Original Research—General Otolaryngology
Regional Differences in Gender Promotion and Scholarly Productivity in Otolaryngology
Otolaryngology– Head and Neck Surgery 2014, Vol. 150(3) 371–377 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599813515183 http://otojournal.org
Jean Anderson Eloy, MD1,2,3, Leila J. Mady, PhD1, Peter F. Svider, MD4, Kevin M. Mauro1, Evelyne Kalyoussef, MD1, Michael Setzen, MD5,6, Soly Baredes, MD1,3, and Sujana S. Chandrasekhar, MD7
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract Objectives. To identify whether regional differences exist in gender disparities in scholarly productivity and faculty rank among academic otolaryngologists. Study Design and Setting. Academic otolaryngologists’ bibliometric data analyses. Methods. Online faculty listings from 98 otolaryngology departments were organized by gender, academic rank, fellowship training status, and institutional location. The Scopus database was used to assess bibliometrics of these otolaryngologists, including the h-index, number of publications, and publication experience. Results. Analysis included 1127 otolaryngologists, 916 men (81.3%) and 211 women (18.7%). Female faculty comprised 15.4% in the Midwest, 18.8% in the Northeast, 21.3% in the South, and 19.0% in the West (P = .44). Overall, men obtained significantly higher senior academic ranks (associate professor or professor) compared to women (59.8% vs 40.2%, P \ .0001). Regional gender differences in senior faculty were found in the South (59.8% men vs 37.3% women, P = .0003) and Northeast (56.4% men vs 24.1% women, P \ .0001) with concomitant gender differences in scholarly impact, as measured by the h-index (South, P = .0003; Northeast, P = .0001). Among geographic subdivisions, female representation at senior ranks was lowest in the Mid-Atlantic (22.0%), New England (30.8%), and West South Central (33.3%), while highest in Pacific (60.0%) and Mountain (71.4%) regions. No regional gender differences were found in fellowship training patterns (P-values . .05). Conclusion. Gender disparities in academic rank and scholarly productivity exist most notably in the Northeast, where women in otolaryngology are most underrepresented relative to men at senior academic ranks and in scholarly productivity.
Keywords h-index, gender disparities, academic promotion, scholarly productivity, academic physician scientific productivity, academic rank determination, regional gender disparities, gender and promotion, gender and academic rank, gender and scholarly productivity Received August 23, 2013; revised October 21, 2013; accepted November 12, 2013.
Introduction Despite the increasing presence of women in general and subspecialty surgical practice, the advancement of women in academic surgery, particularly in positions of leadership, is notably limited.1-3 This is undoubtedly a complex, multifactorial phenomenon influenced by clinical and educational performance metrics, external funding awards granted, as well as psychosocial attitudes involving traditional gender 1
Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA 2 Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA 3 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA 4 Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA 5 Rhinology Section, North Shore University Hospital, Manhasset, New York, USA 6 Department of Otolaryngology, New York University School of Medicine New York, New York, USA. 7 New York Otology, New York Head and Neck Institute, North Shore LIJ Healthcare, Mount Sinai School of Medicine, New York, New York, USA This article was presented at the 2013 AAO-HNSF Annual Meeting & OTO EXPO; September 29–October 3, 2013; Vancouver, Canada. Corresponding Author: Jean Anderson Eloy, MD, Associate Professor and Vice Chairman, Director, Rhinology and Sinus Surgery, Co-Director, Endoscopic Skull Base Surgery Program, Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ 07103, USA. Email: [email protected]
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Table 1. United States Census Bureau Regions and Divisions.a Regions
Divisions
States
Midwest
West North Central East North Central Middle Atlantic New England Pacific Mountain South Atlantic
North Dakota, South Dakota, Nebraska, Kansas, Iowa, Minnesota, Missouri Wisconsin, Michigan, Illinois, Indiana, Ohio New York, New Jersey, Pennsylvania Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont Alaska, California, Hawaii, Oregon, Washington Arizona, Colorado, Idaho, New Mexico, Montana, Utah, Nevada, Wyoming Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia Alabama, Kentucky, Mississippi, Tennessee Arkansas, Louisiana, Oklahoma, Texas
Northeast West South
East South Central West South Central a
Geographic divisions obtained from the US Census Bureau, accessed January 20, 2013 at: https://www.census.gov/geo/www/us_regdiv.pdf.
roles and gender discrimination in the medical milieu.3-6 Decisions regarding academic advancement may be influenced by scholarly productivity, as measured by research output. Research productivity may be commonly assessed by tabulation of an author’s total number of publications and total citations.7-9 These absolute metrics, however, fail to capture the nuances of an author’s academic influence such as scholarly impact, relevance to the field, and relative contribution of each publication within an author’s repertoire.7-12 In contrast to absolute number of publications, the h-index, first described by Dr J. E. Hirsch in 2005, attempts to quantify research relevance and productivity.7 An author’s h-index is valued as the number of published papers, h, that have been cited at least h times in peer-reviewed literature. For example, consider an author with 100 total publications, of which 10 have been cited at least 10 times. The author’s h-index in this case is 10. Consider another author with 50 publications, of which 20 have been cited at least 20 times. Here, the author’s h-index is 20. Though the former is twice as prolific in absolute number of publications, the latter has double the h-index, suggesting an overall greater contribution to academic research that is not reflected when considering publication sums alone. Using the h-index to evaluate academic otolaryngologists, a previous analysis reported that although males demonstrate higher overall research contributions, females exhibit a different productivity curve, with less productivity early on, but matching and exceeding their male counterparts both in publications and impact rate later in their careers.5 Another analysis also reported that independent of career longevity, gender disparities exist in grant funding among otolaryngology departments, as males had higher National Institutes of Health (NIH) funding levels as well as a larger proportion of R-series grants than females in fiscal years 2011 and 2012.13 These findings may contribute to the current gender gap in academic otolaryngology. Though gender disparities in research productivity and faculty rank among academic otolaryngologists have been previously described, there has been no analysis of regional trends in gender promotion and scholarly impact. This study aims to identify whether there are regional differences in
gender promotion and scholarly impact among academic otolaryngologists. Geographic variations may shed light on factors that propagate gender differences, particularly at levels of academic leadership.
Materials and Methods A list of academic otolaryngology departments was acquired from the American Medical Association’s Fellowship and Residency Electronic Interactive Database (FREIDA). An online search was conducted for faculty listings from the 99 civilian programs located in the continental US available from the FREIDA database. One program did not have a website with faculty listing and was excluded. Academic rank and fellowship training status were recorded from these online sites. Non-physician faculty, part-time nonacademic faculty, and faculty for whom academic rank and fellowship status could not be reliably determined were excluded. Two authors (PFS and KMM) determined gender from faculty listings using a combination of names and photos on online faculty listings. Faculty members were further organized by institutional location using US Census Bureau designated regions and divisions (Table 1). The Scopus database (www.scopus.com) was used to obtain the following bibliometric values for all authors: (1) h-index, (2) number of publications, (3) publication range in years. For multiple authors with frequently found names, such as Smith or Brown, the following characteristics were assessed to differentiate authors: (1) journal type in which manuscripts were featured (ie, otolaryngology or surgical journals vs unassociated medical fields) and (2) departmental affiliations listed on Scopus. Additionally, a timeadjusted correction factor to the h-index, the E-Factor, was calculated employing bibliometrics obtained from Scopus with the following equation: E-Factor = h-index 1 (# of publications/publication range in years). The E-Factor has been previously used to characterize scholarly impact among fellowship-trained rhinologists.10 Statistical analysis was performed using Mann-Whitney U-tests for comparison of continuous variables and
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Proportion of Faculty by Academic Rank (% of Total)
Faculty # 916 211
231 42
234 54
306 83
145 34
100%
*
16% 24%
80%
36%
*
37%
24%
13%
32%
*
*
24%
*
26% 41% 27%
36%
26%
60%
11%
11%
28%
20%
*
32%
25%
21%
40%
76% 63%
60% 50%
20% 0%
44%
40%
38%
Overall
Midwest
Northeast
40%
South
38%
41%
West
US Census Bureau Regions
Professor
Associate Professor
Assistant Professor
Figure 1. Gender representation by academic rank organized by location. Left bars in each pair represents male faculty; right bars represent female faculty.
Pearson’s chi square test for comparison of categorical values, with threshold for significance set at P \ .05. All statistical calculations were conducted using SPSSv20 (IBM Corp, Armonk, New York). Data were collected between November 2012 and January 2013. Per the Institutional Review Board of Rutgers New Jersey Medical School, this study qualified as nonhuman subject research.
Results Out of 98 academic departments, 1127 otolaryngologists—916 men (81.3%) and 211 women (18.7%)—were included in this analysis. Women comprised 15.4% of faculty in the Midwest, 18.8% of faculty in the Northeast, 21.3% of faculty in the South, and 19.0% of faculty in the West (P = .44). Overall, 59.8% of men were faculty at senior academic ranks (associate professor or professor), significantly higher than the 40.2% of women serving at these ranks (P \ .0001) (Figure 1). There was no statistical difference in representation at senior versus junior academic rank between men and women in the West (62.1% vs 58.8%, P = 0.73) and in the Midwest (P = .14). However, in the South, 59.8% of male faculty were at senior academic ranks versus 37.3% of female faculty (P = .0003), and the greatest gender difference in representation at senior academic rank was among faculty in the Northeast (56.4% of men vs 24.1% of women, P \ .0001).
Further broken down by US Census Bureau designated geographic divisions, female representation at senior academic ranks was lowest in the Mid-Atlantic (22.0%), New England (30.8%), and the West South Central (33.3%) (Figure 2). In contrast, female representation at senior academic ranks was highest in the Pacific (60.0%) and Mountain (71.4%) divisions. Male faculty, on the other hand, had higher representation at senior academic ranks in all of these geographic divisions with the exception of departments located in the Mountain division (Figure 3). Although 53.0% of men in the Mountain division served at senior academic ranks, compared to 71.4% of women, this difference did not reach statistical significance (P = .32). Regional gender variations in research productivity were found using several bibliometrics. Gender differences in scholarly impact, as measured by the h-index, were statistically significant among academic otolaryngologists in the South (P = .0003) and Northeast (P = .0001) (Figure 4A). The greatest difference in h-index was noted in the Northeast (Dh = 3.92). There were no statistical gender differences in scholarly impact, as measured by the h-index, among otolaryngologists in the West (P = .11) and Midwest (P = .30) with the latter having the smallest difference in h-index (Dh = 1.39). Statistical gender differences in the E-Factor were noted among otolaryngologists in the South (DE = 3.9, P = .0002)
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Otolaryngology–Head and Neck Surgery 150(3) Out of 1127 otolaryngologists in this sample, 857 (76.0%) had completed post-residency fellowship training, including 75.3% of women and 76.2% of men. Although there were no differences at the level of assistant and associate professor, fellowship-trained otolaryngologists of both genders were more likely to serve at the level of professor (33.5%) than non–fellowship-trained practitioners (27.4%), a trend bordering statistical significance (P = .06). Upon further examination by geographic region, there were no statistically significant differences in fellowship-training patterns between men and women (P-values . .05).
Discussion Figure 2. Dorling cartogram illustrating geographic promotion trends among females by US Census Bureau division. Each circle is proportional percentage of faculty that is female. West South Central represents 25.6%, to which other regions are relatively scaled.
Figure 3. Dorling cartogram illustrating geographic promotion trends among males by US Census Bureau division. Each circle is proportional to the percentage of faculty that is male. West North Central represents 85.3%, to which other regions are relatively scaled.
and Northeast (DE = 4.8, P \ .0001), while gender differences did not reach statistical significance in the Midwest (P = .24) and West (P = .06) (Figure 4B). Gender differences in number of publications were found among all regions (P-values \ .05) and were greatest among otolaryngologists in the Northeast (D in publications = 30.0) (Figure 4C). Publication range in years revealed regional gender variations (Figure 4D). In the Northeast, men had a statistically greater publication range than women by 6.5 years (P = .0001). Smaller but statistically significant gender differences were also present among practitioners in the Midwest (P = .049) and South (P = .0003). Difference in publication range did not reach statistical significance among otolaryngologists in the West (P = .19).
Until 1970, less than 10% of graduates from accredited US medical schools were women.14 The interplay of multiple influences including the Women’s Liberation Movement, passage of the Civil Rights and Equal Employment Opportunity Acts, increases in female baby boomers graduating from college, and overall rising numbers of available positions in medical school, propagated a dramatic increase in the proportion of women pursuing careers in medicine after 1970.14,15 Women now represent nearly half of graduates at all LCME-accredited US medical schools.14 Although there has been a rise in the number of women in surgical residencies, the growth is not proportional to that observed in the female medical student ratio.16,17 Females are still underrepresented in surgical specialties as they disproportionately select primary care and nonsurgical careers.3,16-19 In 2010, women comprised 36% of general surgery residents, 26% of plastic surgery residents, and less than 15% of neurological surgery and orthopedic surgery residents.20 Representation of female residents in otolaryngology quadrupled from 8% in 1980 to 32% in 2010.20-22 Women are also underrepresented in academic surgery, particularly in positions of leadership.1-3 It has been shown that female academic surgeons are paid significantly lower salaries than their male colleagues, that the increasing rate of female surgeons attaining full professorship is disproportionately slower than the rise of female medical students and surgery residents, and that women are far less likely to attain leadership roles such as departmental chair or division chief.1,3,21,23,24 In a recent 2011 analysis of academic otolaryngology departments, only 4 of the 103 Accreditation Council for Graduate Medical Education (ACGME)–accredited academic otolaryngology residency programs had female chairs and less than 15% had female program directors.21 In this analysis, men were found to obtain significantly higher senior academic ranks overall compared to women (Figure 1). This finding is consistent with a previous analysis of scholarly productivity within academic otolaryngology departments, in which women comprised 24% of assistant professors, 20% of associate professors, and only 12% of full professors among 1054 academic otolaryngologists.5 The underrepresentation of women in positions of leadership may be attributable, in part, to scholarly productivity, which is largely determined by research output. In examining research productivity, we have reported that men demonstrate higher
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Figure 4. Bibliometrics by geographic region and gender; error bars represent standard error of the mean; asterisks denote statistical significance (Mann-Whitney U-tests, P \.05). MW, Midwest; W, West; NE, Northeast; S, South.
total research contributions as measured by the h-index.5 However, assessment of research output over time of active research years revealed that women demonstrate a different productivity curve than their male counterparts, with greater productivity later in their careers.5 The tension in balancing personal and professional interests and family planning may contribute to the delayed productivity curve observed in women. It has been shown that despite equivalent work hours, female physicians, both surgeon and non-surgeon, devote more than double the time than male physicians on child care and household responsibilities.25-29 Considering the effects of advanced maternal age on female infertility and fetal health, women are encouraged to become pregnant during their prime childbearing years, which traditionally coincide with the periods of surgical residency and early career growth. For female surgeons that defer childbearing until after residency training, more pursue parental leave than their male counterparts, ultimately influencing career advancement.27,30 In addition to family considerations, lack of mentorship3,31-33 and greater didactic responsibilities in lieu of devoted research time3,5,34 are also attributed to the underrepresentation of women in academic surgery. In this analysis, female otolaryngologists produced fewer publications in all
regions, with the greatest gender difference observed in the Northeast (Figure 4C). In all regions except the West, male otolaryngologists published over significantly longer time periods than women (Figure 4D). Gender differences regarding number of publications and publication range in years among academic otolaryngologists may reflect the limitations women may have to committed research time and the discrepancies in career trajectories between male and female faculty. As described previously, women demonstrate a greater rate of productivity later in their careers. As women continue to accumulate experience, it is possible that the extent of regional and gender disparities in scholarly productivity will diminish. Although there are likely fewer numbers of women than men at each academic rank with adequate years of experience required for promotion,35 current promotion practices, which are intrinsically linked to scholarly output, are nevertheless biased toward early productivity, possibly limiting career advancement to positions of leadership for women. Differences were found in gender promotion among academic otolaryngologists by examining regions of the Midwest, Northeast, South, and West (Figure 1). Regions with the most profound deficits in women at senior academic
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ranks (associate professor or professor) were the South and Northeast (Figure 1), with parallel disparities in scholarly impact as measured by the h-index (Figure 4A) and its timeadjusted correction factor, the E-Factor (Figure 4B). Concomitant gender disparities in academic rank and scholarly impact suggests that factors influencing or limiting research productivity may play a greater role in these regions compared to the West and Midwest. In a previous study of geographic differences in academic promotions practices, we reported that otolaryngologists in the West had higher research output compared to other regions as well as one of the highest proportions of faculty at senior ranks,36 emphasizing the impact of scholarly productivity on academic promotion. Geographic promotion trends among academic male otolaryngologists revealed greater representation in senior academic ranks throughout all US Census Bureau divisions, except for Mountain states (Figure 3). Divisions with the lowest proportion of women at senior academic ranks were found in the Northeast, most strikingly in the Mid-Atlantic and New England (Figure 2). In contrast, the proportion of women at senior academic ranks was highest in the Western regions of the Pacific and Mountain divisions. Of note, interpretation of female representation among academic otolaryngologists in Mountain states may be limited considering only 5 programs from this division were recorded on the FRIEDA directory. Of the programs found, only 3 featured comprehensive faculty listings from which 5 of 7 female faculty members were associate or full professors. Nevertheless, given the totality of female representation among Pacific and Mountain divisions as a whole, the lack of gender disparities in academic rank and scholarly productivity in these areas is notable and significant. Taken together, the results of this analysis indicate that although gender disparities in academic rank and scholarly productivity exist regionally, women in otolaryngology are the least promoted to senior academic ranks in the Northeast. Given the demands of women toward family and household duties, factors such as lower earning potential relative to men, higher cost of living, greater child care costs, and longer commute times may influence the productivity curve for women in the Northeast.37-40 According to a report by Child Care Aware of America (formerly the National Association of Child Care Research and Referral Agencies), half of the top 10 least affordable states for child care are found in the Northeast.40 In a nationwide study of more than 3700 mothers, the needs of children, cost of child care, and insufficient earning potential were the 3 greatest factors cited by career-oriented at-home mothers in their decision to stop working.41 For working mothers in the Northeast, time spent behind the desk is as significant as time spent behind the wheel. In a 2011 US Census Bureau American Community Survey Report, the Northeast showed the greatest proportion of states having the highest rates of long commutes to work, with New York and New Jersey among the top states in the country.40 In the report, long commutes was defined as 60 minutes or longer (one way), considerably greater than the national average travel time of 25.5 minutes
Although the h-index quantifies research relevance and productivity, the metric contains several limitations. The hindex does not account for author order in or relative contributions to a manuscript.8 In addition, the h-index does not differentiate the type of research conducted.7,8 Basic science research, for example, that is resource and time intensive may generate significant results, though at a slower rate than clinical research. In this regard, the h-index of a physician-scientist devoted to the lab may lag behind her counterpart in the clinic. Another limitation of this analysis is the use of FRIEDA to acquire faculty listings, from which gender, regional, academic rank, and fellowship training analyses were conducted. Although FREIDA contains information for a majority of otolaryngology programs, the database is not unequivocally complete. There was 1 of 99 programs for which comprehensive faculty data was not available. Given this is a single program it likely did not have a significant impact on our results though it does represent a limitation of this study. Absence of data from particular programs in certain regions may influence the regional differences found in gender promotion and scholarly productivity.
Conclusion Gender disparities in academic rank and scholarly productivity exist regionally. This disparity was most pronounced in the Northeast where women in otolaryngology are most underrepresented relative to men at senior academic ranks and in scholarly productivity. These findings suggest that regionally specific gender barriers affecting women in academic otolaryngology need to be addressed before equality in promotion and scholarly activity can be expected. Author Contributions Jean Anderson Eloy, conception, design, analysis, and interpretation; drafting and revision of article; final approval; Leila J. Mady, analysis, drafting of article, final approval; Peter F. Svider, data acquisition, analysis; drafting of article; final approval; Kevin M. Mauro, data acquisition, analysis; drafting of article; final approval; Evelyne Kalyoussef, analysis, revision, final approval; Michael Setzen, analysis, revision, final approval; Soly Baredes, analysis, revision, final approval; Sujana S. Chandrasekhar, analysis, revision, final approval.
Disclosures Competing interests: Michael Setzen, speaker for TEVA and MEDA on their Speakers Bureau (not related to current study); Sujana S. Chandrasekhar, shareholder and board member, Scientific Development & Research, Inc (not related to current subject). Sponsorships: None. Funding source: None.
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Regional Differences in Gender Promotion and Scholarly Productivity in Otolaryngology
Otolaryngology– Head and Neck Surgery 2014, Vol. 150(3) 371–377 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2013 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599813515183 http://otojournal.org
Jean Anderson Eloy, MD1,2,3, Leila J. Mady, PhD1, Peter F. Svider, MD4, Kevin M. Mauro1, Evelyne Kalyoussef, MD1, Michael Setzen, MD5,6, Soly Baredes, MD1,3, and Sujana S. Chandrasekhar, MD7
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Abstract Objectives. To identify whether regional differences exist in gender disparities in scholarly productivity and faculty rank among academic otolaryngologists. Study Design and Setting. Academic otolaryngologists’ bibliometric data analyses. Methods. Online faculty listings from 98 otolaryngology departments were organized by gender, academic rank, fellowship training status, and institutional location. The Scopus database was used to assess bibliometrics of these otolaryngologists, including the h-index, number of publications, and publication experience. Results. Analysis included 1127 otolaryngologists, 916 men (81.3%) and 211 women (18.7%). Female faculty comprised 15.4% in the Midwest, 18.8% in the Northeast, 21.3% in the South, and 19.0% in the West (P = .44). Overall, men obtained significantly higher senior academic ranks (associate professor or professor) compared to women (59.8% vs 40.2%, P \ .0001). Regional gender differences in senior faculty were found in the South (59.8% men vs 37.3% women, P = .0003) and Northeast (56.4% men vs 24.1% women, P \ .0001) with concomitant gender differences in scholarly impact, as measured by the h-index (South, P = .0003; Northeast, P = .0001). Among geographic subdivisions, female representation at senior ranks was lowest in the Mid-Atlantic (22.0%), New England (30.8%), and West South Central (33.3%), while highest in Pacific (60.0%) and Mountain (71.4%) regions. No regional gender differences were found in fellowship training patterns (P-values . .05). Conclusion. Gender disparities in academic rank and scholarly productivity exist most notably in the Northeast, where women in otolaryngology are most underrepresented relative to men at senior academic ranks and in scholarly productivity.
Keywords h-index, gender disparities, academic promotion, scholarly productivity, academic physician scientific productivity, academic rank determination, regional gender disparities, gender and promotion, gender and academic rank, gender and scholarly productivity Received August 23, 2013; revised October 21, 2013; accepted November 12, 2013.
Introduction Despite the increasing presence of women in general and subspecialty surgical practice, the advancement of women in academic surgery, particularly in positions of leadership, is notably limited.1-3 This is undoubtedly a complex, multifactorial phenomenon influenced by clinical and educational performance metrics, external funding awards granted, as well as psychosocial attitudes involving traditional gender 1
Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA 2 Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA 3 Center for Skull Base and Pituitary Surgery, Neurological Institute of New Jersey, Rutgers New Jersey Medical School, Newark, New Jersey, USA 4 Department of Otolaryngology–Head and Neck Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA 5 Rhinology Section, North Shore University Hospital, Manhasset, New York, USA 6 Department of Otolaryngology, New York University School of Medicine New York, New York, USA. 7 New York Otology, New York Head and Neck Institute, North Shore LIJ Healthcare, Mount Sinai School of Medicine, New York, New York, USA This article was presented at the 2013 AAO-HNSF Annual Meeting & OTO EXPO; September 29–October 3, 2013; Vancouver, Canada. Corresponding Author: Jean Anderson Eloy, MD, Associate Professor and Vice Chairman, Director, Rhinology and Sinus Surgery, Co-Director, Endoscopic Skull Base Surgery Program, Department of Otolaryngology–Head and Neck Surgery, Rutgers New Jersey Medical School, 90 Bergen St., Suite 8100, Newark, NJ 07103, USA. Email: [email protected]
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Table 1. United States Census Bureau Regions and Divisions.a Regions
Divisions
States
Midwest
West North Central East North Central Middle Atlantic New England Pacific Mountain South Atlantic
North Dakota, South Dakota, Nebraska, Kansas, Iowa, Minnesota, Missouri Wisconsin, Michigan, Illinois, Indiana, Ohio New York, New Jersey, Pennsylvania Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont Alaska, California, Hawaii, Oregon, Washington Arizona, Colorado, Idaho, New Mexico, Montana, Utah, Nevada, Wyoming Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia Alabama, Kentucky, Mississippi, Tennessee Arkansas, Louisiana, Oklahoma, Texas
Northeast West South
East South Central West South Central a
Geographic divisions obtained from the US Census Bureau, accessed January 20, 2013 at: https://www.census.gov/geo/www/us_regdiv.pdf.
roles and gender discrimination in the medical milieu.3-6 Decisions regarding academic advancement may be influenced by scholarly productivity, as measured by research output. Research productivity may be commonly assessed by tabulation of an author’s total number of publications and total citations.7-9 These absolute metrics, however, fail to capture the nuances of an author’s academic influence such as scholarly impact, relevance to the field, and relative contribution of each publication within an author’s repertoire.7-12 In contrast to absolute number of publications, the h-index, first described by Dr J. E. Hirsch in 2005, attempts to quantify research relevance and productivity.7 An author’s h-index is valued as the number of published papers, h, that have been cited at least h times in peer-reviewed literature. For example, consider an author with 100 total publications, of which 10 have been cited at least 10 times. The author’s h-index in this case is 10. Consider another author with 50 publications, of which 20 have been cited at least 20 times. Here, the author’s h-index is 20. Though the former is twice as prolific in absolute number of publications, the latter has double the h-index, suggesting an overall greater contribution to academic research that is not reflected when considering publication sums alone. Using the h-index to evaluate academic otolaryngologists, a previous analysis reported that although males demonstrate higher overall research contributions, females exhibit a different productivity curve, with less productivity early on, but matching and exceeding their male counterparts both in publications and impact rate later in their careers.5 Another analysis also reported that independent of career longevity, gender disparities exist in grant funding among otolaryngology departments, as males had higher National Institutes of Health (NIH) funding levels as well as a larger proportion of R-series grants than females in fiscal years 2011 and 2012.13 These findings may contribute to the current gender gap in academic otolaryngology. Though gender disparities in research productivity and faculty rank among academic otolaryngologists have been previously described, there has been no analysis of regional trends in gender promotion and scholarly impact. This study aims to identify whether there are regional differences in
gender promotion and scholarly impact among academic otolaryngologists. Geographic variations may shed light on factors that propagate gender differences, particularly at levels of academic leadership.
Materials and Methods A list of academic otolaryngology departments was acquired from the American Medical Association’s Fellowship and Residency Electronic Interactive Database (FREIDA). An online search was conducted for faculty listings from the 99 civilian programs located in the continental US available from the FREIDA database. One program did not have a website with faculty listing and was excluded. Academic rank and fellowship training status were recorded from these online sites. Non-physician faculty, part-time nonacademic faculty, and faculty for whom academic rank and fellowship status could not be reliably determined were excluded. Two authors (PFS and KMM) determined gender from faculty listings using a combination of names and photos on online faculty listings. Faculty members were further organized by institutional location using US Census Bureau designated regions and divisions (Table 1). The Scopus database (www.scopus.com) was used to obtain the following bibliometric values for all authors: (1) h-index, (2) number of publications, (3) publication range in years. For multiple authors with frequently found names, such as Smith or Brown, the following characteristics were assessed to differentiate authors: (1) journal type in which manuscripts were featured (ie, otolaryngology or surgical journals vs unassociated medical fields) and (2) departmental affiliations listed on Scopus. Additionally, a timeadjusted correction factor to the h-index, the E-Factor, was calculated employing bibliometrics obtained from Scopus with the following equation: E-Factor = h-index 1 (# of publications/publication range in years). The E-Factor has been previously used to characterize scholarly impact among fellowship-trained rhinologists.10 Statistical analysis was performed using Mann-Whitney U-tests for comparison of continuous variables and
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Proportion of Faculty by Academic Rank (% of Total)
Faculty # 916 211
231 42
234 54
306 83
145 34
100%
*
16% 24%
80%
36%
*
37%
24%
13%
32%
*
*
24%
*
26% 41% 27%
36%
26%
60%
11%
11%
28%
20%
*
32%
25%
21%
40%
76% 63%
60% 50%
20% 0%
44%
40%
38%
Overall
Midwest
Northeast
40%
South
38%
41%
West
US Census Bureau Regions
Professor
Associate Professor
Assistant Professor
Figure 1. Gender representation by academic rank organized by location. Left bars in each pair represents male faculty; right bars represent female faculty.
Pearson’s chi square test for comparison of categorical values, with threshold for significance set at P \ .05. All statistical calculations were conducted using SPSSv20 (IBM Corp, Armonk, New York). Data were collected between November 2012 and January 2013. Per the Institutional Review Board of Rutgers New Jersey Medical School, this study qualified as nonhuman subject research.
Results Out of 98 academic departments, 1127 otolaryngologists—916 men (81.3%) and 211 women (18.7%)—were included in this analysis. Women comprised 15.4% of faculty in the Midwest, 18.8% of faculty in the Northeast, 21.3% of faculty in the South, and 19.0% of faculty in the West (P = .44). Overall, 59.8% of men were faculty at senior academic ranks (associate professor or professor), significantly higher than the 40.2% of women serving at these ranks (P \ .0001) (Figure 1). There was no statistical difference in representation at senior versus junior academic rank between men and women in the West (62.1% vs 58.8%, P = 0.73) and in the Midwest (P = .14). However, in the South, 59.8% of male faculty were at senior academic ranks versus 37.3% of female faculty (P = .0003), and the greatest gender difference in representation at senior academic rank was among faculty in the Northeast (56.4% of men vs 24.1% of women, P \ .0001).
Further broken down by US Census Bureau designated geographic divisions, female representation at senior academic ranks was lowest in the Mid-Atlantic (22.0%), New England (30.8%), and the West South Central (33.3%) (Figure 2). In contrast, female representation at senior academic ranks was highest in the Pacific (60.0%) and Mountain (71.4%) divisions. Male faculty, on the other hand, had higher representation at senior academic ranks in all of these geographic divisions with the exception of departments located in the Mountain division (Figure 3). Although 53.0% of men in the Mountain division served at senior academic ranks, compared to 71.4% of women, this difference did not reach statistical significance (P = .32). Regional gender variations in research productivity were found using several bibliometrics. Gender differences in scholarly impact, as measured by the h-index, were statistically significant among academic otolaryngologists in the South (P = .0003) and Northeast (P = .0001) (Figure 4A). The greatest difference in h-index was noted in the Northeast (Dh = 3.92). There were no statistical gender differences in scholarly impact, as measured by the h-index, among otolaryngologists in the West (P = .11) and Midwest (P = .30) with the latter having the smallest difference in h-index (Dh = 1.39). Statistical gender differences in the E-Factor were noted among otolaryngologists in the South (DE = 3.9, P = .0002)
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Otolaryngology–Head and Neck Surgery 150(3) Out of 1127 otolaryngologists in this sample, 857 (76.0%) had completed post-residency fellowship training, including 75.3% of women and 76.2% of men. Although there were no differences at the level of assistant and associate professor, fellowship-trained otolaryngologists of both genders were more likely to serve at the level of professor (33.5%) than non–fellowship-trained practitioners (27.4%), a trend bordering statistical significance (P = .06). Upon further examination by geographic region, there were no statistically significant differences in fellowship-training patterns between men and women (P-values . .05).
Discussion Figure 2. Dorling cartogram illustrating geographic promotion trends among females by US Census Bureau division. Each circle is proportional percentage of faculty that is female. West South Central represents 25.6%, to which other regions are relatively scaled.
Figure 3. Dorling cartogram illustrating geographic promotion trends among males by US Census Bureau division. Each circle is proportional to the percentage of faculty that is male. West North Central represents 85.3%, to which other regions are relatively scaled.
and Northeast (DE = 4.8, P \ .0001), while gender differences did not reach statistical significance in the Midwest (P = .24) and West (P = .06) (Figure 4B). Gender differences in number of publications were found among all regions (P-values \ .05) and were greatest among otolaryngologists in the Northeast (D in publications = 30.0) (Figure 4C). Publication range in years revealed regional gender variations (Figure 4D). In the Northeast, men had a statistically greater publication range than women by 6.5 years (P = .0001). Smaller but statistically significant gender differences were also present among practitioners in the Midwest (P = .049) and South (P = .0003). Difference in publication range did not reach statistical significance among otolaryngologists in the West (P = .19).
Until 1970, less than 10% of graduates from accredited US medical schools were women.14 The interplay of multiple influences including the Women’s Liberation Movement, passage of the Civil Rights and Equal Employment Opportunity Acts, increases in female baby boomers graduating from college, and overall rising numbers of available positions in medical school, propagated a dramatic increase in the proportion of women pursuing careers in medicine after 1970.14,15 Women now represent nearly half of graduates at all LCME-accredited US medical schools.14 Although there has been a rise in the number of women in surgical residencies, the growth is not proportional to that observed in the female medical student ratio.16,17 Females are still underrepresented in surgical specialties as they disproportionately select primary care and nonsurgical careers.3,16-19 In 2010, women comprised 36% of general surgery residents, 26% of plastic surgery residents, and less than 15% of neurological surgery and orthopedic surgery residents.20 Representation of female residents in otolaryngology quadrupled from 8% in 1980 to 32% in 2010.20-22 Women are also underrepresented in academic surgery, particularly in positions of leadership.1-3 It has been shown that female academic surgeons are paid significantly lower salaries than their male colleagues, that the increasing rate of female surgeons attaining full professorship is disproportionately slower than the rise of female medical students and surgery residents, and that women are far less likely to attain leadership roles such as departmental chair or division chief.1,3,21,23,24 In a recent 2011 analysis of academic otolaryngology departments, only 4 of the 103 Accreditation Council for Graduate Medical Education (ACGME)–accredited academic otolaryngology residency programs had female chairs and less than 15% had female program directors.21 In this analysis, men were found to obtain significantly higher senior academic ranks overall compared to women (Figure 1). This finding is consistent with a previous analysis of scholarly productivity within academic otolaryngology departments, in which women comprised 24% of assistant professors, 20% of associate professors, and only 12% of full professors among 1054 academic otolaryngologists.5 The underrepresentation of women in positions of leadership may be attributable, in part, to scholarly productivity, which is largely determined by research output. In examining research productivity, we have reported that men demonstrate higher
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Figure 4. Bibliometrics by geographic region and gender; error bars represent standard error of the mean; asterisks denote statistical significance (Mann-Whitney U-tests, P \.05). MW, Midwest; W, West; NE, Northeast; S, South.
total research contributions as measured by the h-index.5 However, assessment of research output over time of active research years revealed that women demonstrate a different productivity curve than their male counterparts, with greater productivity later in their careers.5 The tension in balancing personal and professional interests and family planning may contribute to the delayed productivity curve observed in women. It has been shown that despite equivalent work hours, female physicians, both surgeon and non-surgeon, devote more than double the time than male physicians on child care and household responsibilities.25-29 Considering the effects of advanced maternal age on female infertility and fetal health, women are encouraged to become pregnant during their prime childbearing years, which traditionally coincide with the periods of surgical residency and early career growth. For female surgeons that defer childbearing until after residency training, more pursue parental leave than their male counterparts, ultimately influencing career advancement.27,30 In addition to family considerations, lack of mentorship3,31-33 and greater didactic responsibilities in lieu of devoted research time3,5,34 are also attributed to the underrepresentation of women in academic surgery. In this analysis, female otolaryngologists produced fewer publications in all
regions, with the greatest gender difference observed in the Northeast (Figure 4C). In all regions except the West, male otolaryngologists published over significantly longer time periods than women (Figure 4D). Gender differences regarding number of publications and publication range in years among academic otolaryngologists may reflect the limitations women may have to committed research time and the discrepancies in career trajectories between male and female faculty. As described previously, women demonstrate a greater rate of productivity later in their careers. As women continue to accumulate experience, it is possible that the extent of regional and gender disparities in scholarly productivity will diminish. Although there are likely fewer numbers of women than men at each academic rank with adequate years of experience required for promotion,35 current promotion practices, which are intrinsically linked to scholarly output, are nevertheless biased toward early productivity, possibly limiting career advancement to positions of leadership for women. Differences were found in gender promotion among academic otolaryngologists by examining regions of the Midwest, Northeast, South, and West (Figure 1). Regions with the most profound deficits in women at senior academic
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ranks (associate professor or professor) were the South and Northeast (Figure 1), with parallel disparities in scholarly impact as measured by the h-index (Figure 4A) and its timeadjusted correction factor, the E-Factor (Figure 4B). Concomitant gender disparities in academic rank and scholarly impact suggests that factors influencing or limiting research productivity may play a greater role in these regions compared to the West and Midwest. In a previous study of geographic differences in academic promotions practices, we reported that otolaryngologists in the West had higher research output compared to other regions as well as one of the highest proportions of faculty at senior ranks,36 emphasizing the impact of scholarly productivity on academic promotion. Geographic promotion trends among academic male otolaryngologists revealed greater representation in senior academic ranks throughout all US Census Bureau divisions, except for Mountain states (Figure 3). Divisions with the lowest proportion of women at senior academic ranks were found in the Northeast, most strikingly in the Mid-Atlantic and New England (Figure 2). In contrast, the proportion of women at senior academic ranks was highest in the Western regions of the Pacific and Mountain divisions. Of note, interpretation of female representation among academic otolaryngologists in Mountain states may be limited considering only 5 programs from this division were recorded on the FRIEDA directory. Of the programs found, only 3 featured comprehensive faculty listings from which 5 of 7 female faculty members were associate or full professors. Nevertheless, given the totality of female representation among Pacific and Mountain divisions as a whole, the lack of gender disparities in academic rank and scholarly productivity in these areas is notable and significant. Taken together, the results of this analysis indicate that although gender disparities in academic rank and scholarly productivity exist regionally, women in otolaryngology are the least promoted to senior academic ranks in the Northeast. Given the demands of women toward family and household duties, factors such as lower earning potential relative to men, higher cost of living, greater child care costs, and longer commute times may influence the productivity curve for women in the Northeast.37-40 According to a report by Child Care Aware of America (formerly the National Association of Child Care Research and Referral Agencies), half of the top 10 least affordable states for child care are found in the Northeast.40 In a nationwide study of more than 3700 mothers, the needs of children, cost of child care, and insufficient earning potential were the 3 greatest factors cited by career-oriented at-home mothers in their decision to stop working.41 For working mothers in the Northeast, time spent behind the desk is as significant as time spent behind the wheel. In a 2011 US Census Bureau American Community Survey Report, the Northeast showed the greatest proportion of states having the highest rates of long commutes to work, with New York and New Jersey among the top states in the country.40 In the report, long commutes was defined as 60 minutes or longer (one way), considerably greater than the national average travel time of 25.5 minutes
Although the h-index quantifies research relevance and productivity, the metric contains several limitations. The hindex does not account for author order in or relative contributions to a manuscript.8 In addition, the h-index does not differentiate the type of research conducted.7,8 Basic science research, for example, that is resource and time intensive may generate significant results, though at a slower rate than clinical research. In this regard, the h-index of a physician-scientist devoted to the lab may lag behind her counterpart in the clinic. Another limitation of this analysis is the use of FRIEDA to acquire faculty listings, from which gender, regional, academic rank, and fellowship training analyses were conducted. Although FREIDA contains information for a majority of otolaryngology programs, the database is not unequivocally complete. There was 1 of 99 programs for which comprehensive faculty data was not available. Given this is a single program it likely did not have a significant impact on our results though it does represent a limitation of this study. Absence of data from particular programs in certain regions may influence the regional differences found in gender promotion and scholarly productivity.
Conclusion Gender disparities in academic rank and scholarly productivity exist regionally. This disparity was most pronounced in the Northeast where women in otolaryngology are most underrepresented relative to men at senior academic ranks and in scholarly productivity. These findings suggest that regionally specific gender barriers affecting women in academic otolaryngology need to be addressed before equality in promotion and scholarly activity can be expected. Author Contributions Jean Anderson Eloy, conception, design, analysis, and interpretation; drafting and revision of article; final approval; Leila J. Mady, analysis, drafting of article, final approval; Peter F. Svider, data acquisition, analysis; drafting of article; final approval; Kevin M. Mauro, data acquisition, analysis; drafting of article; final approval; Evelyne Kalyoussef, analysis, revision, final approval; Michael Setzen, analysis, revision, final approval; Soly Baredes, analysis, revision, final approval; Sujana S. Chandrasekhar, analysis, revision, final approval.
Disclosures Competing interests: Michael Setzen, speaker for TEVA and MEDA on their Speakers Bureau (not related to current study); Sujana S. Chandrasekhar, shareholder and board member, Scientific Development & Research, Inc (not related to current subject). Sponsorships: None. Funding source: None.
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