INTRODUCTION

According to the most recent data from the American Association of Medical Colleges (AAMC), women comprise 42.3% of medical school faculty, but only 26% of full professors, and 19% of medical school department chairs. Women are over-represented in the lower ranks of academic medicine, making up 59% of faculty filling instructor positions.1 Further, Black/African American and Hispanic/Latino/of Spanish Descent faculty comprise only 6.9% of faculty overall, 4.6% of full professors, and 7.3% of department chairs.1 Given that 31.5% of the US population is African American and/or Latino,2 these numbers are alarmingly low.

Potential causes and implications have been explored at length in numerous studies, but concrete answers are scarce.3, 4 Literature is replete with theories, including the paucity of mentoring,4, 5 less robust negotiation skills, particularly with regard to women faculty,6 and fewer members of underrepresented groups at lower levels of the pipeline of academic medicine.7 Yet, even when accounting for these and other factors, a gap exists between majority men and both women and underrepresented minorities.3, 4, 7,8,9 While quantitative data is needed to track progress toward increasing the numbers of women and racial/ethnic minorities who are underrepresented in medicine (URiM), qualitative methods offer insight into lived experiences and allow for open-ended feedback. This combination is crucial to understanding the biases, institutional norms, unspoken assumptions, and systemic racism that reinforce systems of implicit (or unintentional) inequality. Understanding and addressing these issues are taking on increasing importance in the wake of numerous deaths of African Americans in police custody and the ensuing protests that have spread across the USA. Although racism within health care as an institution has been documented for many years,10,11,12 eliminating it has taken on heightened importance in light of recent calls by medical and health organizations to address it as an urgent and critical matter.13

It is not surprising that demographic groups have different perspectives. Previous qualitative studies have examined academic advancement from the perspectives of women and racial/ethnic minorities, but very few have included the perspective of majority males.14,15,16,17 When one group, in this case white males, hold outsized power and influence, we risk basing recommendations for progress on incomplete or inaccurate data if we do not understand the degree to which majority males see their over-representation in positions of power as an issue. We further need to understand the factors to which they attribute their relative over-representation, for example, personal (e.g., work ethic, sacrifice), interpersonal (e.g., networking, mentoring), or institutional (e.g., leaky leadership pipelines, institutional policies, organizational culture), and what role they feel they should or should not play in addressing their relative over-representation.

Because of the lack of representation of women and racial/ethnic minority faculty at the highest levels of academic medicine, this study examines the perceptions of barriers to advancement by men and women academic medical school faculty of differing races and ethnicities. Complementing the extant research which primarily examines the perspectives of URiM and women faculty, the purpose of the current study is to address perceptions of barriers to academic advancement among faculty who are both under- and over-represented in academic medicine.

METHODS

Hurtado et al.18 suggest that factors unique to each institution go into creating its “institutional climate.” These include the historical legacy of inclusion/exclusion (resistance to desegregation, mission, policies), structural diversity (numbers of diverse students and faculty), psychological climate (perceptions of racial/ethnic tension, perceptions of discrimination and attitudes of reduction of prejudice), and the behavioral dimension (social interaction across racial/ethnic groups, campus involvement and diversity, and classroom diversity). In order for programs to be effective in eliminating disparities in faculty advancement, we posit that the institutional climate must be examined through the lens of both over- and underrepresented faculty members.

This study was conducted at a single medical school in the Southeast employing 1300 faculty and the study protocol was approved by the Institutional Review Board of the university (see Table 1 for faculty demographics by rank). Because we wanted to give all faculty (regardless of rank or demographic group) the opportunity to participate, a recruitment email was sent in July 2017 to the School of Medicine faculty listserv, inviting all faculty members, both clinical and research, to participate in a 1 h or less, confidential face-to-face interview examining the institutional climate for diversity and perceived barriers and facilitators to advancement of women and URiM medical school faculty. Informed consent was obtained from all participants and a $50 incentive was offered for participation. Sixty-four faculty consented to participate (56.2% women, 34.4% URiM) (see Table 2 for participant demographics by rank).

Table 1 School of Medicine Faculty Demographics by Rank (%)19
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Table 2 Participants by Rank, Gender, and Race/Ethnicity
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Six interviewers conducted interviews between July and September 2017. When possible, interviewers were matched with participants with whom they were race and gender concordant, to make participants as comfortable as possible and minimize perceived power differentials between interviewer and interviewee. The interview guide was based on the Institutional Climate for Diversity,18 previous studies reported in the literature, and analysis of comments from a recent AAMC-developed Diversity Engagement Survey conducted at the institution (see Appendix 1 for interview guide). In order to maintain a conversational style, however, new themes brought up by participants were pursued. Advancement was defined as moving up in academic rank (from assistant to associate to full professor) or moving into leadership positions within the institution.

Interviews were audio recorded, transcribed, and stored electronically on a password-protected university storage site. Identifying information was removed from the transcripts and participants were assigned study numbers. Coding and analysis were overseen by the principal investigator. In order to explore differences in perspectives, participants were organized into 4 groups—URiM women, majority women, URiM men, and majority men. The AAMC’s definition of URiM was used to classify participants.20 URiM participants included Black/African American faculty and Hispanic/Latino/of Spanish Descent faculty; there were no participants in other underrepresented groups. Asian faculty were considered to be majority in keeping with the AAMC definition.

Members of the research team met regularly to review transcripts and determine if data saturation had been reached for each demographic group. At one point, another recruitment email was sent to URiM faculty as more interviews were needed. Data were analyzed inductively and guided by thematic analysis,21 and Nvivo 11 was utilized to organize the data. Transcribed data was read by two coders (LB and LH) to identify underlying concepts and to develop an initial coding structure. Data was coded line-by-line, and these initial codes were used to start revealing potential thematic categories. Memos were written by two coders throughout the coding process to continuously compare data and make connections between data. This allowed the authors to explore emerging themes while building linkages between concepts.22 Next, through focused coding, the two coders arranged concepts into codes that were more “directive, selective, and conceptual”22 than in the initial coding. These codes classified the data according to emerging themes. At this point, a third coder (CO) was invited to join the project from outside the department to check inherent bias that might exist within the research team. The three coders (LB, LH, CO) independently coded transcripts (each transcript was coded by differing combinations of two of the three coders) to enhance the trustworthiness of the data based on the emergent coding structure. They met regularly to discuss where coding matched and was divergent, and to reconcile differences. Throughout the process, codes were deleted, trimmed, renamed, and elevated into themes.

RESULTS

Themes were identified in three areas: Perceived Barriers to Advancement of Women Faculty, Perceived Barriers to Advancement of African American and Latino Faculty, and the Institutional Climate for Diversity (for a list of themes and subthemes, see Table 3;  for representative quotes for each theme, see Appendix 2).

Table 3 Table of Themes and Subthemes
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Perceived Barriers to Advancement of Women Faculty

Women’s Advancement Getting Better

Majority men painted a more optimistic picture of women’s advancement than other groups, with most stating that women’s advancement was good or getting better. For example, one majority man stated, “I’m also on our Promotions Committee, and I don’t see that there’s any issues there. . . Gender-blind, I would agree with that.” However, only one URiM woman and a few URiM men and majority women agreed that the climate for advancement was acceptable or improving.

Majority men also stated to a greater extent than other groups that the advancement of women in academic medicine would take place naturally, over time, based on the fact that men and women are now entering the medical profession at similar rates. One majority man said, “I think those kinds of differences will gradually improve over time. It may not get to completely equal (sic), just because there seems to be some attrition of women who decide not to work full-time, when they get to the upper career levels. . . .”

Women Choose Family over Advancement

Majority men were likely to believe that women medical school faculty choose to pursue family over advancement, voluntarily eliminating themselves from leadership. For example, “My sense is that working mothers, even on a professional level, may have . . . bias against advancement, promotion, the responsibilities in promotion in rank.” In contrast, only one URiM man mentioned this and only a few women suggested that women chose family over career advancement.

Working Mothers Have Difficulty Meeting the Demands of Advancement

All demographic groups shared the perspective that working mothers had difficulty fulfilling the demands required for advancement because of added responsibilities of parenting, with one-third of participants mentioning this. However, male participants more often suggested that women were responsible for this difficulty, whereas women tended to see it as a problem with the institution, which does not value family commitments, or with society, in which women are assumed to be the primary caregivers for their families. For example, one majority man stated, “I’m not sure that it reflects a bias against women as much as a failure to adapt to competing demands…more women than men also maintain responsibility for children and child care.” Juxtaposed to this view was the perspective of women faculty, who tended to place the difficulty of advancing at the feet of the institution and/or society. One majority woman said, “. . . Well, look. John got all these papers written during this time. Why do I need to give you academic time to write papers? Well, John’s also not cleaning house, cooking dinner, folding laundry, cleaning up after the sick dog or the sick kid.”

Bias Impacts Women’s Advancement

In addition to family-related issues, all groups mentioned that bias affected women’s advancement to some extent, with URiM women suggesting this most often. Divergent views based on gender were seen in three themes related to bias. First, over half of all women brought up the idea of a “good old boys club” or lack of gender representation as a reason why women have difficulty advancing and reaching leadership positions. Less than a quarter of men mentioned this as a reason. Second, more than half of the women respondents mentioned the importance of mentoring and its lack of availability as a key factor; only two men discussed this. Finally, almost half of women discussed the idea that women have to work harder to achieve the same status of men in academic medicine, while few men mentioned this idea.

Perceived Barriers to Advancement of African American and Latino Faculty

URiM Advancement Getting Better

Just as majority men saw advancement for women as either good or getting better, about half of them also suggested the same was true for URiM faculty. Only a few members of the other groups mentioned this, however. The same three men in key leadership positions were mentioned by multiple male participants as evidence that URiMs no longer have difficulty advancing.

URiMs Don’t Advance due to Pipeline Issues

Perceptions of what factors prevented URiM faculty from advancing varied by demographic group. About half of all participants suggested pipeline issues play a role in URiM advancement. But majority men brought pipeline issues up to a greater extent, with most suggesting pipeline issues explain part or all of the disparity in advancement between majority and URiM faculty. A majority male suggested that issues related to the pipeline were solely responsible for the lack of URiM advancement: “There just aren’t enough qualified minorities for these jobs – just not. . . There aren’t qualified people out there . . . totally a pipeline problem.”

URiMs Don’t Advance Because of Bias

All groups discussed bias as a reason that kept URiMs from advancing and reaching the highest levels in medicine, with at least half of URiMs bringing this up. At least one-third of majority men also mentioned this. One female URiM faculty member stated, “You can’t really have an opinion if you’re a woman of color. You could be there, but really not be controversial, look controversial, or look too ethnic. I think that yes, people like diversity, but I think there’s a certain cookie-cutter type of ethnicity that they like.”

URiMs Must Work Harder to Advance

A final emergent theme is that URiM faculty must work harder than their majority counterparts to attain the same level of advancement. Roughly one-third of URiM faculty suggested that one reason for this is that URiM faculty are asked to fulfill minority representation on committees or mentoring, which places an undue burden on faculty who may already be subject to bias. Only a few non-URiM participants mentioned this as a factor. For example, an URiM woman called the extra work a “tax”: “That goes back to . . . sometimes being on things that I'm like, why I am here? I’m clearly helping somebody address a need, right, but it's not really fulfilling my need. . . There’s that added tax or burden that faculty from underrepresented groups have that can impede success.”

Perceptions of the Institutional Climate for Diversity

Equal Opportunity to Advance

When asked if individuals from different backgrounds had an equal opportunity to succeed in the School of Medicine, roughly three-quarters of majority men said “yes,” while approximately three-quarters of URiM women said, “no.” In fact, only one URiM woman said, “yes” with no caveats. For example, a majority man responded, “Yes . . . This is one of the most diverse environments . . . you could work in, really.” URiM women, however, painted a different picture in their responses as the following indicates, “No. I’m a clear illustration of that. I did it despite tremendous obstacles.” Most URiM men and majority women said that individuals did not have equal opportunities or that they were unsure whether they did or not.

Treated with Respect

Further, we found that whether or not participants felt that they were treated with respect at work varied by demographics, with majority men feeling the most respected and URiM women feeling the least so. Almost all majority men stated that they felt respected when at work. One representative response from a majority male: “Definitely. Probably more respect than I ever had.” In contrast, most URiM women said that they did not feel respected or that they were unsure, such as seen in this response, “I think that for most people who are minorities... Once you get to a certain point, it’s like... ‘When am I actually gonna get rewarded for what I’m doing?’... You’re just doing all this stuff, and someone else is sometimes getting the credit for it.” Only a few URiM women said that they felt respected with no contingencies.

Most URiM men said that they felt respected, but provided personal stories that illustrated caveats or qualifiers to their experience of respect. For example, one participant said others joked about his Hispanic last name. Majority women also tended to state they felt respected, with only one responding that she did not feel respected and a few conveying mixed responses.

Feeling and/or Observing Racial Tension

Finally, we also found that whether or not one observed racial tension was based on demographics, with URiM women diverging from the other groups. Only a few majority men and women and URiM men said they observed racial tension at work, although many were quick to point out that it may exist but they did not experience it personally. Most URiM women, however, said they did observe racial tension. For example, one URiM woman stated, “I feel that—so there’s a lot of things that aren’t said… because any time you bring racial issues up, there’s always gonna be some type of controversy.”

DISCUSSION

These findings suggest that perceptions of academic advancement vary by demographic group membership, and that numerous systemic and attitudinal barriers to the advancement of women and underrepresented minorities still play an important role in the career development of those traditionally marginalized. However, this study moves beyond these insights by exploring the gap between the perceptions of majority men and other demographic groups. In our study, URiM men, URiM women, and majority women had differing views from majority males in their perceptions of both the existence and nature of barriers to the advancement of women and underrepresented minorities.

This study affirmed the existence of bias against motherhood, as many majority males seemed to place some of the responsibility for women’s lack of advancement on women who were mothers who, they argued, were likely to choose family over career. Numerous studies across fields have noted that women pay a “motherhood penalty” for having children, regardless of experience or level of education, in which they are perceived as being less committed to their careers, less likely to be suggested for promotion, and more likely to receive a lower starting wage than childless women.23 In the USA, researchers have identified a 7% wage penalty per child, only one-third of which can be attributed to the loss of work experience.24 By contrast, men receive a “bonus” or “premium” for becoming fathers.23

The current study also indicates that majority men may be unaware or insensitive to gender issues such as male-oriented networking and mentoring opportunities and the need on the part of women faculty to overcome gendered stereotypes. Believing that issues influencing the advancement of women will naturally resolve themselves over time allows men to absolve themselves of personal responsibility and leaves them unwilling or incapable of proactively leading or supporting efforts to address such issues. Leadership must become aware of the perspective of women faculty members with regard to concerns about their advancement in order to assist in alleviating these barriers.

In terms of the advancement of members of racially underrepresented groups, majority men and URiM women tended to diverge in their perceptions of URiM advancement. Although at least half of majority men suggested that advancement for URiM faculty was acceptable and getting better, no URiM women posited this notion. Consistent with much of the extant literature surrounding the paucity of members of underrepresented minorities at the highest reaches of academic medicine,4, 7 participants from all groups suggested pipeline issues play a role. But, most majority men suggested that pipeline issues explain part or all of the disparity in advancement between majority and URiM faculty, while women and underrepresented minority faculty members tended to suggest that other factors, such as bias or structural barriers, explained a great deal of the disparity.

While studies on the lack of diversity in academic medicine support the idea of pipeline issues as an important factor, they also point to institutional culture, re-examining hiring and promotion criteria for bias, and aggressive outreach as equally crucial to the quest for race-equitable representation.25, 26 Other factors which researchers have found to contribute to the lack of advancement of URiMs include inadequate development opportunities,26 inadequate mentoring opportunities,15, 16 isolation,15, 27, 28 and a sense of being overburdened with additional work due to their minority status.28, 29 Indeed, the URiM faculty in this study often mentioned the necessity of working harder than their majority counterparts to advance to the same level, and all groups mentioned racial bias as a reason for lack of advancement. Racial bias is consistently mentioned throughout research literature as a key obstacle to the advancement of racial/ethnic minorities.28,29,30 The characterization of lack of minority representation in academic medicine as a pipeline issue is, therefore, a substantial oversimplification which absolves (predominantly White) leadership of responsibility and makes it unlikely that they will address systemic institutional factors. Because majority males as a group tended to feel respected by their institution, it is possible that they are less likely to feel that the institution is burdened by systemic bias in need of rectifying.

Racism in health care, including among leaders in academic medical centers, is systemic and multidimensional. However, much of the race-critical literature does not name or examine the White males who control medical institutions and who operate out of a White racial framing.12 White racial framing includes racial bias, racial ideologies, narratives, emotions, and inclinations to discriminate. It is important that these leaders are compelled to listen to underrepresented voices about their experiences with institutionalized racism as well as their solutions.12 This study is an important step in that direction in that it highlights the divergence of perspectives based on lived experiences of structural bias. The contrast between these perspectives draws attention to the limitations of the majority perspective in perceiving structural barriers.

Limitations

The small sample size of URiM men may have limited our ability to understand the perspective of that group. Although, we combined URiM groups for analysis purposes, we acknowledge there may be differences in perspectives between URiM groups (i.e., Latinos vs. Blacks). Further, because our study is based on the AAMC definition of URiM, Asians were included in the majority group. We realize that this may have masked the unique perspectives that this group had in terms of advancement. Also, selection bias is likely in that participants volunteered to be in the study by responding to an email sent to all faculty in the School of Medicine, and respondents may have been more extreme on either side of the spectrum.

Another limitation relates to the race and gender concordance of the interviewer-interviewee or lack thereof in terms of reflexivity.31 To minimize potential bias that can occur in both situations, we assembled a team of diverse researchers to serve in a peer consultation role to check biases in interviewing, coding, and analysis.31 Finally, as with all qualitative studies, only a fraction of faculty in the institution were represented, and therefore, our conclusions cannot be seen as generalizable.

CONCLUSION

We uncover perceptions of how and why some and not others advance to positions of leadership and how these perspectives differ across lines of race/ethnicity and gender. In so doing, we seek to inform current efforts to address the unconscious biases and systemic structural barriers that promote and sustain inequities in leadership in academic medicine. This study suggests that a possible reason for the underrepresentation of women and underrepresented minorities in senior and leadership positions in academic medicine is that majority males may not perceive systemic bias against women or racial/ethnic minorities. This may render majority males, including those in leadership, less likely to work to eliminate systemic and historical barriers, leaving women and underrepresented minorities responsible for removing obstacles to their advancement that they did not create.

Given that the perception and acknowledgement of barriers is a necessary pre-requisite to active engagement in work to combat these barriers, diversity and inclusion initiatives which endeavor to broaden the perspectives of majority males might prove efficacious over the long run. Training on implicit/unconscious bias, town halls, and panel discussions at which women and underrepresented minority faculty and staff share their experiences, and institutional accountability for equity in recruitment and promotion practices could all play a role in this enterprise. Moreover, the intentional creation of institutional goals related to the recruitment and retention of women and URiM faculty might function as the necessary impetus to encourage local leadership, such as department chairs, to assume personal responsibility for altering internal practices. This work may be necessary to narrow the gap in perception between different demographic groups before diversity and inclusion efforts can achieve maximum efficacy.