Abstract
Introduction
In 2008, the then Chief Medical Officer commissioned Baroness Deech 1 to chair an Independent Working Group looking at the position and participation of women in the medical profession. We update and extend the Deech report to cover academic medicine in the UK. In doing so, we are not offering a systematic or exhaustive review of the data. Rather, we describe female participation rates in medicine and academic medicine based on secondary analysis. We demonstrate that although women are equally represented in medicine, they are under-represented in academic medicine. We conclude by arguing that, although progress has been made, inequity in academic medicine matters because: (a) it is a waste of public investment due to a loss of research talent; (b) as a consequence, some areas of medicine are under-researched at a cost to patients and society; and, (c) discriminatory practices and unconscious bias continue to occur.
The case of women in medicine
To understand the role of women in academic medicine, we briefly review data on the women in medicine more broadly. Traditional discrepancies between men and women in medicine have fallen substantially in recent years. Women are well represented across the medical workforce, even if there are differences between roles: women represent 44% of doctors, 56% of National Health Service (NHS) senior managers and 89% of nursing, midwifery and health visiting staff.2,3 This is the result of significant changes over the past 50 years, as the proportion of women entering medical school and the medical workforce has increased. In the 1960s, women accounted for about 25% of those entering medical school, rising to 35% in 1975 and 46% by 1985. The proportion of female medical students reached a peak in the mid-2000s at 61% and has now stabilised around 53%. 4
When working full-time, female and male doctors progress at the same speed in the NHS. Evidence from a postal survey of the 1977, 1988 and 1993 cohorts entering medical school shows that, for male and female doctors who always worked full-time, there were minimal differences in progression rates to consultant posts. Nevertheless, significant differences in working patterns between male and female doctors remain, and these differences do impact on progression. Female doctors are about five times more likely than men to have worked part-time in general practice and almost seven times more likely in hospital practice. 5 Taking into account career breaks and part-time work in the 15 years after graduation, women on average provide 60% of a full-time equivalent role, compared with 80% for men. 5
Possibly as a result of decisions to undertake part-time working, female doctors are under-represented in senior positions. Women represent 44% of medical doctors, but just 30% of consultants. 2 Women tend to occupy less stable or prestigious positions than men, which may also be influenced by a higher proportion of part-time workers. Elston argues, for instance, that an increasing number of young General Practitioners (GPs) are now entering practice as salaried doctors and most of these are women working part-time. 6
Finally, female clinicians are disproportionately represented in certain specialties as illustrated in Figure 1. The greatest differences are found in general practice, in which 37% of men specialise against 47% of women, and surgical specialties, in which 16% of men specialise against 3.5% of women.
5
The challenge in assessing female distribution across specialties lies in determining whether over or under representation of women is linked to inherent differences between men and women’s preferences in finding certain specialities more fulfilling, or whether it results from discrimination. Deech
1
argued that women’s specialty choices tend to be influenced by personal factors such as family obligations, fixed hours and a sense of altruism, while men are more influenced by role models prior to medical school as well as the opportunity for personal and professional success. Conversely, it could be argued that the concentration of women in certain specialties may be due to conscious or unconscious bias, the absence of senior role models and direct or indirect discrimination.
5
Percentage by medical specialties of men and women practitioners, 2009 (adapted from The Health and Social Care Information Centre
7
).
The case of women in clinical academia
The progress seen in medicine, however, has not been reflected in academic medicine, where there continues to be a longstanding gender imbalance particularly at senior levels. For the ‘medical sciences’ more broadly (which include clinical academia as well as laboratory-based basic medical sciences and other subsets), the proportion of female ‘grade A’ researchers (i.e. the single highest grade/post at which research is normally conducted and is a definition used to aid international comparisons) is 23%. 8
More specific 2012 data from the Medical Schools Council show that just 26.3% of clinical academics are women. This inequality increases substantially with seniority, with women representing 42.3% of Lecturers, 30.1% of Readers/Senior Lecturers and 15.1% of Professors. 9 (It would be interesting to see whether this level of female participation in academic medicine is uniform across all medical schools, or whether there are differences by different groupings, such as pre- and post-1992, Russell Group, etc. Unfortunately, the data are not currently presented in a format that allows for this form of secondary analysis.) Considering that there has been near gender parity in student intake to medical schools for the past 25 years, the low level of female professors in UK medical schools seems to be a (cultural) phenomenon that is associated with academic medicine as opposed to medicine or academia per se.
Encouragingly, there is some evidence that these disparities are set to improve. Since 2004, there has been a 33% increase in the number of female clinical academics across all grades, and a 60% increase in the number of professorial women. 9 However, as the 2012 Medical School Council report notes, there are gender differences in age and clinical academic grade that imply that men are still more likely to achieve promotion to senior grades at a younger age, which could, itself, be evidence of bias in the system. 9 Relying solely on demographic momentum is therefore not an acceptable policy solution.
So why are these differences occurring and do they matter? First of all, it is important to note that there are important differences in research activity and behaviour between men and women in academic medicine. It has been shown that women publish less frequently than men, 10 are less likely to apply for research funding, and when they do they typically apply for less but are more likely to be successful than their male counterparts. 11 There is also evidence that the proportion of papers with female first authorship and female last authorship is increasing (from 11% in the 1970s to 37% in 2004 and 12% to 17%, respectively), 12 perhaps reflecting some small but slow moving cohort affect. A recent bibliometric study found that not only are female authors proportionately less cited than male authors but female authors tend to also reference less their own work than their male counterparts. 13
One of the consequences of these differences is that women may have limited access to positions of influence and power in the research system. For example, women are under-represented on Expert Groups, advisory/policy committees and peer-review panels. 10 Overall, of 443 scientific boards reviewed as part of a European Commission project, 31% of UK participants were women, ranking it sixth out of 27 countries and lagging behind the Nordic countries where scientific boards comprised up to 48% women. 14
In parallel with the fact that certain specialty areas of academic medicine continue to be characterised by over- or under-representation of women, 15 there also appear to be variations in publication subspecialties by gender, both in the US 16 and the UK. 12 A 2009 study investigating gender differences in first and senior authorship in six peer-reviewed British journals reveals a greater rise in female authorship in obstetrics and gynaecology and paediatrics, as compared with publications in the journals Gut and Lancet, which have both seen a decline in the number of senior female authors. This finding leads the authors to conclude that ‘the more women within a subspecialty, the more likely there will be prominent female authors’. 12 A similar US study found the highest magnitude of increase in female authorship in the Journal of Pediatrics and Obstetrics and Gynecology and the lowest for Annals of Surgery. 16 This leads us to speculate whether certain specialities are equally valued in clinical academia and if not whether this is confounding gender differences. This could further influence the health research agenda, with specialties attractive to and predominantly represented by women perhaps generating less research. In light of general practice being one of the most feminised specialties in the UK, 15 it is interesting to note that there is evidence that only 5% of academic clinical staff in the UK were academic GPs. 17
Therefore, in opposition with medical practice, not as much progress has been made in academic medicine towards greater equity. Women continue to be under-represented in senior leadership, in positions of influence and in authorship and citation practice.
Why equity matters
The review of the data suggests that although there has been significant progress in reducing barriers to female participation in the medical workforce, unfortunately the same cannot be said for academic medicine. This matters for three interconnected reasons. First, it is a waste of talent. There are many women who could participate in clinical research and academic teaching but do not. One of the key policy successes of recent years has been improvements in career pathways and incentives for those individuals who wish to combine clinical practice with academic research. 18 However, there is a cost and an opportunity cost to society when these prospects are not pursued by appropriately qualified women. Second, the lack of women participating in the clinical academic research system is likely to be implicitly biasing today’s research agenda and, by consequence, tomorrow’s clinical practice. Finally, and more speculatively, the comparison between medicine, academic medicine and other areas of academia, especially at a senior level, suggests there may be a more fundamental culture difference in the clinical academic research system than systemic (process-based) differences. This conscious or unconscious bias could be the result of by a dominant group restricting access to prestigious specialities and research areas and the highest levels of influence.
It is because of this intractability that the National Institute of Health Research (NIHR) announced in 2011 that future funding of Biomedical Research Centres (BRC) and Biomedical Research Units (BRU) will be linked with the achievement of the Silver Athena Scientific Women’s Academic Network (SWAN) status for institutions. Athena SWAN is one of the initiatives aiming at greater gender equity and evolved from work between the Athena Project and the SWAN. It is organised as a charter for women in science that ‘recognises commitment to advancing women's careers in science, technology, engineering, maths and medicine (STEMM) employment in higher education’. Membership of the Athena SWAN Charter is open to any university or research institute that is committed to the advancement and promotion of the careers of women in STEMM in higher education and research. Membership is stratified into three ‘awards’ encouraging departments and universities to adopt initiatives and practices. This includes, for instance, encouraging more informal interactions between staff, adding gender and equality issues on management training or publishing gender balance of committees. 19
Number of universities and departments that held an Athena SWAN when successfully awarded BRCs or BRUs in 2011.
The DH/NIHR leadership believes that extensive work is needed over the coming five years, with medical schools in England needing to improve the culture for and chances of women in clinical academia. The adoption and embedding of gender neutral policies, such as for example flexible working, will be of benefit to all clinical academics whether women or men. Thus, the challenge is to focus on reforming the system and while Athena SWAN provides an essential lever in incentivising such change, it is crucial that real cultural change occurs within medical schools and that the award does not become a ‘tick box’ type exercise in its own right. Only then will we begin to see gender parity throughout clinical academia with benefits to researchers, research agendas and most importantly the patients they serve.