001), while male students pursuing dermatology compared with other specialties were more likely to identify as SM (64 of 532 [12.0%] vs 1997 of 29 056 [6.9%]; P < .001) but did not differ significantly by URM identity (Table 1).
Table 1. Demographic Characteristics of GMS-OS and GMS-D Among All Study Participants and Stratified by Sex, 2016-2019.
| Demographic characteristic | All participants (N = 58 077) | Male participants (n = 29 588) | Female participants (n = 28 489) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| GMS-OS (n = 56 716) | GMS-D (n = 1361) | P value | GMS-OS (n = 29 056) | GMS-D (n = 532) | P value | GMS-OS (n = 27 660) | GMS-D (n = 829) | P value | |
| Sexa | |||||||||
| Male | 29 056 (51.2) | 532 (39.1) | <.001 | 29 056 (100) | 532 (100) | NA | NA | NA | NA |
| Female | 27 660 (48.8) | 829 (60.9) | NA | NA | 27 660 (100) | 829 (100) | |||
| Age, y | |||||||||
| <26 | 23 172 (40.9) | 590 (43.4) | .01 for trend | 11 051 (38.0) | 193 (36.3) | .81 for trend | 12 121 (43.8) | 397 (47.9) | .004 for trend |
| 27-29 | 23 698 (41.8) | 566 (41.6) | 12 286 (42.3) | 237 (44.6) | 11 412 (41.3) | 329 (39.7) | |||
| 30-32 | 6628 (11.7) | 148 (10.9) | 3764 (13.0) | 68 (12.9) | 2864 (10.4) | 80 (9.7) | |||
| >33 | 3218 (5.7) | 57 (4.2) | 1955 (6.7) | 34 (6.4) | 1263 (4.6) | 23 (2.8) | |||
| Sexual orientationb | |||||||||
| Heterosexual | 53 155 (93.7) | 1281 (94.1) | .55 | 27 059 (93.1) | 468 (88.0) | <.001 | 26 096 (94.4) | 813 (98.1) | <.001 |
| SM | 3561 (6.3) | 80 (5.9) | 1997 (6.9) | 64 (12.0) | 1564 (5.7) | 16 (1.9) | |||
| Race and ethnicityc | |||||||||
| Non-URM | 46 336 (84.8) | 1164 (88.9) | <.001 | 25 090 (86.4) | 471 (88.5) | .15 | 22 900 (82.8) | 733 (88.4) | <.001 |
| URM | 8301 (15.2) | 146 (11.2) | 3966 (13.7) | 61 (11.5) | 4760 (17.2) | 96 (11.6) | |||
| Degree program | |||||||||
| MD only | 53 197 (93.8) | 1244 (91.4) | <.001 | 27 100 (93.3) | 481 (90.4) | <.001 | 26 097 (94.4) | 763 (92.0) | <.001 |
| MD combined degree | 3519 (6.2) | 117 (8.6) | 1956 (6.7) | 51 (9.6) | 1563 (5.7) | 66 (8.0) | |||
| Total educational debt, $d | |||||||||
| None | 13 619 (24.0) | 469 (34.5) | <.001 for trend | 6961 (24.0) | 166 (31.2) | <.001 for trend | 6658 (24.1) | 303 (36.6) | <.001 for trend |
| >0-99 999 | 6883 (12.1) | 197 (14.5) | 3423 (11.8) | 84 (15.8) | 3460 (12.5) | 113 (13.6) | |||
| 100 000-199 999 | 13 464 (23.7) | 292 (21.5) | 6795 (23.4) | 98 (18.4) | 6669 (24.1) | 194 (23.4) | |||
| 200 000-299 999 | 14 436 (25.5) | 249 (18.3) | 7481 (25.8) | 106 (19.9) | 6955 (25.1) | 143 (17.3) | |||
| ≥300 000 | 6623 (11.7) | 113 (8.3) | 3566 (12.3) | 58 (10.9) | 3057 (11.1) | 55 (6.6) | |||
| Missing | 1691 (3.0) | 41 (3.0) | 830 (2.9) | 20 (3.8) | 861 (3.1) | 21 (2.5) | |||
| Mean (SE), $ | 148 898 (529) | 115 890 (3382) | <.001 | 109 346 (3464) | 168 110 (11 741) | <.001 | 146 711 (750) | 108 296 (4121) | <.001 |
| Mean (SE) debt among those with educational debt, $ | 197 873 (508) | 179 759 (3744) | <.001 | 174 745 (3882) | 211 216 (11 811) | <.001 | 195 209 (725) | 173 273 (4602) | <.001 |
Abbreviations: GMS-D, graduating medical students intending to practice dermatology; GMS-OS, graduating medical students intending to practice other specialties; MD, medical degree; NA, not applicable; SM, sexual minority; URM, underrepresented in medicine.
Sex was classified as either male or female and populated from previously collected Association of American Medical College data sources, such as the American Medical College Application Service.
SM students were defined as participants selecting bisexual or gay or lesbian, and heterosexual students were defined as those selecting heterosexual or straight in response to the question “How do you self-identify?”
URM students were defined as participants identifying as a race and ethnicity of American Indian or Alaska Native; Black or African American; Hispanic, Latino, or of Spanish origin; or Native Hawaiian or other Pacific Islander. Participants selecting more than 1 race and ethnicity were classified as URM if 1 of their responses fell within these categories. Non-URM were those selecting any other race and ethnicity.
Composite summary variable based on the sum of self-reported premedical educational debt and medical educational debt, excluding noneducational debt. Mean total educational debt was calculated both among all study participants and specifically among those with educational debt (excluding participants with no educational debt).
Intended Career Goals Between Students Pursuing Dermatology and Other Specialties
Students pursuing dermatology compared with those pursuing other specialties had decreased odds of intending to care for underserved populations (247 of 1350 [18.3%] vs 19 142 of 56 343 [34.0%]; fully adjusted odds ratio [aOR], 0.40; 95% CI, 0.35-0.47; P < .001), practice in underserved areas (172 [12.7%] vs 14 570 [25.9%]; aOR, 0.40; 95% CI, 0.34-0.47; P < .001), and practice public health (230 [17.0%] vs 17 028 [30.2%]; aOR, 0.44; 95% CI, 0.38-0.51; P < .001), but had increased odds of intending to pursue research in their careers (874 [64.7%] vs 29 121 [51.7%]; aOR, 1.76; 95% CI, 1.57-1.97; P < .001). Adjusting for differences in sex, race and ethnicity, and sexual orientation in the fully adjusted model did not significantly affect relationships identified in the age-adjusted models (Table 2). Analyses stratified by sex, race and ethnicity, and sexual orientation found similar relative differences between students pursuing dermatology and students pursuing other specialties in all subgroups (eTables 1-3 in the Supplement).
Table 2. Crude and Adjusted Odds Ratio for Intended Career Goals Between GMS-OS and GMS-D Among All Study Participants, 2016-2019.
| Intended career goala | All participants (n = 57 693) | ||
|---|---|---|---|
| GMS-OS (n = 56 343) | GMS-D (n = 1350) | P value | |
| Care for underserved populations | |||
| Prevalence, No. (%) | 19 142 (34.0) | 247 (18.3) | <.001 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 0.44 (0.38-0.50) | <.001 |
| Adjustedc | 1 [Reference] | 0.40 (0.35-0.47) | <.001 |
| Practice in underserved area | |||
| Prevalence, No. (%) | 14 570 (25.9) | 172 (12.7) | <.001 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 0.42 (0.36-0.50) | <.001 |
| Adjustedc | 1 [Reference] | 0.40 (0.34-0.47) | <.001 |
| Public health | |||
| Prevalence, No. (%) | 17 028 (30.2) | 230 (17.0) | <.001 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 0.48 (0.41-0.55) | <.001 |
| Adjustedc | 1 [Reference] | 0.44 (0.38-0.51) | <.001 |
| Teaching | |||
| Prevalence, No. (%) | 46 859 (83.2) | 1140 (84.4) | .22 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 1.09 (0.94-1.27) | .25 |
| Adjustedc | 1 [Reference] | 1.07 (0.92-.125) | .36 |
| Medical school faculty | |||
| Prevalence, No. (%) | 25 362 (45.0) | 630 (46.7) | .23 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 1.07 (0.96-1.19) | .22 |
| Adjustedc | 1 [Reference] | 1.08 (0.97-1.20) | .18 |
| Administration (eg, department chair, dean) | |||
| Prevalence, No. (%) | 15 959 (28.3) | 372 (27.6) | .54 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 0.96 (0.85-1.09) | .56 |
| Adjustedc | 1 [Reference] | 1.02 (0.90-1.15) | .80 |
| Research | |||
| Prevalence, No. (%) | 29 121 (51.7) | 874 (64.7) | <.001 |
| Odds ratio | |||
| Crudeb | 1 [Reference] | 1.73 (1.55-1.94) | <.001 |
| Adjustedc | 1 [Reference] | 1.76 (1.57-1.97) | <.001 |
Abbreviations: GMS-D, graduating medical students intending to practice dermatology; GMS-OS, graduating medical students intending to practice other specialties.
Individuals were categorized as intending to pursue a specific goal if they answered yes to the question: “In which of the following activities do you plan to participate during your career? Select all that apply.” Those selecting no or undecided were categorized as not pursuing that specific goal. Individuals with missing data on 1 or more career goals were excluded from those analyses.
Crude odds ratios adjusted for age only.
Adjusted odds ratios adjusted for age, sex, race and ethnicity, and sexual orientation.
Demographic Characteristics by Sex, Race and Ethnicity, and Sexual Orientation Among Students Pursuing Dermatology
Female compared with male students pursuing dermatology were less likely to identify as SM (16 of 829 [1.9%] vs 64 of 532 [12.0%]; P < .001) and had lower mean (SE) total educational debt ($108 296 [$4121] vs $127 875 [$5770]; P = .005). URM compared with non-URM students pursuing dermatology were more likely to identity as SM (18 of 157 [11.5%] vs 62 of 1204 [5.2%]; P = .002) and had higher mean (SE) total educational debt ($168 110 [$11 741] vs $109 346 [$3882]; P < .001). Sexual minority students compared with heterosexual students pursuing dermatology were more likely to be in an MD combined degree program (11 of 80 [13.8%] vs 106 of 1281 [8.3%]; P = .04) and had higher mean (SE) total educational debt ($136 426 [$16 810] vs $114 583 [$3432]; P = .04) (Table 3).
Table 3. Demographic Characteristics by Sex, Race and Ethnicity, and Sexual Orientation Among Graduating Medical Students Intending to Practice Dermatology, 2016-2019.
| Demographic characteristic | Stratified by sex | Stratified by race and ethnicity | Stratified by sexual orientation | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Male (n = 532) | Female (n = 829) | P value | Non-URM (n = 1204) | URM (n = 157) | P value | Heterosexual (n = 1281) | SM (n = 80) | P value | |
| Sexa | |||||||||
| Male | 532 (100) | NA | NA | 471 (39.1) | 61 (38.9) | .95 | 468 (36.5) | 64 (80.0) | <.001 |
| Female | NA | 829 (100) | 733 (60.9) | 96 (61.2) | 813 (63.5) | 16 (20.0) | |||
| Age, y | |||||||||
| <26 | 193 (36.3) | 397 (47.9) | <.001 for trend | 525 (43.6) | 65 (41.4) | .28 for trend | 563 (44.0) | 27 (33.8) | .04 for trend |
| 27-29 | 237 (44.6) | 329 (39.7) | 505 (41.9) | 61 (38.9) | 529 (41.3) | 37 (46.3) | |||
| 30-32 | 68 (12.8) | 80 (9.7) | 126 (10.5) | 22 (14.0) | 138 (10.8) | 10 (12.5) | |||
| >33 | 34 (6.4) | 23 (2.8) | 48 (4.0) | 9 (5.7) | 51 (4.0) | 6 (7.5) | |||
| Sexual orientationb | |||||||||
| Heterosexual | 468 (88.0) | 813 (98.1) | <.001 | 1142 (94.9) | 139 (88.5) | .002 | 1281 (100) | NA | NA |
| Sexual minority | 64 (12.0) | 16 (1.9) | 62 (5.2) | 18 (11.5) | NA | 80 (100) | |||
| Race and ethnicityc | |||||||||
| Non-URM | 471 (88.5) | 733 (88.4) | .95 | 1204 (100) | NA | NA | 1142 (89.2) | 62 (77.5) | .002 |
| URM | 61 (11.5) | 96 (11.6) | NA | 157 (100) | 139 (10.9) | 18 (22.5) | |||
| Degree program | |||||||||
| MD only | 481 (90.4) | 763 (92.0) | .30 | 1102 (91.5) | 142 (90.5) | .65 | 1175 (91.7) | 69 (86.3) | .04 |
| MD combined degree | 51 (9.6) | 66 (8.0) | 102 (8.5) | 15 (9.6) | 106 (8.3) | 11 (13.8) | |||
| Total educational debt, $d | |||||||||
| None | 166 (31.2) | 303 (36.6) | .01 for trend | 439 (36.5) | 30 (19.1) | <.001 for trend | 447 (34.9) | 22 (27.5) | .25 for trend |
| >0-99 999 | 84 (15.8) | 113 (13.6) | 177 (14.7) | 20 (12.7) | 178 (13.9) | 19 (23.4) | |||
| 100 000-199 999 | 98 (18.4) | 194 (23.4) | 254 (21.1) | 38 (24.2) | 278 (21.7) | 14 (17.5) | |||
| 200 000-299 999 | 106 (19.9) | 143 (17.3) | 216 (17.9) | 33 (21.0) | 239 (18.7) | 10 (12.5) | |||
| ≥300 000 | 58 (10.9) | 55 (6.6) | 87 (7.2) | 26 (16.6) | 99 (7.7) | 14 (17.5) | |||
| Missing | 20 (3.8) | 21 (2.5) | 31 (2.6) | 10 (6.4) | 40 (3.1) | 1 (1.3) | |||
| Mean (SE), $ | 127 874 (5770) | 108 296 (4121) | .005 | 109 346 (3464) | 168 110 (11 741) | <.001 | 114 583 (3432) | 136 426 (16 810) | .04 |
| Mean (SE) debt among those with educational debt, $ | 189 225 (6271) | 173 273 (4603) | .04 | 174 745 (3882) | 211 216 (11 811) | <.001 | 179 090 (3772) | 189 082 (19 176) | .51 |
Abbreviations: MD, medical degree; NA, not applicable; SM, sexual minority; URM, underrepresented in medicine.
Sex was classified as either male or female and populated from previously collected Association of American Medical College data sources such as the American Medical College Application Service.
SM students were defined as participants selecting bisexual or gay or lesbian, and heterosexual students were defined as those selecting heterosexual or straight in response to the question “How do you self-identify?”
URM students were defined as participants identifying as a race and ethnicity of American Indian or Alaska Native; Black or African American; Hispanic, Latino, or of Spanish origin; or Native Hawaiian or other Pacific Islander. Participants selecting more than 1 race and ethnicity were classified as URM if 1 of their responses fell within these categories. Non-URM were those selecting any other race and ethnicity.
Composite summary variable based on the sum of self-reported premedical educational debt and medical educational debt, excluding noneducational debt. Mean total educational debt was calculated both among all study participants and specifically among those with educational debt (excluding participants with no educational debt).
Intended Career Goals by Sex, Race and Ethnicity, and Sexual Orientation Among Students Pursuing Dermatology
Female compared with male students pursuing dermatology had increased odds of intending to care for underserved populations (166 of 825 [20.1%] vs 81 of 525 [15.4%]; aOR, 1.49; 95% CI, 1.09-2.05, P = .01) and pursue public health (149 [18.1%] vs 81 [15.4%]; aOR, 1.40; 95% CI, 1.02-1.92, P = .04), but did not differ in intent to practice in underserved areas, teach, pursue medical school faculty or administrative roles, or pursue research in their careers. URM compared with non-URM students pursuing dermatology had increased odds of intending to care for underserved populations (66 of 156 [42.3%] vs 181 of 1194 [15.2%]; aOR, 4.05; 95% CI, 2.83-5.80; P < .001), practice in underserved areas (49 [31.4%] vs 123 [10.3%]; aOR, 3.93; 95% CI, 2.66-5.80; P < .001), and pursue public health (40 [25.6%] vs 190 [15.9%]; aOR, 1.70; 95% CI, 1.14-2.53; P = .01), but did not differ in intent to teach, pursue medical school faculty or administrative roles, or pursue research in their careers. Sexual minority respondents compared with heterosexual respondents had increased odds of intending to care for underserved populations (23 of 80 [28.8%] vs 224 of 1270 [17.6%]; aOR, 2.02; 95% CI, 1.16-3.49; P = .01), pursue public health (25 [31.3%] vs 205 [16.1%]; aOR, 2.55; 95% CI, 1.51-4.31; P < .001), become medical school faculty (45 [56.3%] vs 485 [46.1%]; aOR, 1.60; 95% CI, 1.01-2.57; P = .04), serve in administrative roles (31 [38.9%] vs 341 [26.9%]; aOR, 1.60; 95% CI, 1.01-2.59; P = .04), and conduct research (61 [76.3%] vs 813 [64.0%]; aOR, 1.73; 95% CI, 1.01-2.98, P = .04) but did not differ in intent to practice in underserved areas or teach in their careers (Table 4).
Table 4. Crude and Adjusted Odds Ratio for Intended Career Goals By Sex, Race and Ethnicity, and Sexual Orientation Among Graduating Medical Students Intending to Practice Dermatology, 2016-2019.
| Intended career goala | Stratified by sex | Stratified by race and ethnicity | Stratified by sexual orientation | ||||||
|---|---|---|---|---|---|---|---|---|---|
| Male (n = 525) | Female (n = 825) | P value | Non-URM (n = 1194) | URM (n = 156) | P value | Heterosexual (n = 1270) | SM (n = 80) | P value | |
| Care for underserved populations | |||||||||
| Prevalence, No. (%) | 81 (15.4) | 166 (20.1) | .03 | 181 (15.2) | 66 (42.3) | <.001 | 224 (17.6) | 23 (28.8) | .01 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 1.34 (1.00-1.80) | .04 | 1 [Reference] | 4.18 (2.92-5.97) | <.001 | 1 [Reference] | 1.95 (1.17-3.24) | .01 |
| Adjustedc | 1 [Reference] | 1.49 (1.09-2.05) | .01 | 1 [Reference] | 4.05 (2.83-5.80) | <.001 | 1 [Reference] | 2.02 (1.16-3.49) | .01 |
| Practice in underserved area | |||||||||
| Prevalence, No. (%) | 61 (11.6) | 111 (13.5) | .33 | 123 (10.3) | 49 (31.4) | <.001 | 158 (12.4) | 14 (17.5) | .19 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 1.17 (084-1.64) | .35 | 1 [Reference] | 4.00 (2.72-5.90) | <.001 | 1 [Reference] | 1.51 (0.83-2.76) | .18 |
| Adjustedc | 1 [Reference] | 1.22 (0.86-1.74) | .27 | 1 [Reference] | 3.93 (2.66-5.80) | <.001 | 1 [Reference] | 1.39 (2.67-5.80) | .32 |
| Public health | |||||||||
| Prevalence, No. (%) | 81 (15.4) | 149 (18.1) | .21 | 190 (15.9) | 40 (25.6) | .002 | 205 (16.1) | 25 (31.3) | <.001 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 1.28 (0.92-1.67) | .16 | 1 [Reference] | 1.81 (1.22-2.68) | .003 | 1 [Reference] | 2.33 (1.42-3.83) | <.001 |
| Adjustedc | 1 [Reference] | 1.40 (1.02-1.92) | .04 | 1 [Reference] | 1.70 (1.14-2.53) | .01 | 1 [Reference] | 2.55 (1.51-4.31) | <.001 |
| Teaching | |||||||||
| Prevalence, No. (%) | 438 (83.4) | 702 (85.1) | .41 | 1013 (84.8) | 127 (81.4) | .27 | 1072 (84.4) | 68 (85.0) | .89 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 1.13 (0.84-1.53) | .42 | 1 [Reference] | 0.78 (0.50-1.20) | .25 | 1 [Reference] | 1.06 (0.56-1.99) | .87 |
| Adjustedc | 1 [Reference] | 1.15 (0.85-1.57) | .37 | 1 [Reference] | 0.77 (0.50-1.19) | .24 | 1 [Reference] | 1.16 (0.60-2.23) | .66 |
| Medical school faculty | |||||||||
| Prevalence, No. (%) | 234 (44.6) | 396 (48.0) | .22 | 551 (46.2) | 79 (50.6) | .29 | 485 (46.1) | 45 (56.3) | .08 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 1.19 (0.96-1.48) | .13 | 1 [Reference] | 1.17 (0.84-1.64) | .35 | 1 [Reference] | 1.48 (0.94-2.34) | .09 |
| Adjustedc | 1 [Reference] | 1.25 (0.99-1.57) | .06 | 1 [Reference] | 1.14 (0.82-1.60) | .45 | 1 [Reference] | 1.60 (1.01-2.57) | .04 |
| Administration (eg, department chair, dean) | |||||||||
| Prevalence, No. (%) | 158 (30.1) | 214 (25.9) | .10 | 325 (27.2) | 47 (30.1) | .44 | 341 (26.9) | 31 (38.9) | .02 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 0.82 (0.63-1.04) | .09 | 1 [Reference] | 1.14 (0.79-1.65) | .48 | 1 [Reference] | 1.73 (1.08-2.77) | .02 |
| Adjustedc | 1 [Reference] | 0.85 (0.66-1.10) | .21 | 1 [Reference] | 1.11 (0.77-1.60) | .58 | 1 [Reference] | 1.60 (1.01-2.59) | .04 |
| Research | |||||||||
| Prevalence, No. (%) | 347 (66.1) | 527 (63.9) | .41 | 768 (64.3) | 106 (68.0) | .37 | 813 (64.0) | 61 (76.3) | .03 |
| Odds ratio | |||||||||
| Crudeb | 1 [Reference] | 0.97 (0.77-1.23) | .83 | 1 [Reference] | 1.16 (0.81-1.67) | .42 | 1 [Reference] | 1.73 (1.01-2.95) | .04 |
| Adjustedc | 1 [Reference] | 1.03 (0.81-1.30) | .84 | 1 [Reference] | 1.13 (0.78-1.62) | .53 | 1 [Reference] | 1.73 (1.01-2.98) | .04 |
Abbreviation: URM, underrepresented in medicine.
Individuals were categorized as intending to pursue a specific goal if they answered yes to the question: “In which of the following activities do you plan to participate during your career? Select all that apply.” Those selecting no or undecided were categorized as not pursuing that specific goal. Individuals with missing data on 1 or more career goals were excluded from those analyses.
Crude odds ratios adjusted for age only.
Adjusted odds ratios adjusted for age, sex, race and ethnicity, and sexual orientation.
Discussion
This study using a nationally representative sample of graduating allopathic medical students identified a relative lack of SM and URM diversity and lack of interest in careers focused on underserved care and public health among students pursuing dermatology when compared with those pursuing other specialties. Furthermore, the study found that SM and/or URM identity is significantly associated with the intent of students pursuing dermatology to pursue careers in underserved care, public health, academic dermatology, and/or research. These findings have important implications for dermatology residency recruitment and workforce diversity initiatives—suggesting efforts are needed to increase SM and URM diversity and interest in careers focused on underserved care and public health among students pursuing dermatology.
While representation of female students remains high among those pursuing dermatology,1,15 there is an ongoing lack of URM and SM diversity in the dermatology workforce training pipeline, particularly among female individuals. These findings parallel the lack of URM individuals among all dermatologists1 as well as female dermatologists who identify as LGBT.8 Several factors likely contribute to the relative underrepresentation of URM and SM students among those pursuing dermatology. First, there is an overall lack of URM16 and female SM17 students among medical students compared with their representation in the general population, indicating a loss of diverse trainees at other transitional periods between high school, college, and medical school. Many structural barriers likely account for this trend.18 Second, given the importance of mentorship in specialty choice,19 the lack of visible role models from underrepresented backgrounds among practicing dermatologists likely contributes to the lack of diversity among incoming trainees. Third, competitive specialties such as dermatology have been found to be perceived by trainees to be less inclusive of SM students,12 and URM students face interpersonal and structural racism, as well as unconscious biases, that likely contribute to barriers to pursuing careers in dermatology.20
Finally, dermatology continues to rank among the most competitive specialties based on national residency match rates.21 Despite recent changes to shift the US Medical Licensing Step 1 examination to pass/fail, which may benefit URM groups that have traditionally faced barriers associated with lower scores on standardized tests, other metrics, such as research and audition rotations, may consequently carry more weight and risk disadvantaging students from lower socioeconomic backgrounds.22,23,24 Emphasizing such metrics in residency selection may act as extrinsic motivators to medical students pursuing dermatology and preserve a tendency toward attracting applicants from affluent backgrounds with better access to educational and financial resources. This study found that students pursuing dermatology had significantly lower overall educational debt than those pursuing other specialties, indicating that they may come from higher socioeconomic backgrounds.25 Both SM and URM students pursuing dermatology reported high educational debt, which may indicate financial barriers to pursuing careers in dermatology for these minority groups. Emphasis on such metrics is important and likely contributes to an increased interest in research among medical students pursuing dermatology. However, dermatologists should recognize the barriers certain students may face and strive to achieve more equitable access to such opportunities for all medical students.
Further studies are needed to better characterize specialty choice motivations and barriers to pursuing careers in dermatology among medical students who identify as URM, SM, or other groups, to help close these gaps. However, implementable strategies to address underrepresentation may include emphasizing diversity in residency selection and faculty recruitment practices, recognizing the merit of overcoming hardships and personal grit, and expanding formal mentorship opportunities that support URM and SM medical students and residents. Particular attention should be paid to reducing socioeconomic barriers to pursuing careers in dermatology through efforts such as advocating for increased financial aid, scholarships, and paid fellowships targeted toward URM and SM individuals, and continuing to offer videoconferencing options to reduce expenses during residency interviews.26
This study also found that students pursuing dermatology were less likely to pursue careers focused on underserved care. There is a dire need for physicians in underserved communities, which have a high burden of skin disease and disproportionately include persons from lower socioeconomic classes, racial and ethnic minority individuals, and SM individuals.27 Female, URM, and SM students pursuing dermatology were the most engaged with pursuing careers in underserved care, although there was an overall relative lack of interest in underserved care among all students pursuing dermatology compared with those pursuing other specialties regardless of sex, race and ethnicity, or sexual orientation. Efforts are thus needed to increase engagement with underserved care among all trainees in the dermatology workforce pipeline. Such efforts may include increasing service-based learning opportunities in undergraduate and graduate medical education in dermatology28,29; emphasizing the importance of a demonstrated commitment to underserved care, including through research, in dermatology residency recruitment policies and practices30; formal residency training tracks focused on health equity and/or community-based care31,32,33; and financial incentives that encourage careers in underserved care.34,35
Finally, this study found that SM students pursuing dermatology had increased interest in careers focused on academic practice, leadership, and research. This is consistent with a prior study that found LGBT dermatologists are more likely to report practicing in academic settings.8 However, SM individuals may face unique barriers to career advancement in academic medicine. For instance, nearly half of LGBT health professionals in academic medical centers avoid disclosing their sexual orientation in professional settings due to fear of negative consequences and/or discrimination.36 In a single-institution survey of academic physicians,11 LGBT faculty were found to be less satisfied than non-LGBT faculty with their pace of advancement, had lower perceived equitability for advancement criteria, and lower satisfaction with their department’s recruitment of individuals with minority backgrounds. Relatively few empirical data exist on the experiences of SM individuals in academic dermatology as sexual orientation data have not been routinely collected in dermatology workforce surveys. However, dermatologists from diverse backgrounds are known to face unique challenges throughout careers in academic dermatology. For instance, female dermatologists are less likely than male dermatologists to receive grant funding37 or obtain senior leadership roles (eg, department chair) in academic dermatology.38 In the US, only 7.4% of dermatology faculty are URM individuals and 79.7% of all department chairs are White individuals.15 Sexual orientation data, much like data on sex and race and ethnicity, should be standardized in dermatology trainee and physician workforce surveys to better understand the experiences of SM dermatologists and ensure supportive training and workplace environments that promote equitable advancement.
Limitations
This study has limitations, including lack of data delineating sex, sex assigned at birth, and gender identity and lack of intersectional analyses between multiple minority identities and multiple career goals. Importantly, diversity factors and their relationship to underserved care is likely multidimensional, and many students pursuing dermatology identified with multiple minority identities, highlighting the need for future studies focused on intersectionality. URM and SM students were analyzed as single pooled groups, which may limit the generalizability of these results when applied individually across these heterogenous groups. There have also been rapid changes within organized medicine toward an increased focus on addressing diversity, equity, and inclusion and underserved care,39 reiterating the need for future longitudinal studies to better understand how diversity and focus on underserved care in the dermatology workforce and training pipeline might change over time. Finally, graduating medical students may change career goals during or after training and survey questions related to intended career goals may also have been subjectively interpreted.
Conclusions
This cross-sectional study found that URM and SM female medical students are underrepresented in the dermatology workforce pipeline and that there is an overall lack of interest in careers focused on underserved care among students pursuing dermatology. Addressing health inequities and improving care for undeserved patients is the responsibility of all dermatologists, and efforts are needed to increase diversity and interest in careers focused on underserved care among trainees in the dermatology workforce pipeline. These efforts may help reduce health disparities faced by underserved populations by increasing the collective engagement of all dermatologists in underserved care and by enriching training and practice environments. Finally, sexual orientation data should be standardized in trainee and physician workforce surveys to better understand and track the representation and career trajectories of SM dermatologists and ensure equitable training and workplace environments. These combined efforts will create a more visibly diverse, equitable, and inclusive workforce that is better equipped to engage with and serve all patients.
eTable 1. Age-Adjusted and Fully Adjusted Odds Ratio for Intended Career Goals between GMS-OS and GMS-D Among Male and Female Participants, 2016-2019
eTable 2. Age-Adjusted and Fully Adjusted Odds Ratio for Intended Career Goals between GMS-OS and GMS-D Among Non-URM and URM Participants, 2016-2019
eTable 3. Age-Adjusted and Fully Adjusted Odds Ratio for Intended Career Goals between GMS-OS and GMS-D Among Heterosexual and SM Participants, 2016-2019
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
eTable 1. Age-Adjusted and Fully Adjusted Odds Ratio for Intended Career Goals between GMS-OS and GMS-D Among Male and Female Participants, 2016-2019
eTable 2. Age-Adjusted and Fully Adjusted Odds Ratio for Intended Career Goals between GMS-OS and GMS-D Among Non-URM and URM Participants, 2016-2019
eTable 3. Age-Adjusted and Fully Adjusted Odds Ratio for Intended Career Goals between GMS-OS and GMS-D Among Heterosexual and SM Participants, 2016-2019
