Context Previous studies have suggested that minority medical
school faculty
are at a disadvantage in promotion opportunities compared with
white faculty.
Objective To compare promotion rates of minority and white medical
school faculty
in the United States.
Design and Setting Analysis of data from the Association of American Medical
Colleges'
Faculty Roster System, the official data system for tracking US
medical school
faculty.
Participants A total of 50,145 full-time US medical school faculty who
became assistant
professors or associate professors between 1980 and 1989.
Faculty of historically
black and Puerto Rican medical schools were excluded.
Main Outcome Measures Attainment of associate or full professorship among
assistant professors
and full professorship among associate professors by 1997, among
white, Asian
or Pacific Islander (API), underrepresented minority (URM;
including black,
Mexican American, Puerto Rican, Native American, and Native
Alaskan), and
other Hispanic faculty.
Results By 1997, 46% of white assistant professors (13,479/28,953)
had been
promoted, whereas 37% of API (1123/2997; P<.001),
30% of URM (311/1053, P<.001), and
43% of other
Hispanic assistant professors (256/598; P = .07)
had been promoted. Similarly, by 1997, 50% of white associate
professors (7234/14,559)
had been promoted, whereas 44% of API (629/1419; P<.001),
36% of URM (101/280; P<.001), and
43% of other
Hispanic (122/286; P = .02) associate
professors
had been promoted. Racial/ethnic disparities in promotion were
evident among
tenure and nontenure faculty and among faculty who received and
did not receive
National Institutes of Health research awards. After adjusting
for cohort,
sex, tenure status, degree, department, medical school type, and
receipt of
NIH awards, URM faculty remained less likely to be promoted
compared with
white faculty (relative risk [RR], 0.68 [99% confidence interval
{CI}, 0.59-0.77]
for assistant professors and 0.81 [99% CI, 0.65-0.99] for
associate professors).
API assistant professors also were less likely to be promoted
(RR, 0.91 [99%
CI, 0.84-0.98]), whereas API associate professors and other
Hispanic assistant
and associate professors were promoted at comparable
rates.
Conclusion Our data indicate that minority faculty are promoted at
lower rates
compared with white faculty.
While several studies have demonstrated that female
faculty are less
likely than men to be promoted to senior rank,1-9
less is known about the promotion of racial/ethnic minority
faculty members.
In recent decades, the numbers of minority faculty have
increased, and these
increases have encompassed minority groups traditionally
underrepresented
in medicine, including blacks, Mexican Americans, Puerto Ricans,
American
Indians, and Alaska Natives, as well as minority groups that
have not been
considered underrepresented, including Asian or Pacific
Islanders (APIs) and
other Hispanic Americans.10
In 1980-1981, 2.6% of newly appointed assistant professors
were underrepresented
minorities (URMs), 10.3% were APIs, and 1.9% were other
Hispanics (Figure 1);
by 1996-1997, 4.6% of new assistant
professors were URMs, 13.8% were APIs, and 2.1% were other
Hispanics. Much
smaller increases over time are noted among newly appointed
associate professors
(Figure 1).11
Although these increases indicate steady improvement in the
representation
of minority faculty, they suggest that medical schools have been
more successful
at recruiting minority junior faculty and less successful at
helping minority
junior faculty achieve senior rank.
To our knowledge, only 2 studies have explicitly addressed
racial/ethnic
disparities in faculty promotion in medical schools. Petersdorf
et al12 examined faculty with a
doctor of medicine (MD) degree
in 1989 and found that minority faculty typically are promoted
to the associate
professor level 3 to 7 years later than white faculty. However,
this seminal
study excluded faculty without MD degrees and did not adjust for
potential
confounders such as professional age or faculty productivity.
More recently,
Palepu et al13 conducted a
national survey
of medical school faculty and found that minority faculty were
less likely
to be promoted to senior rank than white faculty. While both
faculty with
and without MD degrees were included and adjustment was made for
age and faculty
productivity, this study was limited by a sample that included
only 344 minority
faculty and the self-reported nature of the survey data.
This study builds on these previous studies of
racial/ethnic disparities
in faculty promotion and examines promotions using data from the
official
roster of all US medical school faculty maintained by the
Association of American
Medical Colleges (AAMC), while controlling for faculty
productivity using
a more objective criterion, receipt of an award from the
National Institutes
of Health (NIH), as well as other potential confounders.
Data used in this study were obtained from the AAMC's
Faculty Roster
System, the official data system for tracking US medical school
faculty.11 This database contains
updated information about
faculty members including demographics, education, employment,
and promotions.
Based on a 1997 AAMC survey of department chairs of US medical
schools, it
is estimated that the database contains records for
approximately 90% of all
active full-time US medical school faculty (Charles A. Elliott,
director of
the Faculty Roster System, oral communication, March
1999).
Each medical school has a designated Faculty Roster System
representative
who is responsible for gathering faculty data, including
information about
race and ethnicity, and submitting this information to the AAMC.
Typically,
new medical school faculty complete the Faculty Roster form when
they are
first appointed, while Faculty Roster System representatives
make updates
to the database about changes in employment status. However, as
the data are
reported voluntarily by medical schools, there are variations in
consistency
across data elements.
The study population consists of full-time US medical
school faculty
who became assistant or associate professors between 1980 and
1989. These
years were chosen to allow all faculty to be tracked for a
minimum of 8 years
during which a promotion could be identified. Faculty who remain
in academia
may not reflect all faculty who aspire for and are eligible for
promotion.
Because some evidence suggests that minority faculty may be more
likely to
leave academia,14 all faculty,
including those
who left academic medicine during the observation period, were
included in
the study population. Because predominantly minority medical
schools may be
atypical in providing minority faculty with more mentorship and
professional
support than other schools, faculty from historically black
medical schools
and Puerto Rican medical schools were excluded (387 assistant
and 253 associate
professors). In addition, faculty in departments other than
clinical and basic
science departments, such as social science or allied health
departments,
were excluded (674 assistant and 360 associate
professors).
Because faculty composition and the probability of
promotion may change
over time, the study population was divided into 5 cohorts
representing faculty
who attained their rank in 1980-1981, 1982-1983, 1984-1985,
1986-1987, and
1988-1989. The construction of these study cohorts relied on
data elements
in the Faculty Roster System about the year in which each
faculty member attained
different ranks. These variables were missing for about a
quarter of medical
school faculty, and they were consequently excluded from the
study population.
About half of these faculty with missing data were listed as
faculty members
prior to 1980; hence, they are not part of the later study
cohorts and their
exclusion is appropriate. However, some of the remaining faculty
likely belonged
in the 1980-1989 cohorts used for our study. To address possible
bias introduced
by these excluded faculty, we compared racial/ethnic disparities
in promotion
among these faculty and among the faculty included in our study.
We found
the disparities to be quite similar between the 2 groups of
faculty and believe
that data selection bias is not a major factor in our
study.
To define our key dependent variable, promotion, each
faculty member
in our study population was followed up through 1997. Faculty
whose reported
academic rank changed from assistant professor to associate or
full professor
or from associate professor to full professor during the years
of observation
were considered to have been promoted. Faculty for whom no rank
change was
reported, including faculty who left academia, were considered
not to have
been promoted.
Faculty race and ethnicity was our key independent
variable of interest.
Information about race and ethnicity is based on self-reported
designations.
The Faculty Roster System classifies faculty as American Indian
or Alaska
Native; API; black, not of Hispanic origin; Mexican American or
Chicano; Puerto
Rican; other Hispanic; white, not of Hispanic origin; or "do not
wish to respond."
For this study, faculty classified as black, Mexican American,
Puerto Rican,
American Indian, or Alaska Native were considered URMs. These
classifications
do not conform exactly to official AAMC designations, which
include Native
Hawaiians and exclude Commonwealth Puerto Ricans from URM
designation. For
most analyses, URM faculty are included as a single category
because the counts
of faculty of specific racial/ethnic groups are small. The URM
faculty were
compared with white, API, and other Hispanic faculty. Faculty
who did not
indicate their race/ethnicity were excluded (2230 assistant and
840 associate
professors).
In addition to rank, cohort, and race and ethnicity, other
faculty characteristics
included in the analyses were sex, type of degree, tenure
status, department,
medical school type, and research productivity. Degrees
differentiated include
faculty with MD degrees from US medical schools, MD degrees from
foreign medical
school, doctor of philosophy (PhD) degrees, and other degrees.
Faculty with
both MD and PhD degrees were classified by their medical degree.
Tenure status
differentiated faculty with tenure or on a tenure track from
faculty on nontenure
tracks. Medical school departments differentiated basic science,
primary care
(family medicine, internal medicine, and pediatrics), surgery,
and other clinical
departments. Medical school type differentiated public from
private institutions.
No measure of research productivity is available from the
Faculty Roster
System. As a proxy for research productivity, data from the 17th
Update of
the Consolidated Grant Applicant File of the NIH15
were used to identify receipt of NIH awards. This file contains
information
on all individuals who have applied for NIH grants or contracts
from fiscal
year 1938 to 1998 and includes any NIH awards received. Included
are awards
that specifically target minority investigators, such as
Research Supplements
for Minority Investigators and Minority Opportunities in
Research Faculty
Development awards. For each faculty member, we determined
whether he/she
received any NIH awards during the observation period prior to
promotion.
Traditional research awards (RO1s) were differentiated from all
other NIH
awards including individual training grants.
Data for assistant and associate professors were analyzed
separately.
Bivariate analyses compared the characteristics and rates of
promotion of
white, API, URM, and other Hispanic faculty members. While the
data used in
this study approach the population of all US medical school
faculty, significance
testing with χ2 tests is reported to facilitate
interpretation
of findings. Multivariate analyses used logistic regression
models to examine
the differential likelihood of promotion of minority and white
faculty. These
models adjust for cohort, sex, degree, tenure status, receipt of
NIH research
awards, department, and medical school type. To allow comparison
with results
from previous studies, results are presented as adjusted odds
ratios (ORs)
with 99% confidence intervals. However, because promotion is not
an uncommon
event, ORs tend to overstate relative risk.16
Hence, adjusted ORs were used to estimate risk ratios17
and are also presented. All analyses were performed using SAS
statistical
software (Version 6.12, SAS Institute Inc, Cary, NC).
The study population included 28,953 white, 2997 API, 1053
URMs, and
598 other Hispanic assistant professors and 14,559 white, 1419
API, 280 URMs,
and 286 other Hispanic associate professors. The characteristics
of faculty
who became assistant professors between 1980 and 1989 differed
by race and
ethnicity (Table 1).
All minority
assistant professors shared a number of differences compared
with white assistant
professors. API, URMs, and other Hispanic assistant professors
were more likely
to be graduates of foreign medical schools or affiliated with
other clinical
science departments. These faculty members were less likely to
be tenured
or on tenure tracks, were less likely to be recipients of RO1
and other NIH
awards, and were more likely to have appointments in private
medical schools.
In addition, API and URM assistant professors were more likely
to be women.
The URM assistant professors were more likely to be graduates of
US medical
schools, while API assistant professors were more likely to have
PhD degrees
or to be affiliated with basic science departments. Rates of
promotion among
faculty who became assistant professors between 1980 and 1989
also differed
by race and ethnicity. By 1997, 46% of white assistant
professors from these
cohorts had been promoted. In comparison, 37% of API, 30% of
URM, and 43%
of other Hispanic assistant professors had been promoted.
Faculty who achieved associate professor rank between 1980
and 1989
demonstrated similar differences by race and ethnicity. Compared
with white
associate professors, API, URM, and other Hispanic associate
professors were
more likely to be graduates of foreign medical schools or
affiliated with
other clinical science departments and to have appointments in
private medical
schools. These faculty were less likely to be tenured or on
tenure tracks
and were less likely to be recipients of RO1 and other NIH
awards. API and
URM associate professors also were more likely to be women.
White associate
professors had the highest rate of promotion (50%), while API
(44%), URM (36%),
and other Hispanic (43%) associate professors had lower rates of
promotion.
The numbers of new faculty of specific URM racial/ethnic
groups are
small (742 black, 150 Mexican American, 123 Puerto Rican, and 38
American
Indian or Alaska Native assistant professors and 191 black, 37
Mexican American,
31 Puerto Rican, and 21 American Indian or Alaska Native
associate professors).
Hence, we limited analyses of these groups to rates of promotion
only, and
these results need to be interpreted with caution. Among URM
faculty, different
racial/ethnic groups tended to have comparable rates of
promotion with the
exception of American Indian or Alaska Natives who had higher
rates of promotion.
Twenty-nine percent of black, 29% of Mexican American, 30%
Puerto Rican, and
45% of American Indian or Alaska Native assistant professors
were promoted.
Thirty-four percent of black, 24% of Mexican American, 39% of
Puerto Rican,
and 71% of American Indian or Alaska Native associate professors
were promoted.
Tenure and Research Awards
Among assistant professors, those on tenure tracks were
more likely
to be promoted than those on nontenure tracks (Table 2). However, within
each track, rates of promotion differed
by race and ethnicity. Among assistant professors on tenure
tracks, API, URM,
and other Hispanic faculty were less likely to be promoted than
white faculty.
Among assistant professors on nontenure tracks, API and URM
faculty were also
less likely to be promoted than white faculty.
Similarly, among assistant professors, those who had
served as principal
investigators on NIH awards were more likely to be promoted
compared with
assistant professors without NIH grant funding. However, among
both assistant
professors who received NIH awards and those who did not receive
such support,
API and URM faculty were less likely to be promoted than white
faculty. In
contrast, other Hispanic faculty were not promoted at lower
rates.
Similar patterns were observed among URM associate
professors. Compared
with white associate professors, URM faculty were less likely to
be promoted
regardless of tenure status or receipt of NIH grant funding. API
and other
Hispanic associate professors demonstrated a slightly different
pattern of
promotion. Compared with white associate professors, API and
other Hispanic
associate professors on nontenure tracks or who did not receive
NIH awards
were less likely to be promoted, but those with tenure or on
tenure tracks
or who did receive NIH grant funding were promoted at rates
comparable with
white associate professors.
Trends in Faculty Promotion
Compared with white assistant professors, minority
assistant professors
experienced lower rates of promotion in every cohort from 1980
to 1989 (Table 3).
These gaps in promotion rates
were largest for URM faculty, smaller for API faculty, and not
statistically
significant for other Hispanic faculty. These gaps appeared
constant across
the cohorts, and there is no evidence that these gaps had
narrowed over time.
Similarly, minority associate professors tended to experience
lower rates
of promotion than white associate professors, although this
difference was
not statistically significant in most cohorts. There was no
evidence that
these gaps in promotion rates had narrowed over time.
Because later cohorts had shorter follow-up periods during
which promotion
could occur and be reported, their promotion rates were expected
to be lower.
To account for this effect, analyses were repeated counting only
those promotions
that were reported during a fixed 10-year follow-up period of
observation
for each cohort (excluding the 1988-1989 cohort which could not
be followed
up for 10 years). The results of these analyses also
demonstrated lower rates
of promotion among minority faculty.
Logistic regression analyses that adjusted for cohort,
faculty sex,
degree, tenure status, receipt of NIH awards, department,
medical school type,
and tenure status were the strongest predictors of promotion
among assistant
professors (Table
4). Men, physicians,
faculty not affiliated with other clinical departments, and
faculty at public
medical schools also were more likely to be promoted. After
controlling for
these covariates, API and URM assistant professors remained less
likely to
be promoted compared with white assistant professors.
Similar findings, although of a smaller magnitude, were
observed among
associate professors. Again, men, physicians, faculty with
tenure, recipients
of NIH awards, faculty in surgical departments, and faculty at
public schools
were more likely to be promoted. After controlling for these
covariates, URM
faculty remained less likely to be promoted compared with white
associate
professors, whereas differences in rates of promotion among API
and other
Hispanic faculty were not statistically significant.
The major finding of this study is that racial/ethnic
minority faculty,
at both the assistant and associate professor rank, are lagging
in rates of
promotion compared with white faculty, even though their
representation in
academic medicine has steadily increased over time. These
findings are consistent
with the findings by Pertersdorf et al11 and
Palepu et al.12 However, our
study goes beyond
previous work by demonstrating an association using a database
that includes
all medical school faculty and after controlling for cohort
effects and multiple
potential confounding factors.
One difference with the study by Palepu et al12
merits comment. In our study, estimates of the influence of
race/ethnicity
on promotion tend to be smaller than comparable influence
reported by Palepu
et al. For example, our study found an OR of promotion for URM
assistant professors
relative to white assistant professors of 0.54 (risk ratio,
0.68) whereas
Palepu et al reported an OR of 0.29. Similarly, our study found
an OR of promotion
for API assistant professors of 0.85 (risk ratio, 0.91) whereas
Palepu et
al reported an OR of 0.58. We believe that these differences can
be attributed
to differences in study design and population. Palepu et al used
a case-control
design, and consequently, the study population included faculty
whose first
faculty appointment spanned many decades. A much higher
proportion of the
oldest faculty were white men. Since we have observed that
promotion rates
were higher in the 1960s and 1970s, inadequate adjustment for
cohort effects
may overestimate disparities between minority and white faculty.
In contrast,
our study used a retrospective cohort design that allowed focus
on cohorts
of faculty who attained their rank between 1980 and 1989.
Our study has several limitations. First, while our study
used the official
roster of medical school faculty and tracked the progress of
more than 33,000
assistant professors and more than 16,000 associate professors,
some faculty
were excluded because the year they first attained particular
ranks is unknown.
While about half of these faculty are known to belong to cohorts
from the
1970s and earlier, some faculty undoubtedly belonged in the
study cohorts.
To address possible bias due to the exclusion of these faculty,
racial/ethnic
disparities in promotion among these faculty and among the
faculty included
in our study were compared and found to be similar. In addition,
to allow
focus on the experiences of minority faculty in the typical US
medical school,
faculty of historically black and Puerto Rican medical schools
were excluded
from the study population. The promotion experiences of the 10%
of black faculty
with appointments in historically black medical schools and the
50% of Puerto
Rican faculty with appointments in Puerto Rican schools may
differ from the
experiences of minority faculty presented in this study.
Second, faculty research productivity was measured using
receipt of
NIH awards. We focused on measures of research productivity
because objective
and uniform measures of teaching and administrative productivity
are generally
not available. We chose receipt of NIH awards because this
information is
available and because the competitive merit review process used
by the NIH
ensures that these awards uniformly represent high-quality
research. We believe
that medical schools routinely use this information in making
promotion decisions
and found that receipt of NIH awards is one of the strongest
predictors of
promotion. However, other measures, particularly publication of
articles in
peer-reviewed journals may reflect research productivity more
comprehensively
and also are used to make promotion decisions. Hence, we cannot
exclude the
possibility that minority faculty are less likely to be promoted
because they
publish less frequently.
Third, faculty tenure status captured in the database may
reflect status
at initial appointment rather than at subsequent points in time.
Hence, adjustment
for tenure status in our models may not correctly classify
faculty who transfer
from tenure tracks to nontenure tracks. However, analyses that
focus on faculty
who were never on a tenure track demonstrate that minority
faculty in this
group were also less likely to be promoted than comparable white
faculty.
Promotion was defined as a dichotomous variable, and hence,
faculty who were
not promoted represent a heterogeneous group. This group
includes faculty
who sought but were denied promotion, faculty who did not seek
promotion,
faculty who left academic medicine to pursue other career
opportunities, faculty
who left academic medicine because they perceived that they
would never be
promoted, and faculty who were terminated. Analyses of associate
professors,
who presumably have a significant investment in academic
medicine, as well
as of assistant professors who remain in academic medicine for
at least 3
years demonstrate lower promotion rates among minority faculty.
Hence, we
do not believe that differences in desire for promotion or
commitment to an
academic career can explain these differences in promotion
rates. However,
additional work is needed to examine other reasons faculty are
not promoted
and to differentiate lack of promotion from attrition.
The findings of our study have implications for faculty
members, medical
schools, and health policymakers. All faculty members may be
discomforted
by the low rates of promotion. Only half of the faculty members
who became
assistant or associate professors in 1980-1981 had been promoted
after 17
years of follow-up. Minority faculty members, in particular, may
be concerned
by the knowledge that they face many barriers to advancement. In
general,
minority faculty are more likely to be affiliated with
departments and medical
schools with lower promotion rates, and are less likely to be on
tenure tracks
or to receive NIH awards, the 2 strongest positive predictors of
promotion.
API and URM faculty are more likely to be women, for whom lower
promotion
rates have been well documented. Moreover, after these factors
are taken into
consideration, minority faculty are still less likely to be
promoted.
Medical schools may be equally concerned about these
findings. Academic
medicine has long been committed to increasing the diversity of
the physician
workforce. It has championed efforts to ensure a diverse
applicant pool to
medical school, defended equal opportunity in admissions to
medical schools,
and has led the opposition to activities to curb affirmative
action in medical
education. Hence, in the interest of equity, medical schools may
perceive
the need to examine the reasons racial/ethnic disparities in
promotion exist
in their institutions. Specifically, they may be encouraged to
review promotion
criteria that may place too much emphasis on basic research and
undervalue
contributions in education, administration, and community
service often made
by minority faculty.
From a practical perspective, medical schools also may be
concerned
that they have inadequate numbers of minority faculty to
properly mentor minority
students entering medical school and residency programs.
Moreover, as many
medical schools expand their faculty practices and compete with
managed care
organizations for patients, they may wonder if they have
adequate numbers
of minority faculty to provide culturally competent care and to
meet the medical
care needs of an increasingly diverse patient population in the
United States.
Policymakers also may be interested in these findings.
They may appreciate
that efforts to train minority researchers and health
professional school
faculty will be jeopardized if these individuals are unable to
find faculty
positions with reasonable opportunities for professional growth
after completion
of training. Policymakers may consider expanding initiatives to
support minority
investigators and educators during later stages of their careers
as medical
school faculty.
Additional research is needed to address issues and
questions raised
by this study. For instance, why are minority faculty less
likely to be promoted?
Are they isolated or burdened with service duties that limit
their academic
pursuits? Are these faculty members subjected to unconscious
discrimination
as suggested by some?18 Or are
less subtle
factors at play? Do culture, language, or skin color factor into
the promotion
process? Can faculty development programs be devised to help
minority faculty
overcome barriers to promotion or will medical educators
continue to mirror
our tiered system of health care delivery? Answers are needed to
enable faculty
and medical schools to better understand the reasons for
racial/ethnic disparities
in faculty promotion and to ensure an equitable system of
professional advancement
for all faculty members.
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