Research, Academic Rank, and Compensation of Women and Men Faculty in Academic General Internal Medicine

PHYLLIS CARR, MD, ROBERT H. FRIEDMAN, MD, MARK A. MOSKOWITZ, MD, LEWIS E. KAZIS, ScD, HARRISON G. WEED, MD

Objective: To evaluate the status o f men and women faculty in academic general internal medicine, including their professional training, faculty responsibilities, r e s e a r c h performance, academic rank, and compensation, to deter - m i n e whether systematic differences exist by gender . Design/setting: The authors analyzed responses to a 55- part questionnaire sent to all full-time general internal medicine faculty at the major teaching hospitals in the Uni t ed States. U n a d j u s t e d m e a n s w e r e genL~ated f o r m e n versus women faculty in demographics, training back- g r o u n d , hours o f work, professional time allocations, in- stitutional support, professional seif-assessmeng r e s e a r c h performance, academic rank, and compensatiom M e a n s w e r e recalculated after adjusting f o r other variables using multivariate methods. Results: The authors found no significant difference in the frequency o f fellowship training between m e n a n d w o m e n faculty. Women and men perform similar professional ac- tivities, but even after multivariate adjustraeng women de- vote less t ime to r e s e a r c h and perceive less r e s e a r c h skill and institutional support f o r their research, but have simi- lar numbers o f grants, abstracts, and publications in re- fereed journals a n d h a v e similar academic ranks . W o m e n faoaty, houmtmr, receive lower compensation than do m e n faculty, even after adjustmenL Conclusion: Whae the c h a r a c t e r i s t i c s o f m e n a n d w o m e n faculty are quite similar, including those defining their academic productivity, important differences exist in re- search time, perceived institutional suppor~ and compen- sation. These d i f f e r e n c e s cannot be explained by such obvi- ous factors a s age differentials, academic rank, or hours o f w o r k p e r weel~ Key words: women,, general internal medicine; rank,, re- search; compensa t ion , , f ac td t y . J GEN II~t'ra~I MED 1992;7:418-423.

DESPITE A LARGE INCREASE in the numbers of women en- tering the medical profession over the past 20 years, the increase in the percentage of women faculty in medical schools has been modest: from 13% of all faculty in 1967 to 20% in 1989.1, 2 Studies have indicated that disparities in academic rank persist between men and women, particularly at upper-rank levels, 2-7 and that

Received from the Sections of General Internal Medicine, Uni- versity Hospital (RHF, MAM, LEK) and Boston City Hospital (HGW), Boston University School of Medicine, and the General Medicine Unit, Massachusetts General Hospital (PC), Harvard Medical School, Boston, Massachusetts.

Presented at the annual meeting of the Society of General Inter- nal Medicine, Arlington, Virginia, April 26-28, 1989.

Supported in part by a grant from the Henry J. Kaiser Family Foundation.

Address correspondence and reprint requests to Dr. Carr: Gen- eral Medicine Unit, Bulfinch I, Massachusetts General Hospital, Fruit Street, Boston, MA 02114.

418

women tend to be less involved in research. 1 More de- tails about the patterns of career development for men and women medical faculty have not been available. We undertook this study to evaluate whether differ- ences exist in professional training, faculty responsibil- ities, perceived professional skills and support for pro- fessional activities, academic performance, rank, and compensation among men and women faculty in divi- sions of general internal medicine in the United States. We chose to look at academic general internal medi- cine because the large influx of women into this field and the relative youth of general medicine divisions might offer women particular opportunit ies for profes- sional development and advancement, s

METHODS

This studyis based on a 1986 survey of all full-time faculty in general internal medicine at the major teach- ing hospitals of each medical school in the United States. The 1 9 8 5 - 1 9 8 6 A A M C D i r e c t o r y o f A m e r i c a n

M e d i c a l Educa t ion" was used to select the list of medi- cal schools, including all 124 AAMC member institu- tions granting four-year medical degrees. The teaching hospitals affiliated with these medical schools were evaluated using data reported in the 1 9 8 5 - 8 6 Direc-

tory o f R e s i d e n c y T r a i n i n g P r o g r a m s . Up to three pri- mary teaching hospitals for each medical school were selected using a rating scheme based on the academic status of the chief of medicine at the hospital, the total number of accredited residency programs sponsored by the hospital, and the number of residency positions in the internal medicine program. The appropriateness of the results of the selection process was verified by te lephone interviews with a department of medicine representative at each medical school. A total of 262 primary teaching hospitals were so identified.

The chief or chairman or other representative of the department of medicine at each selected hospital was asked to identify whether a section or division of general internal medicine existed at the hospital. Fifty- six percent of the hospitals ( n = 144) had such a divi- sion in their departments of medicine. These depart- ments provided lists of the names and mailing addresses of the full-time faculty in general internal medicine. A total of 841 individuals were identified.

°AAMC = Association of American Medical Colleges.

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 7 (July/August), 1992 419

Surveys were mailed in early 1986. Respondents were not aware that the data would be analyzed by gender. Each questionnaire contained 55 questions, some multipart, requiring about 45 minutes to com- plete. Included were items repor ted by Eisenberg 9 to be important in research productivi ty in general inter- nal medicine. We have categorized Eisenberg's compo- nents of research productivi ty into four general areas (Table 4): personal characteristics (ambition, imagina- tion, tenacity, endurance, energy, commitment , and in- terest in research); research training (research-ori- ented fellowship training or other formal training in research methods); research skills (knowledge of re- search methods, the ability to identify important re- search questions, and the ability to operationalize general ideas into research design); and research environment (space, equipment , institutional funds, and methodologic, secretarial, and research assistant suppor t ) .

All nonrespondents were fol lowed by mail and te lephone. Sixty-nine percent of general internal medi- cine faculty re turned the questionnaires, including 435 men (69% of the men) and 145 women (75% of the women) . Gender could not be determined for 6% of the nonrespondents. Because of confidentiality concerns, we do not have further information about the non- respondents.

ANALYSIS

Data were analyzed using SAS (Statistical Analysis System). Data cleaning included data checks for im- proper ly coded variables and outliers. Frequency dis- tributions and descriptive statistics were generated for the assessments. Unadjusted means were generated for men versus women faculty for variables in the follow- ing areas: demographics, training background, hours of work, actual and desired allocations of time, institu- tional support for work activities, assessment of profes- sional skills, assessed factors in research performance, numbers of research grants as principal investigator, abstracts and articles published in refereed journals, academic status, and compensat ion (salary and clinical payments). Faculty were asked to report the precise amounts of compensation.

Means were recalculated for the male/female vari- able after adjusting for other variables using multivar- iate methods. These adjusted means are an estimate of the means for hypothetical populat ions of men and women whose distribution on all of the control led vari- ables matches that of the entire combined sample of both men and women. Independent variables con- trol led for in all multivariate models included race (1 = white, non-Hispanic); membership in the Alpha Omega Alpha Honor Society (1 = yes); year of gradua- tion from medical school (1 = 1973 or after); primary care residency training (1-----yes); chief residency (1 -~ yes); general internal medicine or subspecialty

TABLE 1 Demographic Data for General Internal Medicine (GIM) Faculty

Women (n = 145) Men (n = 435)

Age (mean + SD) 37 + 5.9 40 + 8.3* Black or Hispanic 6% 3% Medical school year of

graduation (mean + SD) 1976 + 6.3 1972 + 8.6* Alpha Omega Alpha Honor

Society membership 24% 29% Primary care residency 30% 19%t Chief residency 17% 37%~ GIM or subspecialty fellowship 50% 57%

*p < 0.0001. tp < 0.01. :l:p < 0.001.

fellowship training (1 = yes); hours of work per week ( 1 = --> 60 hours per week); faculty rank (1 = associate or full professor); and whether the individual was chief of a general internal medicine section (1 = yes). For d ichotomized variables (hours of work per week, year of graduation from medical school) , cutoff points were chosen at the medians of the distributions.

RESULTS

Demographic Data

Women faculty in sections of general internal med- icine were younger (mean age 37 vs. 40 years, p < 0 .0001) and had graduated from medical school more recently than their male colleagues (Table 1). There was no significant difference between men and women faculty by race or membership in the Alpha Omega Alpha Honor Society. However, 6% of women faculty were black or Hispanic, a figure that is higher than that for men faculty (3%). Women more often had had pri- mary care residency training, whereas men were more than twice as likely to have been chief residents. There was no significant difference in fellowship training be- tween men and women faculty, including separate con- sideration of different lengths of training (one and two years) and different types of fellowships (general medi- cine and the subspecialties).

Hours of Work and Allocation of Time

Men faculty reported working more hours, on average, per week (58 hours vs. 55 hours, p < 0.01) (Table 2). The allocations of work t ime were slightly different for women and men: women spent a greater proport ion of their t ime in patient care (46% vs. 40%, p < 0.05), while men devoted relatively more t ime to administration (18% vs. 14%, p < 0.01) and research (18% vs. 14%, p < 0.05). There was no significant dif- ference in the proport ions of t ime spent in teaching/ed- ucational activities. When faculty were asked to choose their ideal t ime allocation to patient care, research,

4 2 0 Carr etaL, WOMEN AND MEN GIM FACULTY

teaching and educational activities, or administration, w o m e n did not differ significantly f rom men, excep t that w o m e n stated their p reference for slightly more teaching t ime (31% vs. 27%, p < 0 .01) .

After mult ivariate adjustment (Table 2), the differ- ence be tween men and w o m e n faculty in hours worked pe r week was no longer significant. Men, however , cont inued to have a greater p ropor t ion of their t ime al located to research (12% vs. 7%, p < 0 .05) . The dif- ference in t ime allocations to administrat ion and pa- t ient care, identified in the univariate analysis, did not remain fol lowing adjustment. All other analyses were unchanged.

Support for Work Activities and Self-assessment of Skills

Men in general internal medic ine faculties per- ceived more suppor t than did w o m e n for each of their professional activities, including pat ient care, teach- ing/educat ion, research, and administrat ive work (Table 3). There was no significant difference in the

availabilities of secretaries (0.8 FTE vs. 0.6 FTE), but men had greater access to research assistants (0.6 FTE vs. 0.3 FTE, p < 0 .05) . Women faculty had lower self- assessed research skills and administrative skills. In other areas of professional activity, including pat ient care and teaching/educat ion, there was no difference in self-assessed skills be tween men and women .

After mult ivariate adjustment, the difference iden- tified be tween men and w o m e n was no longer present for perce ived suppor t for pat ient care. Men still per- ceived more suppor t for all o ther professional activi- ties. They also had greater access to research assistants (0 .47 FTE vs. 0 .18 FTE, p < 0 .05) . In evaluating s e l l assessed skills, only the difference in research skills was still significant.

Self-assessed Factors in Research Performance

Men judged numerous factors in their research per- formance more highly than did w o m e n (Table 4), in- c luding personal characteristics, research training, re- search skills, and the research environment . They were

TABLE ~. Time Allocation of Women and Men Faculty in General Internal Medicine

Unadjusted Means

Men (n = 435)

Hours of work per week 58

Percentage of time in patient care 40% Percentage of time in teaching/education 25% Percentage of time in research 18% Percentage of time in administration 18%

Ideal percentage of time in patient care 35% Ideal percentage of time in teaching/education 27% Ideal percentage of time in research 27% Ideal percentage of time in administration 13%

Women (n = 145)

55t

46o/o$ 26% 14 °/or 14%§

34% 31 °/of 24% 11%

Men

Adjusted Means*

(n = 435)

59

42% 25% 12% 21%

34% 29% 23% 14%

Women (n = 145)

57

44% 28%

70/o$ 21%

32% 33O/ol . 19% 15%

*Adjusted for ten variables (see Methods section in text). tp < 0.01. $p < 0.05. §p < 0.001,

TABLE 3

Support for Work Activities and Self-assessment of Skills by General Internal Medicine Faculty*

Unadjusted Means

Men (n = 435) Women (n = 145)

Adjusted Meanst

Men (n = 435) Women (n = 145)

Perceived support for patient care Perceived support for teaching/education Perceived support for research Perceived support for administrative work

Self-assessed skills in patient care Self-assessed skills in teaching/education Self-assessed skills in research Self-assessed skills in administration

3.9 4.0 3.1 3.5

4.1 4.9 3.6 4.3

3.55 3.65 2.5* 3.1§

4.1 4.7 3.0t 4.0§

4.0 4.1 3.2 3.7

4.3 5.0 3.5 4.5

3.8 3.8§ 2.75 3.4¶

4.3 5.0 3.1§ 4.5

*On a scale of 1-6, 1 = very poor, 6 = exceptional. tAdjusted for ten variables (see Methods section in t e x t ) . tp < 0.001. §p < 0.01. ¶p < 0.05,

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 7 (July/August), 1992

TABLE 4

Self-assessed Factors* in Research Performance for General Internal Medicine Faculty/

421

UnadJusted Means Adjusted Means*

Men (n = 435) Women (n = 145) Men (n = 435) Women (n = 145)

Personal characteristics 4.4 4.2§ 4.5 4.4 Research training 2.9 2.6¶ 2.9 2.6 Research skills 3.9 3.511 3.7 3.4¶ Research environment 3.5 2,911 3.3 2.811

*Factors were derived from Eisenberg. ~ tOn a scale of 1 - 6 , 1 = low, 6 = high. *Adjusted for ten variables (see Methods section in text). §p < 0.05. ¶ p < O . 0 1 . liP < 0.001.

TABLE 5

Grants, Publications, Academic Rank, and Compensation of Women and Men General Internal Medicine (GIM) Faculty

UnadJusted Means

Men (n = 435) Women (n = 145)

AdJusted Means*

Men (n = 435) Women (n = 145)

Grants submitted 1 9 8 3 - 8 6 2.8 2.Of 3.5 2.8 Grants funded 1 9 8 3 - 8 6 1.4 0.8* 1.4 0.9 Grant funding rate 0.6 0.4t 0.6 0.5

Authorship in refereed journals- - 1 9 8 4 - 8 6 4.0 2.5§ 4.0 3.0 Authorship in refereed journals- - entire career 18.1 6.5§ 19.6 14.3

Full or associate professor 42% 16%§ 48% 44% Tenure 28% 13%§ 37% 37% GIM chief 20% 9%* 22% 25%

Compensation $74,000 $62,000¶ $77,000 $73,000f

*Adjusted for ten variables (see Methods section in text). tp < 0.05. *p < 0.0 I . §p < 0.001. ¶p < O.OO01.

also more likely to conclude that they had sufficient t ime to pe r fo rm research. After adjustment, only the differences in percept ions of research skills and the suppor t level of the research envi ronment remained be tween men and w o m e n faculty.

Grants, Publications, Academic Rank, and Compensation

Men submit ted more grants (2.8 vs. 2.0, p < 0.05) and had more grants funded than did w o m e n (1.4 vs. 0.8, p < 0 .01) during the per iod 1 9 8 3 - 1986 (Table 5). Men faculty repor ted a higher ratio of grants funded to grants submit ted (0.6 vs. 0.4, p < 0 .05) . Men also had more articles publ i shed in refereed journals be- tween 1984 and 1986 (4.0 vs. 2.5, p < 0 .001) , as wel l as more of such publ icat ions over the courses of their entire careers (18.1 vs. 6.5, p < 0 .001) . (None of these differences remained after mult ivariate adjust- ment . ) There was no difference in the numbers of ab- stracts submi t ted (unadjusted 3.1 vs. 2.9, NS; adjusted 2.2 vs. 2.2) or accepted (unadjusted 1.3 vs. 1.0, NS; adjusted 1.1 vs. 0.9, NS) be tween male and w o m e n faculty in the 1985 - 86 year or in the ratios of abstracts

accepted to abstracts submit ted (unadjusted 0.6 vs. 0.7, NS; adjusted 0.8 vs. 0.7, NS).

Men were more often full or associate professors (42% vs. 16%, p < 0 .001) , tenured (28% vs. 13%, p < 0 .001) , and chiefs of general medic ine sections [87 (20%) vs. 13 (9%), p < 0.01]. Women were compen- sated at a lower rate than were men (mean annual salary of $62,000 vs. $74,000, p < 0 .0001) . Following mul- tivariate adjustment, only the difference in amounts of compensa t ion remained.

DISCUSSION

A number of recent studies have revealed differ- ences in research performance , academic rank, and compensa t ion be tween men and w o m e n in academic medicine.3, 10, 11 We have looked at these areas in detail in a single academic discipline to understand some of the reasons for these differences, including the contri- but ion of factors such as age, type of training, hours worked per week, and faculty rank. Our study involved academic faculty from divisions of general internal medicine, a field wi th a relat ively high propor t ion of w o m e n faculty (23% as demonstra ted by our data).

4ZZ Carretal., WOMEN AND MEN GIM FACULTY

Research and publications have traditionally been the hallmark of achievement in academic medicine. Several studies have shown that women are less produc- tive in research and the resulting publications.3, 10 With such differences in amounts of research productivity, women might not be regarded as serious in their pursuit of advancement in academic medicine, and this could be at the very core of differences in the levels of aca- demic promot ion and success.

In our study we have examined in detail factors affecting research in divisions of general internal medi- cine. Women enter faculty positions in general medi- cine with fellowship training similar to that of men. Despite this, women do not assess their research skills as highly as do their men colleagues. This could repre- sent the fact that women do their fellowships in less research-oriented programs, that they opt for a more clinically directed track during their fellowships de- spite the availability of research training, or that they have more difficulty in applying the research training they have acquired. It is also possible that women have similar skills but assess their abilities more harshly than do men or that men overestimate their abilities. We do not have information that would allow us to correlate self-assessed skills with actual ones, but certainly a lack of confidence can be detrimental to an academic career.

There were also differences between men and women in how they judge the degree of support for research that they received in their institutional set- tings and how much time they were able to devote to research. Overall, women perceived less support for their research as well as their teaching/educat ional ac- tivities and administrative duties, with differences in mean value scores of 1 0 - 20%. Women rated the insti- tutional support for their research and the research en- vironment more harshly than did men. In addition to the perceived differences in amounts of institutional support for men and women, we also found actual dif- ferences in the availabilities of research assistants and a trend toward less access to secretarial support for women. Women also reported less time available to conduct research studies than did men.

Perhaps women simply do not choose to pursue the research component of academic medicine. Pre- vious studies have shown that women in medical school place a high value on patient contact in their specialty training selection, while men are more tech- nically and cognitively oriented. 12-15 This may help to explain why women faculty have gravitated to divisions of general medicine, which are more clinically and ed- ucationally oriented than most other fields in internal medicine. 4 Still our study indicates that within general medicine women and men sought similar amounts of time devoted to patient care and protected time for research. Women did, however, express a desire for more teaching/educat ional time than did men, but the

actual difference was small. Women also indicated the same commitment and interest in research as did their men colleagues, and similar levels of tenacity, endur- ance, and energy. It appears that women have the gen- eral desire to do research but that they have less time and support to engage in it.

Other studies have suggested that women are not as academically productive as are their men colleagues. Men scientists published about twice as many scientific papers as did their women counterparts, and this dis- parity increased over the courses of their careers.16 Our data show that when adjusted for other variables, there is no significant difference in the number of abstracts, grants, or publications in refereed journals, both in a discrete two-year period and over the course of entire academic careers. Our study is limited by the fact that we did not control for marriage and children. Previous studies have not revealed these factors to have a nega- tive impact on academic productivity, 17, 18 al though women faculty assert that children have slowed their academic progress. 19

We conclude from our data that women are as likely to be promoted, to be tenured, and to become chiefs of a general medicine section as are men, when age and other factors are taken into consideration. How- ever, our numbers may be too small to show minor differences. Our data should be interpreted with cau- tion: other studies, including a recent study of medi- cine and radiology faculty, have not shown that women and men are equally likely to be promoted. 1, 3

Women working in many fields have been paid less than their men counterparts. 2° American Medical Asso- ciation data have previously shown that women physi- cians earn less than their men colleagues even after adjusting for hours of work per week and specialty type.21.22 Our study has controlled for many other fac- tors in addition to these two variables. We still find a significant difference in levels of compensat ion be- tween men and women faculty.

The conclusions of our study are limited by the fact that the data are based on faculty self-report, not inde- pendent observations. We have no way to verify the accuracy of the responses. However, faculty did not know that their answers would be analyzed by gender, minimizing the likelihood of response bias by gender. We also acknowledge that academic advancement by rank is a complex procedure that necessitates judgment on the quality of publications and clinical work, which is difficult to analyze in any study. Still, we provide data that have not previously been available, which allows a more comprehensive evaluation of the status of women in general internal medicine.

Overall there are a great many similarities between men and women faculty in divisions of general internal medicine. Important differences remain, especially in areas of research time, perceived research skills, sup- port for research, and compensation. Do these differ-

JOURNAL OF GENERAL INTERNAL MEDICINE, Volume 7 (July/August), 1992 423

e n c e s r e f l e c t a s y s t e m a t i c b i a s a g a i n s t w o m e n a n d / o r

p e r s o n a l p r e f e r e n c e s o n t h e p a r t o f i n d i v i d u a l f a c u l t y

t h a t a l i g n t h e m s e l v e s b y g e n d e r ? A c a d e m i c i n t e r n a l

m e d i c i n e n e e d s to c o n s i d e r t h e s e r e s u l t s a n d s c r u t i -

n i z e i n s t i t u t i o n a l a n d d e p a r t m e n t a l p o l i c i e s t o w a r d s

w o m e n p h y s i c i a n s . W o m e n f a c u l t y , l i k e w i s e , n e e d to

e v a l u a t e t h e i r c a r e e r s a n d t h e i r p r i o r i t i e s a m o n g d i f fe r -

e n t p o t e n t i a l p r o f e s s i o n a l a c t i v i t i e s .

The authors acknowledge the contribution of Ms. Karen Tracey in the preparation of the manuscript.

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17. Cole JR, Zuckerman H. Marriage, motherhood and research per- formance in science. Sci Am. 1987;256:119-25.

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Correction

An error occu r r ed in the article, "Laboratory Diagnosis of I ron-def ic iency Anemia: An Overv iew," w h i c h appeared in the March/Apri l issue (J Gen Intern Med. 1992 ;7 :145-53) . The equa t ion for the l ike l ihood ratio l ine for the " m i x e d " popu la t ion appeared on page 149 as fol lows:

L = e (O.65429-- 1.6985"In(x))

One of the dec imal po in t s was in the w r o n g place. The cor rec t equa- t ion is as follows:

L = e (6.5429 - 1 . 6 9 8 5 . I n ( x ) )