A, Number of dermatology department faculty by sex and URM status. B, Proportion of dermatology department faculty by sex and URM status. P values are for trend lines. Significant P value indicates that the slope is significantly different from 0. Data sources: Association of American Medical Colleges Faculty Roster, December 31 snapshots.6
A, Proportion of female dermatology department faculty by academic rank. B, Proportion of URM dermatology department faculty by academic rank. P values are for trend lines. Significant P value indicates that the slope is significantly different from 0. Data sources: Association of American Medical Colleges Faculty Roster, December 31 snapshots.6
A, Change in proportion of female faculty in clinical departments. B, Change in proportion of URM faculty in clinical departments. There were no emergency departments in 1970; for emergency departments, the data compare 1980 with 2018. Data sources: Association of American Medical Colleges Faculty Roster, December 31 snapshots.6
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Xierali IM, Nivet MA, Pandya AG. US Dermatology Department Faculty Diversity Trends by Sex and Underrepresented-in-Medicine Status, 1970 to 2018. JAMA Dermatol. 2020;156(3):280–287. doi:10.1001/jamadermatol.2019.4297
What are the diversity trends in US academic dermatology departments?
This cross-sectional study assesses the trends from 1970 through 2018 in diversity among US medical school dermatology department faculty by sex, race, and ethnicity. A review of diversity in the US population and among medical school faculty and students suggests that although academic dermatology departments have had an increase in the proportion of female faculty, the proportion of minorities underrepresented in medicine remains low.
Additional attention and efforts to increase racial and ethnic diversity in academic dermatology departments are needed and should be essential aims of a comprehensive plan to prepare a future dermatologist workforce that provides culturally sensitive and clinically competent health care for an increasingly diverse population in the United States.
Faculty diversity has important implications for improving the cultural competency and diversity of medical students and residents. However, dermatology is one of the least diverse fields in medicine.
To measure faculty diversity by sex, race, and ethnicity in academic dermatology departments in US medical schools and to evaluate how this representation compares with the diversity of the US population, medical students, department chairs, and faculty in other clinical departments.
Design, Setting, and Participants
In this cross-sectional study, data from the Association of American Medical Colleges Faculty Roster were evaluated to differentiate full-time faculty by sex and designation as a minority underrepresented in medicine (URM; currently including black, Hispanic, American Indian/Alaska Native, Native Hawaiian, and Pacific Islander individuals). Trends in female and URM representation among academic dermatology departments were analyzed from 1970 to 2018.
Main Outcomes and Measures
The numbers and proportions of US dermatology department faculty by sex, race, and ethnicity.
The number of full-time US dermatology department faculty increased from 167 in 1970 to 1464 in 2018. The number of female faculty increased from 18 (10.8%) in 1970 to 749 (51.2%) in 2018; the number of URM faculty grew from 8 (4.8%) in 1970 to 109 (7.4%) in 2018. Proportions of female and white dermatology department faculty were similar to the US population in 2018; however, like other clinical departments, the proportion of URM faculty was lower than in the general population. There was an inverse association between increasing faculty rank and the proportion of female faculty overall, but this was not the case among URM faculty. At every rank, there was a proportionately low number of URM faculty represented. Across all specialties, department chairs were least diverse, with white individuals representing 79.7% (n = 2856 of 3585) of all chairs in 2018 and women representing 19.4% (n = 694 of 3585) of all chairs.
Conclusions and Relevance
Expansion of faculty in US dermatology departments over the past half century has led to greater female representation, now similar to that in the general population. Higher-ranking faculty is associated with lower diversity. Although dermatology department faculty diversity by sex, race, and ethnicity has partially improved over the past 49 years, continued attention to the lagging representation of URM faculty should be a priority for the field of academic dermatology.
Although significant progress in racial equality has been made over the last few decades in the United States, much more remains to be achieved, particularly with racial and ethnic health disparities. Recently, the lack of diversity among dermatologists and dermatology residency programs was highlighted.1,2 However, diversity among academic dermatology department faculty has not been clearly elucidated. These faculty are charged with the training of the next generation of dermatologists, who should leave their dermatology residency programs as compassionate, patient-centered, culturally competent dermatologists attentive to the needs of diverse patients. These faculty also serve as role models for future dermatologists through their interaction with medical students, residents, and fellows, and—through this relationship—will influence how trainees learn to deliver culturally sensitive and clinically competent health care for a patient base that is increasingly diverse. Multiple studies have shown that diversity in the medical workforce helps reduce health care disparities and may be important for achieving the quadruple aim of enhancing the patient experience, improving population health, reducing health care costs, and improving the well-being of clinicians.1,3,4
Although medical school faculty diversity has been increasing overall, this increase is lower than the increased diversity of medical school students or of the general population in the United States.5 Despite the continued efforts in academic medicine to increase the representation of women and minorities underrepresented in medicine (URM), there is a lack of information on trends in dermatology department faculty diversity and how they compare with those in other clinical departments. This study aimed to determine the long-term trends in representation of dermatology department faculty on the basis of sex, race, and ethnicity.
The University of Texas Southwestern Medical Center Institutional Review Board designated this study exempt from human subject research guidelines because it involves secondary analysis of existing deidentified data. Data were acquired from the Association of American Medical Colleges Faculty Roster to determine sex, race, and ethnicity trends in diversity of medical school faculty, including department chairs. The Association of American Medical Colleges initiated the Faculty Roster in 1966, which has collected comprehensive information on the characteristics of full-time faculty members at US medical schools accredited by the Liaison Committee on Medical Education.6
This study defined racial and ethnic groups as mutually exclusive: Hispanic or Latino (of any race), referred to as Hispanic; non-Hispanic white, referred to as white; non-Hispanic black or African American, referred to as black; non-Hispanic Asian or Asian American, referred to as Asian; non-Hispanic American Indian, Alaska Native, Native Hawaiian, or Pacific Islander, grouped in 1 category as Native American; others, defined in this study as any non-Hispanic person of another race or multiple races; and unknown racial and ethnic information. The concept of URM was first addressed by the Association of American Medical Colleges in 1970 and was modified in 2004 to describe minority groups that are underrepresented relative to their numbers in the general population, which currently includes black, Hispanic, and Native American individuals.7
To assess long-term trends in sex, race, and ethnicity, we calculated proportion of faculty by sex and URM status and by faculty rank from 1970 to 2018. The slopes and the associated P values for each group were estimated by using a simple linear regression model, in which year was used as an independent variable. The Duncan Multiple Range Test was used to compare proportions by sex, race, and ethnicity across the US population, medical students, faculty, and department chairs for 2018. The 2–independent sample t test was used to compare the proportions of female and URM faculty in 1970 with the proportions in 2018 for each clinical department. All P values were 2 sided; P < .05 was considered to be statistically significant. Statistical analyses were conducted with SAS statistical software (version 9.4, SAS Institute).
During the study period from 1970 to 2018, there was significant growth in faculty size in academic dermatology departments. Nationally, the number of full-time faculty increased from 167 in 1970 to 1464 in 2018. The number of female faculty grew steadily from 18 (10.8%) in 1970 to 749 (51.2%) in 2018 (trend line P < .001), with the proportion of female faculty surpassing male faculty for the first time in 2017 (Figure 1). The number of URM faculty also increased from 8 (4.8%) in 1970 to 109 (7.4%) in 2018 (trend line P < .001). Analysis of the trends by sex and URM status shows that the number of non-URM female faculty grew by 13.8 faculty members per year (trend line P < .001) compared with a 10.8-per-year increase among non-URM male faculty (trend line P < .001). The number of URM female faculty increased by 1.2 per year (trend line P < .001) compared with 0.8 per year (trend line P < .001) for URM male faculty during the same period. Whereas the overall proportion of URM was low in the field of dermatology, women became the majority of both URM and non-URM dermatology department faculty.
In 2017, the United States reached a new milestone in racial and ethnic diversity, with the URM population comprising an estimated 31.4% of the overall population (Table).8 The proportion of female faculty in the fields of dermatology (51.2% [749 of 1464]) and family medicine (51.5% [2938 of 5708]) was similar to the proportion of women in the US population (50.8%). The proportion of female faculty in dermatology departments was lower than in pediatrics (58.3%) but higher than in internal medicine (40.3%) and in other clinical departments combined (38.2%). Department chairs across all specialties were least diverse among the cohorts studied, with a small proportion of female chairs (19.4% [694 of 3585]) and a high proportion of white chairs (79.7% [2856 of 3585]) in 2018. The proportion of URM was highest in the US population (31.4%), followed by medical students (18.5%),9 and lowest among dermatology department faculty (7.4% [109 of 1464]). Asian (21.9% [320 of 1464]) and white (65.8% [963 of 1464]) representation among dermatology department faculty were both significantly higher than in the US population (5.2% and 60.8%, respectively).
Results also showed significant differences in diversity by faculty rank (Figure 2). Although the proportion of female faculty in dermatology departments grew faster when compared with URM faculty, a higher proportion of female faculty members had lower academic rank compared with men (Figure 2A). However, this pattern was not apparent when only URM faculty were analyzed (Figure 2B). At every rank, there was a proportionately low number of URM faculty represented. In 2018, women made up 59.2% (n = 383 of 647) of dermatology department assistant professors, whereas URM accounted for 9.1% of assistant professors (n = 59 of 647).
Interdepartmental comparisons show that the proportion of women in each clinical department increased significantly (Figure 3A). In 2018, the field of dermatology ranked fifth for the proportion of female faculty. However, dermatology department faculty experienced the second-largest growth in the proportion of women from 1970 (10.8% [18 of 167]) to 2018 (51.2% [749 of 1469]), just behind the field of obstetrics and gynecology during the same period (from 11.9% [107 of 896] in 1970 to 63.8% [4057 of 6357] in 2018). The comparison also shows that the proportionate growth in female faculty was uneven among clinical departments, with surgical specialty departments generally experiencing less growth compared with medical specialty departments.
The growth in URM faculty representation was slow across all clinical departments from 1970 to 2018 (Figure 3B). The growth in URM faculty was also uneven among clinical departments. This was similar to female faculty trends, but to a lesser extent. Dermatology departments ranked 12th among clinical departments in the proportion of URM faculty in 2018. The proportion of URM faculty in the field of dermatology increased from 4.8% (8 of 167) in 1970 to 7.4% (109 of 1464) in 2018, but the change did not attain statistical significance (P = .14). Other departments where change in URM proportion did not attain statistical significance include emergency medicine, pathology, and ophthalmology.
This study shows that even though dermatology department faculty diversity has grown, it still reflects neither the diversity of the US population nor that of medical students. The finding of equal female representation in the field of academic dermatology in this study is a sign of important early progress. However, substantial progress in increasing URM representation is needed in academic dermatology departments. The slow pace at which racial and ethnic diversity among dermatology department faculty is increasing likely reflects trends in academic medicine and the physician workforce in general. Approximately 13.5% of physicians in the United States were from underrepresented racial and ethnic minority backgrounds compared with 31% of the US population.10,11 Although more women entered the field of academic dermatology, growth in URM faculty remained low among all dermatology department faculty ranks.
Barriers to promotions persist for women and minorities. The fact that lower-rank professoriates had higher proportions of female faculty than higher-rank professoriates highlights the barriers female faculty members face regarding promotion. There was a lack of URM across all ranks, which may be attributed to many factors including (but not limited to) overt prejudice, subtle discrimination, undervaluing of the unique contributions of URM faculty, personal and family responsibilities, lack of mentorship, and opting out of promotion paths, although future studies need to explore the specific reasons. Early studies have found that female and minority faculty members have lower promotion rates and leave full-time faculty appointments at a higher rate than male and white faculty members.12,13
The study also found that proportions of female faculty tend to be lower among surgical specialty departments than medical specialty departments. This pattern was similar for URM proportions but to a lesser extent. It may stem from individual preferences as well as from systematic constraints, such as higher United States Medical Licensing Examination score requirements and limited graduate training positions in certain specialties.14 Whereas proportions of URM faculty were generally low among all clinical departments compared with URM proportion among the US population, the fact that URM physicians tend to practice primary care may be a result more of systematic constraints than individual preferences.15 This may partially explain the uneven growth in diversity among departments.
Similar to previous findings, this study shows that URM representation among medical students and dermatology department faculty continues to be lower than URM representation in the general population.14 It demonstrates that even though the lack of URM representation in medicine and academic medicine overall begins early in the process, as evidenced by lower URM representation in pools of medical school applicants than among the general population, medical schools have been working to improve the diversity of their students through efforts such as pipeline programs and holistic review processes.16 However, these efforts have yet to translate into a commensurate increase in dermatologist diversity. The finding that the representation of URM in dermatology training and faculty is lower than URM representation among medical students means that these students are not applying for or getting into dermatology residency programs. This difference presents an important area for study and an opportunity for dermatology residency programs to recruit diverse applicants to the specialty. A recent report17 from the Association of American Medical Colleges suggests that medical graduates’ interest in the field of dermatology is relatively low (about 2.2%-2.4% from 2015-2018) and may be even lower among URM medical graduates. Although the lack of URM medical student interest in dermatology may stem from scarce residency positions available in this field, other factors such as lack of exposure to the area of dermatology, lack of role models, and higher United States Medical Licensing Examination score requirements may also play a role.18
Potential strategies for addressing these issues in dermatology residency programs may include initiating programs to expose URM medical students to dermatology in their preclinical years, highlighting patient contact and health education opportunities, and providing meaningful exposure to the field of dermatology during third- and fourth-year medical student rotations. Strengthening and expanding dermatology curriculum activities in all medical schools and providing mentorship early in medical school may also increase the number of medical students interested in the field of dermatology. Residency programs may need to consider a more holistic review of candidates in their admissions process, placing more focus on the applicant’s commitment to address health care disparities as well as additional strengths including cultural competence, distance traveled, interpersonal skills, and grit.19,20
The pressure is forming to create a third wave of health professions education reform to hold programs accountable to their communities.21 This may be an opportunity for academic dermatology departments to help grow the dermatologist workforce that meets the needs of the changing health care system. While more research is needed to further assess the value of diversity in academic dermatology departments and the dermatologist workforce, a diverse physician workforce may be important for mitigating health care disparities.22 Implementing strategies to enhance resident and faculty diversity should be a priority of graduate medical education. The Accreditation Council for Graduate Medical Education recently revised all residency program requirements, including those for dermatology, with an explicit recommendation to consider workforce diversity as a core element when conducting residency program evaluations.23 This may become an important mechanism to periodically assess program effectiveness in improving diversity to determine additional interventions to increase URM proportions in dermatology residency programs, which ultimately may improve URM representation in academic dermatology departments.
Study limitations include reliance on data reported by medical schools. For example, we could not discern whether faculty sex, race, and ethnicity were self-reported or based on secondary data. Second, we used cross-sectional data reported on December 31 of each calendar year and not an average or reflection of data trends over the whole year. Moreover, not all faculty are necessarily physicians. In 2018, 85.4% of full-time faculty in dermatology departments were physicians. Diversity of nonphysician faculty is also important to measure, and different approaches may be required to enhance diversity among nonphysician faculty.24,25 Furthermore, the data were based on department classifications among medical schools. Although the analysis captures national trends for diversity in faculty, it does not permit controls like differentiating medical schools by school characteristics that affect their missions. Future studies should conduct school-level analysis, which may permit the identification of intervention targets at a local level. Department chair data were for all department chairs. We were unable to break down the category of department chairs by specific department type owing to limitations in our data access. Finally, our analysis does not establish a causal relationship between faculty diversity and medical student diversity, although strong associations have been demonstrated in previous studies.4
This study identifies a need to improve diversity in the field of academic dermatology. This may be achieved through improvement of diversity in dermatology residency programs,26 strengthened faculty pipeline programs,27 and mentorship of junior URM faculty members.27 Academic dermatology departments may need to frame diversity as a means to achieve excellence in medical education and quality health care for all.28 A holistic review policy for resident, fellow, and faculty position applicants should also be encouraged.16 Improving diversity is only one part of the overall effort to train future dermatologists to provide culturally relevant and competent care to patients. The solution will require best practices for delivering culturally competent care, improving the understanding of disparities in the field of dermatology as well as skin and hair conditions affecting diverse populations, and teaching diverse groups of learners in a safe and inclusive learning environment.29
Accepted for Publication: November 12, 2019.
Corresponding Author: Imam M. Xierali, PhD, Department of Family and Community Medicine, The University of Texas Southwestern Medical Center, 5959 Harry Hines Blvd, Ste 720, Dallas, TX 75390-9194 (firstname.lastname@example.org).
Published Online: January 8, 2020. doi:10.1001/jamadermatol.2019.4297
Author Contributions: Dr Xierali had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Xierali, Pandya.
Acquisition, analysis, or interpretation of data: Xierali, Nivet.
Drafting of the manuscript: Xierali.
Critical revision of the manuscript for important intellectual content: Nivet, Pandya.
Statistical analysis: Xierali.
Administrative, technical, or material support: Pandya.
Supervision: Nivet, Pandya.
Conflict of Interest Disclosures: None reported.