Wake up to the gender gap in academic anesthesiology and address the pipeline

Abstract

Diversity, equity, and inclusion are important values in health care and academic medicine. Although women have comprised nearly 50% of all US medical school graduates since the early 2000s, gender disparities continue in many specialties and persist in medical education leadership. For women in anesthesiology, gender inequities exist along the academic pipeline, with greater disparity in the higher ranks of academia and leadership. Successful endeavors to improve gender equity in the specialty include increasing awareness, engaging in faculty development, and encouraging transparent promotions processes. The strides will be short and change will be slow unless we shift focus to when the gender imbalance begins—at the transition from undergraduate medical education to graduate medical education. Currently women comprise 37% of academic anesthesiology faculty; however, the current resident pool is only 33% women. If recruitment of a gender-equitable workforce at the undergraduate-to-graduate medical education transition is not a priority, the downstream measures will have minimal impact toward gender equity in academic anesthesiology.

Diversity, equity, and inclusion are important for all facets of society: business, government, education, health care, and academic medicine. Diverse teams are smarter, and gender balance improves team collaboration.¹ Despite the fact that women have made up nearly 50% of US medical school graduates for the past 20 years, gender disparities are prevalent in many specialties and persist in medical education leadership. In 2021, the Association of American Medical Colleges (AAMC) reported that women comprise 41% of full-time faculty at US medical schools and disproportionately fill the lower-rank positions. For women in academic anesthesiology, a traditionally male-dominated specialty, this well-described gender chasm is even more disparate. Women currently comprise 37% of academic anesthesiologists, compared with 53% of all clinical instructors, 37% of assistant professors, 34% of associate professors, 22% of full professors, and 13% of department chairs.²

As a specialty, anesthesiology is making efforts to rectify gender balance. Efforts include white papers reporting objective data on explicit and implicit disparities,³ inclusive and transparent processes for promotion and leadership selection,⁴ and inclusive faculty and leadership development opportunities.⁵ Bissing et al reported a rise in women faculty in anesthesiology over 10 years, from 2006 to 2016 (30% to 34%), as well as an increase in the percentage of female anesthesiology resident trainees (32% to 37%). Gonzalez et al identified evidence of improved gender equity in academic leadership, reporting an increasing representation of female anesthesiology program directors, from 15% in 2003 to 36% in 2018. Unfortunately, the Accreditation Council for Graduate Medical Education reported that the percentage of program directors has been unchanged since the 2018 report.⁶ Methankool and colleagues surveyed female cardiothoracic anesthesiologists, with 57% of respondents holding a “significant leadership role.” Women were more likely to hold education leadership roles (program directors, faculty development, and simulation) rather than major departmental-level roles (chair, vice chair) and/or research roles. The authors astutely stated, “What leadership roles women are occupying deserves greater scrutiny.”⁷

The need for gender equity and diversity has been recognized by national societies and governing bodies as well. The American Board of Anesthesiology (ABA), the specialty’s credentialing body, released a diversity, equity, and inclusion public statement in 2020, noting the need to ensure that “board leaders are representative of the anesthesiology community.” The current ABA board of directors includes two women, one of whom is a physician, and 10 men, all of whom are physicians.⁸ Additionally, the percentage of women chairs in the specialty has declined in recent years, from 15% in 2003 to 13% in 2021. The number of women choosing a career in anesthesiology peaked in 2016, with 37% female resident trainees, but successful match for women to the specialty declined to 33% in 2021. Unfortunately, small successes in awareness are inadequate to maintain momentum for significant gender equity movement. The pool of qualified women available to pursue leadership roles remains small with little hope of filling the pipeline. I propose three areas for improvement: 1) recognize the gender gap in our specialty; 2) engage learners at the undergraduate medical education (UME) level; and 3) learn from general surgery (Table 1).

Table 1.

Addressing the academic anesthesiology pipeline

Focus area	Measures
Recognize the gender gap	Engage in research to better understand career choice decisions of female medical students Focus diversity, equity, and inclusion efforts before the career-choice decision Engage in a holistic review of resident applicants
Engage undergraduate medical education learners	Support a positive and inclusive learning environment for medical students Maximize educational influence with students during clinical experience (e.g., surgery and ob/gyn rotations)
Learn from general surgery	Ask difficult questions, e.g., What are the barriers to recruiting women into anesthesiology? Recognize and eliminate gender discrimination from the workplace Support gender-matched mentoring

RECOGNIZE THE GENDER GAP

Efforts previously described are important yet inadequate to make a significant impact in our specialty. We need to shift our focus to where the gender imbalance begins, the moment of pipeline break—at the transition from UME to graduate medical education (GME). Are we failing to attract female medical students or are we failing to match them? Review of Electronic Residency Application Service and AAMC data revealed it was the former.⁶ The percentage of women applying to anesthesiology residency programs is proportional to their successful match. The question then arises: What are the barriers to recruiting women to anesthesiology? Future research endeavors should strive to answer this question, thereby understanding the career choice decisions of female medical students.

American Society for Anesthesiology (ASA) grant recipients Ramachandran et al suggested a holistic recruitment process to improve diversity in our workforce. A holistic review takes “personal attributes and circumstances of the applicant into account,” thereby limiting bias encountered in traditional rubric models that often focus on board scores, pedigree, and medical school.⁹ Support from the ASA and ABA is valuable in pursuit of DEI in the specialty; however, we also need to identify opportunities to advance DEI before the residency application, before the career-choice experience of medical students. In my anecdotal conversations with faculty and trainees, including those in leadership positions, many do not recognize the significant gender imbalance that exists in our specialty. We need to expose the early pipeline and collectively focus on recruiting a gender-equitable workforce, one that mirrors recruitment, matriculation, and graduation at our medical schools.

ENGAGE UME LEARNERS

For most medical schools, anesthesiology is not included in the core clinical experience, yet, I propose, through genuine inclusive efforts we can provide educational opportunities to students during their core clinical experiences (e.g., obstetrics, general surgery). There is much to be taught and learned as we practice our specialty. Induction and emergence are opportune times to indulge the student sitting at the periphery of the operating room, unsure and unfamiliar. A simple explanation of the capnogram or an over-the shoulder view of the vocal cords is often enough to engage and excite a medical student about our specialty. With some effort, we can enhance learning and the learning environment for students both in and out of the operating room. The message to academic anesthesiologists: We need a more diverse, equitable, and inclusive workforce. Through genuine support of a positive learning environment for all, we can inspire and engage medical students.

LEARN FROM GENERAL SURGERY

Recruiting against society’s gender-specific roles can be challenging, especially for the traditionally male-dominated fields of anesthesiology and general surgery. The AAMC reported that women comprised only 24% of general surgery residency positions and 32% of anesthesiology trainee positions in 2005. Over the past 17 years, general surgery has experienced a boom in the percentage of female trainees, with women filling 43% of all general surgery residency positions in 2021 (Figure 1). Likewise, the percentage of female vascular surgery residents experienced nearly a 75% increase over the same time—comprising 20% of residents and fellows in 2005 vs 33% in 2021. Anesthesiology’s track record for recruiting female medical students is unfavorable, with a hopeful peak in 2016 at 37% of resident trainees, followed by a down trend to 33% in 2021.⁶

Figure 1.

Trends in female resident trainees by specialty.

Anesthesiologists spend much of their time collaborating with surgical colleagues, providing patient care in the perioperative arena. Much of the recruitment, training, and clinical experience, for surgeons and anesthesiologists, occurs in the operating room. I propose we can learn from our surgical colleagues. Through conversations with leaders in surgical education, we can learn the innovations and interventions initiated over the past 15 to 20 years that ultimately led to more gender-equitable recruitment. In 2004, Park et al investigated deterrents to choosing a career in general surgery. Both gender discrimination during the general surgery rotation and a lack of gender-matched mentorship deterred women from selecting the specialty.¹⁰ Faculty from one Canadian medical school suggested that an inclusive learning environment that highlights the collaborative team experience would enhance recruitment into general surgery.¹¹

Recognition of recruitment barriers may be applied to anesthesiology. Gender discrimination is commonly reported by female anesthesiologists.^7,12 Gender discrimination in the workplace contributes to a negative team culture and provider burnout.¹² Medical students may recognize a culture of discrimination in anesthesiology and choose other career pursuits. Additionally, gender-matched mentors and role models may prove to be facilitators to recruitment in anesthesiology. Only in asking the questions, as our surgical colleagues have done, can we gain insight and understanding regarding career choices of female medical students, thereby identifying creative resolutions for our pipeline crisis.

CONCLUSION

Gender equity is an important mission, but the need for equity extends beyond and before the leadership arena. There has been significant focus recently on improving gender equity in anesthesiology, including recognition and awareness, supportive faculty development programs for women, and inclusive and transparent leadership selection. Yet, promoting women to leadership positions is only one component of the solution. To achieve gender equity and diversity in academic anesthesiology, we need to first recognize and rectify the lack of gender equity and diversity in our pipeline. We cannot sit on the sidelines and cry “foul” when a male physician once again is promoted to a leadership position when a smaller pool of qualified women exists. The collective efforts of all anesthesiologists can impact positive change. Only in recognizing where the gender imbalance begins, thereby focusing energy at the UME-to-GME transition, can we collaboratively identify and apply innovative platforms to recruit a diverse and equitable group of future academic leaders.