Satisfaction of Women Faculty in Academic Medicine

Abstract

Purpose:

Research about academic medicine women faculty has focused on comparisons of men and women or specific groups who achieved leadership. To better understand the low percentages of women in academic medicine leadership, attention should be paid to the career continuum within genders. Study findings will inform policies and programs to support women in building careers and acquiring leadership positions.

Materials and Methods:

Association of American Medical Colleges (AAMC) StandPoint Faculty Engagement Survey data are used to describe and compare women assistant, associate and full professors' perceptions of (1) career development and advancement opportunities, and (2) a culture and climate that fosters diversity, equity, and inclusion. Specific similarities and differences with men are highlighted.

Results:

Fifty-nine percent of women respondents were assistant, 25% associate, and 16% full professors. Associate professors of both genders were the least satisfied on the main measures. Women were less satisfied than men at each career stage across the majority of variables. Among women, fewer than half of full and associate professors, and 52% of assistant professors believe they can express their opinions without fear of retribution. While the majority at all ranks (69%–75%) report feeling respected in the workplace, among those who did not, the highest percentage of disrespect based on gender was among associate professors.

Conclusions:

The perceptions of >7,500 academic medicine women faculty, representing different generations and ranks, underscore the need to broadly address gender inequity and sexism throughout the career continuum. It identifies the mid-career stage as a challenging experience for both men and women. Women, especially at the associate professor rank, remain a critically dissatisfied and underresourced group that is at risk for underutilization and potentially exit from academic medicine. All ranks of women need career development and equitable policies to support their sense of belonging and career advancement.

Introduction

Gender parity among U.S. medical student matriculants occurred in 2017 and since that time, the women matriculants have exceeded the number of men matriculants annually.¹ While this numeric equality was celebrated, women have accounted for >40% of medical students for more than two decades. Despite this robust cohort, in U.S. medical schools, increasing disparities in the representation of women faculty persist with each increase in rank.^2
–4 In 2021, 52% of assistant professors, 40% of associate professors, and 28% of full professors were women.⁵ Furthermore, women remain highly underrepresented in leadership positions within academic medicine,^3,6 especially at the highest levels, representing only 22% of interim and permanent department chairs⁷ and 24% of deans of medical schools in 2021.⁸ The lack of women in senior and leadership roles keeps academic medicine from reaping the organizational benefits of a diverse workforce.

To achieve equity in leadership roles in academic medicine, we must understand why greater equity in faculty ranks and senior leadership has not been achieved for women. Previous research has identified contributing factors, including gender-based disparities in salaries, start-up packages, NIH funding, and tenure track appointments, as well as detrimental organizational structures, including traditional academic measures of productivity such as first- and last-author publications and impact.^3,9
–11 Some gender inequities in faculty careers can also be partially attributed to organizational climate, including gender stereotypes and unconscious bias, as well as lack of mentorship and sponsorship, which impact women throughout their careers and impact their paths to leadership.^12
–14 Furthermore, for women of color or LGBTQ+ women, these factors and the impact on their career advancement are even more pronounced.^15

–18

To date, research about women faculty in academic medicine has largely focused either on gender disparities or on particularly successful women such as department chairs or deans.^6,19 To better understand the challenges, a targeted look at the important differences of advancement trends by rank within gender is needed. Previous studies have presented the career barriers to women as a singular group or by rank looking at promotion or attrition trends.^20
–22 Recent data indicate that at every rank, women are less satisfied than men with experiences in academic medicine and its climate for promotion and equity.²³

This study seeks to understand the unique needs and challenges to women's advancement by examining their perceptions of promotion, diversity, and respect at all ranks. This approach confirms an emerging understanding that while many challenges are shared, “women” are not a monolithic group with entirely shared experiences–specific and targeted analyses are needed to understand advancement and attrition of different groups. Moreover, by studying the perceptions of groups, not just data trends, we can better understand barriers to advancement.

To achieve this, engagement survey data from 19,364 medical school faculty across 30 institutions were analyzed, specifically women faculty perceptions by rank as related to (1) career development and advancement opportunities, including mentorship, and (2) a culture and climate that fosters diversity, equity, and inclusion, including respect in the work environment. Women faculty at the ranks of assistant, associate, and full professors were compared to describe their demographics as well as their perceptions. To inform the generalizability of significant perceptions among the women and to provide context for the findings, analyses were completed to compare men and women.

Findings from this study should inform policy and program developments that support women faculty in building their careers in senior ranks and acquiring leadership positions in academic medicine.

Materials and Methods

Thirty institutions administered the Association of American Medical Colleges (AAMC) StandPoint Faculty Engagement Survey (SFES) between March 2017 and March 2020. The AAMC SFES, is a web-based survey offered as a tool to U.S. medical schools to assess the engagement and retention intentions of faculty. The survey is an optional service through which schools may choose to collaborate with the AAMC who administers the survey on their behalf. The AAMC sends the initial survey to faculty through email and follows up with a series of reminders over a 4–6-week period. Participation is voluntary, and respondents may stop the survey or skip any question.

The SFES was developed in 2008 and first administered in 2009 based on rigorous literature review, faculty focus groups, and cognitive testing by experts in academic medicine and organizational management.²⁴ It has been administered continually at periodic intervals by schools since 2009. The majority of survey items use a five-point Likert agreement and satisfaction scales (one lowest and five highest) and are organized into topical domains that reflect the factors known to drive engagement within academic medicine. This study presents faculty data from the following topical domains of the SFES to address our hypotheses: workplace culture, relationship with supervisor, feedback and mentoring, opportunities for growth, promotion equality, collegiality and collaboration, and faculty diversity and inclusion. Analyses include an examination of the data by academic rank, defined as assistant, associate, and full professors.

We used IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, NY) to generate descriptive statistics and chi-square analyses that examined SFES data by gender and rank, describing the experiences of women faculty groups at all stages of their career. Due to the potential for confounding age and rank, especially among associate and full professors, data analyses were conducted by age groups within ranks. While this analysis focused on examining the perceptions of women across ranks, additional analyses were conducted for comparisons with men faculty to further contextualize the findings. This research was approved by the AAMC's IRB of record, the American Institutes of Research.

Results

Demographics

Approximately 64% of invited faculty (n = 19,364/30,306) participated in the survey from across 30 institutions. Institutions included are diverse in terms of region, faculty size, research intensity, ownership type (public/private), community-based designation, and age of school. Of the 19,364 respondents, 7,594 women faculty in assistant, associate, and full professor ranks responded, representing 39% of respondents. More than half of those women respondents were in the assistant professor rank (59%), one quarter of women were in the associate professor rank (25%), and 16% were in the full professor rank (Table 1). These demographics are consistent with national faculty gender trends presented in the AAMC's Faculty Roster.⁵ Comparisons among rank show higher percentages of underrepresented in medicine faculty at lower ranks (Table 1). Those who identify as lesbian, gay, or bisexual (LGB+) are consistently between 3% and 4% at each rank. Most full professors are age 56 or older (N = 750, 73%), compared with 27% (N = 418) of associate professors and only 9% (331) of assistant professors.

Table 1.

2017–2020 StandPoint Women Faculty Engagement Survey Respondent Characteristics

Demographic categories	Full professors	Associate professors	Assistant professors
All women faculty respondents	1,198	1,912	4,484
Appointment type
Full-time	1,082 (91.5%)	1,680 (89.4%)	3,889 (88.0%)
Part-time	100 (8.5%)	200 (10.6%)	532 (12.0%)
Race
White	908 (77.1%)	1,268 (68.1%)	2,569 (59.9%)
Asian	172 (14.6%)	370 (19.9%)	1,139 (26.6%)
AIAN, Latinx, Black, NHPI, other	98 (8.3%)	223 (12.0%)	579 (13.5%)
Department/degree type
Basic Science Department	262 (22.0%)	211 (11.2%)	357 (8.1%)
Clinical Department with MD/equiv. degree	741 (62.3%)	1,401 (74.1%)	3,388 (76.7%)
Clinical Department with PhD or other degree	187 (15.7%)	280 (14.8%)	675 (15.3%)
Patient care (faculty in Clinical Departments)
Provides patient care	681 (77.4%)	1,340 (86.2%)	3,253 (89.7%)
Does not provide patient care	199 (22.6%)	214 (13.8%)	374 (10.3%)
Age (generation age bands, age equivalent in 2020)
1996–later (24 years old or younger)	1 (0.1%)	11 (0.7%)	50 (1.4%)
1977–1995 (25–45 years old)	7 (0.7%)	282 (18.0%)	2,373 (64.5%)
1965–1976 (46–55 years old)	269 (26.2%)	857 (54.7%)	925 (25.1%)
1946–1964 (56–75 years old)	698 (68.0%)	410 (26.1%)	328 (8.9%)
1945–earlier (75 years old or older)	52 (5.1%)	8 (0.5%)	3 (0.1%)
Sexual orientation
LGB+	36 (3.8%)	42 (3.0%)	96 (3.0%)
Straight/heterosexual	908 (96.2%)	1,360 (97.0%)	3071 (97.0%)
Administrative title
Administrative title	720 (62.6%)	987 (53.5%)	1,243 (28.6%)
No administrative title	430 (37.4%)	859 (46.5%)	3,102 (71.4%)

LGB+, lesbian, gay, or bisexual.

Within each rank, the majority of faculty are in clinical departments (78%–98%) (Table 1). Among those in basic science departments (N = 830), 32% are full professors, 25% are associate professors, and 43% are assistant professors. In comparison, among those in clinical departments (N = 6,672), 14% are full professors, 25% associate professors, and 61% assistant professors. Many full professors have administrative titles (63%) compared with 54% of associate professors and 29% of assistant professors (Table 1). Administrative titles in the SFES are defined as Deans, Sr. Associate, Associate and Assistant Deans, Department Chairs, Division/Section Chiefs, Vice Chairs, Center Directors, Residency/Fellowship Program Directors, Course/Clerkship Directors, Clinic/Medical Director, and Laboratory Directors and other self-identified administrative roles.

Overall satisfaction

At all ranks, women were statistically less satisfied with their medical school's culture as it pertains to diversity, appreciation by their supervisor, pace of advancement, and equity in promotion than men faculty. While associate professor women and men were less satisfied than women and men full professor or assistant professor colleagues, women associate professors were the least satisfied not only among the women faculty but also in comparison to the associate professor men faculty.

Career development and advancement opportunities

The majority of women at all ranks reported being satisfied with their sense of belonging in their departments, and approximately three-quarters feel appreciated and listened to by their supervisors and colleagues (Table 2). When exploring the relationship of age to responses of satisfaction, a significantly higher percentage of younger (age 46–55) associate and full professors were satisfied with their sense of belonging within their medical school department than older associate and full professors (age 56–75). Similarly younger full professor women were more satisfied with their sense of belonging in their department. A similar trend was seen for younger associate professor women but did not meet statistical significance (Table 3). Findings were similar for men.

Table 2.

StandPoint Survey Responses for Women Faculty By Rank

Survey item—percent agreement	Full professors (reference group)	Associate professors (p)	Assistant professors (p)
Career development and advancement
I feel appreciated by my supervisor	75.3%	73.3% (0.280)	75.7% (0.745)
My supervisor actively encourages my career development	65.4%	67.8% (0.011)	74.4% (<0.001)
My supervisor listens to what I have to say	75.0%	73.6% (0.693)	76.9% (0.044)
I feel appreciated by my departmental colleagues	78.1%	74.4% (0.011)	77.2% (0.801)
I am satisfied with my sense of belonging in my department	76.0%	73.8% (0.427)	74.8% (0.254)
I am satisfied with my sense of belonging in my medical school	64.4%	61.2% (0.238)	63.3% (0.014)
I am interested in opportunities for new roles and responsibilities at this medical school	63.7%	71.7% (<0.001)	77.4% (<0.001)
I am satisfied with the pace of my professional advancement at this medical school	69.5%	52.0% (<0.001)	53.6% (<0.001)
I am satisfied with my opportunities for professional development at this medical school	61.2%	51.4% (<0.001)	56.9% (0.001)
Culture and climate of diversity equity and inclusion
I feel that the workplace culture at this medical school cultivates diversity	65.7%	63.9% (0.313)	71.8% (<0.001)
Diversity, inclusion, and equity are recognized as components of institutional excellence	73.4%	71.6% (0.400)	77.3% (0.023)
Faculty can express their opinions about the medical school without fear of retribution	47.2%	40.1% (0.002)	52.1% (<0.001)
At my medical school the criteria for promotion are consistently applied to faculty across comparable positions	60.6%	45.6% (<0.001)	52.3% (<0.001)
My medical school offers equal opportunities to all faculty members regardless of gender	62.2%	57.1% (0.022)	68.0% (0.001)
My medical school offers equal opportunities to all faculty members regardless of race/ethnicity	68.7%	67.3% (0.338)	74.9% (0.001)
My medical school offers equal opportunities to all faculty members regardless of sexual orientation	75.7%	73.0% (0.209)	79.0% (0.102)
My department is successful in recruiting racial/ethnic minority faculty members	48.6%	55.9% (0.001)	64.7% (<0.001)
My department is successful in retaining racial/ethnic minority faculty members	50.3%	53.2% (0.323)	62.2% (<0.001)
Diversity is represented at all levels of the medical school	42.7%	47.9% (0.021)	60.3% (<0.001)

Table 3.

StandPoint Survey Responses for Full and Associate Women Faculty by Age

Survey item—percent agreement	Associate		Full
Survey item—percent agreement	Born 1965 through 1975 (46–55 years old)	Born 1964 through 1946 (56–75 years old)	Born 1965 through 1975 (46–55 years old)	Born 1964 through 1946 (56–75 years old)
Career development and advancement
I feel appreciated by my supervisor	75.4%	71.2% (0.290)	79.9%	76.2% (0.457)
My supervisor actively encourages my career development	69.7%	62.9% (0.056)	73.1%	64.5% (0.031)
My supervisor listens to what I have to say	75.4%	71.4% (0.124)	79.8%	74.9% (0.109)
I feel appreciated by my departmental colleagues	75.3%	74.0% (0.330)	83.3%	78.1% (0.181)
I am satisfied with how well I “fit” (i.e., my sense of belonging) in my department	76.5%	70.9% (0.066)	82.9%	75.7% (0.054)
I am satisfied with how well I “fit” (i.e., my sense of belonging) in my medical school	63.8%	59.6% (0.048)	74.2%	62.5% (0.001)
I am interested in opportunities for new roles and responsibilities at this medical school	73.3%	66.7% (0.056)	72.4%	60.4% (<0.001)
I am satisfied with the pace of my professional advancement at this medical school	55.1%	40.9% (<0.001)	72.5%	70.3% (0.060)
I am satisfied with my opportunities for professional development at this medical school	53.8%	43.9% (0.003)	66.7%	61.6% (0.199)
Culture and climate of diversity, equity, and inclusion
I feel that the workplace culture at this medical school cultivates diversity	65.8%	65.4% (0.964)	67.3%	65.2% (0.825)
Diversity, inclusion, and equity are recognized as components of institutional excellence	73.0%	73.1% (0.726)	73.5%	73.6% (0.869)
Faculty can express their opinions about the medical school without fear of retribution	41.3%	40.1% (0.511)	48.2%	48.9% (0.810)
At my medical school the criteria for promotion are consistently applied to faculty across comparable positions	49.0%	36.5% (0.001)	63.7%	60.2% (0.625)
My medical school offers equal opportunities to all faculty members regardless of gender	59.9%	53.1% (0.095)	66.0%	62.4% (0.544)
My medical school offers equal opportunities to all faculty members regardless of race/ethnicity	70.3%	64.5% (0.172)	72.7%	67.9% (0.061)
My medical school offers equal opportunities to all faculty members regardless of sexual orientation	75.6%	67.9% (0.050)	81.7%	74.5% (0.110)
My department is successful in recruiting racial/ethnic minority faculty members	58.9%	54.8% (0.075)	48.6%	48.7% (0.967)
My department is successful in retaining racial/ethnic minority faculty members	58.0%	51.0% (0.096)	51.5%	49.4% (0.023)
Diversity is represented at all levels of the medical school	50.9%	44.3% (0.122)	42.1%	43.5% (0.809)

Regarding satisfaction with professional development opportunities and career advancement, there were statistically significant differences among women at different ranks. Fewer women at the higher ranks perceived that their supervisor actively encourages their career development compared with assistant professors. Older (age 56–75) associate and full professor women were less satisfied than younger (age 46–55) associate and full professor women with their supervisor's encouragement of their career development (Table 3). Approximately half of women associate and assistant professors reported being satisfied with the pace of advancement and professional development, with associate professors having the lowest satisfaction. Both assistant and associate women professors were less satisfied than full professors in professional development opportunities (Table 2). Yet, when age is considered, the older cohort of women associate professors were significantly less satisfied than the younger cohort of associate professors with professional development. There were no differences by age within the full professor group (Table 3).

Trends were similar among men, but women reported significantly lower satisfaction at each rank compared with men, except when examining satisfaction with professional development among full professors. However, this difference was not significant.

An important aspect of professional development explored in the SFES is the type of mentoring received by faculty. The percentage of men and women who reported no formal or informal mentoring increased with rank (women 18.8%–34%; men 21%–43.6%). Across all ranks, men were statistically significantly less likely to have a formal or informal mentor. Formal mentorship was reported by low percentages of women and men faculty at all ranks, with the lowest percentage among full professors. Women assistant and associate professors were statistically significantly less likely than men to receive formal mentoring through their schools. Reports of informal mentorship, were higher than formal mentorship especially for women who were more likely than men at all ranks to report informal mentors from their medical school or from colleagues at other institutions (Table 4).

Table 4.

Faculty Mentorship by Gender and Rank

Rank and gender	I receive formal mentoring through my department or the medical school	I receive formal mentoring through a society or professional organization	I receive informal mentoring from a colleague at this medical school	I receive informal mentoring from a colleague at another institution	Have neither formal nor informal mentoring	Total of Faculty who receive formal mentoring	Total of Faculty who only receive informal mentoring	Total of Faculty who receive neither formal nor informal mentoring	Do not receive formal mentoring but is important to them
Full professor
Women	18.9%	12.9%	42.8%	32.9%	34.0%	26.3%	38.7%	35.0%	40.6%
Men	19.2% (0.833)	10.5% (0.023)	33.8% (<0.001)	21.8% (<0.001)	43.6% (<0.001)	24.9%	29.4%	45.7%	29.7%
Associate professor
Women	26.2%	11.9%	52.0%	34.9%	25.0%	31.3%	42.0%	26.7%	57.8%
Men	29.8% (0.010)	11.6% (0.809)	47.2% (0.002)	26.9% (<0.001)	28.6% (0.009)	34.4%	35.3%	30.3%	50.1%
Assistant professor
Women	36.6%	10.3%	56.9%	31.0%	18.8%	41.1%	38.7%	20.2%	65.5%
Men	43.9% (<0.001)	12.2% (0.007	52.4% (<0.001)	27.1% (<0.001)	21.0% (0.016)	47.7%	30.1%	22.2%	55.1%

The survey question presented here allowed participants to select multiple responses, with the exception of the response regarding not receiving formal or informal mentoring. For example, a respondent could select that they received formal mentoring at their medical school and informal mentoring from a colleague at another institution. Data was then aggregated into the following three categories: (1) those faculty who received formal mentoring, regardless if they received informal mentoring, (2) those faculty who only received informal mentoring, and (3) those faculty who received neither formal nor informal mentoring.

Culture and climate of diversity, equity, and inclusion

The greatest discordance observed between women at different ranks and ages is related to issues of culture and climate. While the majority of women report that their medical school cultivates and recognizes diversity, inclusion, and equity as components of institutional excellence, less than half of full and associate professors (47% and 40% respectively), and 52% of assistant professors believe they can express their opinions without fear of retribution (Table 2). For comparison, a similar pattern was found among men, although in each category slightly >50% reported being able to express their opinions without fear of retribution (full 53.7%, associate 50.3%, assistant 57.7%) Associate professors were the most concerned about expressing their opinions with only 40% of women endorsing that they felt that they could.

With regard to equity of promotion criteria, women associate and assistant professors were less likely than full professors to endorse that promotion criteria are consistently applied to faculty across comparable positions (Table 2). However, within the associate professor cohort, those who are age 57–75 were significantly less likely to agree promotion criteria are consistently applied–at a low 36.5% (Table 3).

Associate professors also consistently respond less positively to questions about equity in opportunities and promotion. This pattern is true for men and women, but significantly less women associate professors endorsed equity in opportunities than men associate professors. Most striking is that only 57% of associate professor women agreed that their medical school offers equal opportunities to all faculty members regardless of gender compared with 83.3% of men associate professors. Similar gender differences were found for full professors (62.2% vs. 85%) and assistant professors (68% vs. 85.1%). Assistant professors are more likely than full professors to endorse equal opportunities to all faculty regardless of race/ethnicity or gender and for success in recruitment of diverse faculty members. Women full professors are significantly less likely than either associate or assistant professors to endorse that their medical school has diversity represented at all levels (Table 2).

An additional measure of the workplace environment asked respondents whether over the past 12 months, they felt respected or disrespected in the workplace based on various aspects of their identity. Those who replied that they felt respected could not choose any other responses. Those who felt disrespected could identify specific areas of disrespect experienced. A significantly lower percentage of women associate professors reported being respected than full professors (68.6% vs. 74.7%) (Table 5). Women associate professors reported the highest percentage of disrespect based on their gender at 20.8% while assistant professors reported the highest percentage of disrespect based on their age at 9.6%. Women from racially and ethnically underrepresented groups in medicine reported higher rates of disrespect based on race or ethnicity than White women. Asian women also reported higher rates of disrespect than White women but lower rates than women from racially and ethnically underrepresented groups in medicine. Women across all ranks reported being disrespected because of their gender at rates between 16.3% and 20.8% (Table 5).

Table 5.

StandPoint Survey Women Faculty by Rank and Race/Ethnicity Reporting Workplace Respect

Rank	Over the past year…I feel respected in the workplace (exclusive choice)	I have felt disrespected because of my race/ethnicity	I have felt disrespected because of my gender	I have felt disrespected because of my age
Full professor	74.7% (reference group)	2.6%	16.3%	6.8%
White (n = 850)	73.9%	0.6%	17.2%	7.3%
Asian (n = 159)	79.9%	8.8%	11.3%	3.8%
AIAN, Latinx, Black, NHPI, Multiple race/ethnicity, other race/ethnicity (n = 95)	75.6%	10.5%	14.7%	6.3%
Associate professor	68.6% (<0.001)	4.0%	20.8%	6.5%
White (n = 1138)	67.6%	1.2%	22.6%	7.5%
Asian (n = 339)	75.8%	7.7%	13.9%	5.0%
AIAN, Latinx, Black, NHPI, Multiple race/ethnicity, other race/ethnicity (n = 203)	64.5%	13.3%	20.7%	4.4%
Assistant professor	72.8% (0.212)	4.0%	17.9%	9.6%
White (n = 2252)	72.6%	1.0%	19.0%	9.5%
Asian (n = 965)	75.5%	5.9%	14.1%	9.3%
AIAN, Latinx, Black, NHPI, Multiple race/ethnicity, other race/ethnicity (n = 519)	67.8%	13.7%	20.6%	10.6%

Men faculty reported very high percentages of feeling respected in the workplace across all ranks (87.7% assistant, 84.4% associate, 86.6% full). Among those who felt disrespected between 1% and 1.7% reported feeling disrespected based on gender, 2.4%–3.1% based on race or ethnicity, and 3.2%–4.8% based on age.

Discussion

This study is the first of its kind to analyze data from >7,500 women medical school faculty from across the United States representing the three primary ranks of assistant, associate, and full professors. This study presents the diverse experiences of women who vary in age, rank, race/ethnicity, and roles and, therefore, reveals areas for further study and intervention around career development, advancement, and retention. It also highlights specific areas of gender differences to illustrate what factors may be experienced differently by men and women and, therefore, may be contributing to the continued underrepresentation of women at the highest ranks of medicine. Across the main areas explored—career development and advancement opportunities, and a culture and climate that fosters diversity, equity, and inclusion—women at the rank of associate professor were the least satisfied. While men associate professors were also less satisfied than men full and assistant professors, women associate professors were significantly less satisfied than their male colleagues at the same rank.

These findings suggest that the period of being an associate professor is challenging for men and women alike but that for women faculty, the associate professor rank warrants specific attention and intervention. It is speculated that women leave academic medicine (i.e., the leaky pipeline) in the late-early to mid-career years and yet, to date, there are no national or/multi-institutional data to support the specific reasons and timing for women faculty's exit from academic medicine.²² Our findings suggest possible reasons for the loss of women at this stage of their careers. Specifically, women at the associate professor rank consistently report being the least satisfied with their sense of belonging, their career development opportunities, and their feelings of respect based on gender. Furthermore, they are the most likely to endorse a lack of equal opportunity and lack of consistency of application of promotion criteria. These findings may suggest interventions that institutions can take to retain valuable mid-career women faculty.

Our findings echo a recent study that explored senior faculty considerations toward retirement and found that senior women faculty endorsed feeling devalued for their work contributions, challenging relationships with supervisors, and lack of advancement opportunities as contributing factors in considering retirement.²⁵ One hypothesis that will require further exploration is that if senior women are considering retirement due to these challenges, the same challenges may also influence mid-career women's decisions to remain in or pursue leadership or advancement opportunities in academic medicine.

Another emerging theme was that women assistant professors were more positive than their more senior counterparts regarding career development opportunities, pace of career development, and perception of equal opportunities and promotion. However, only about half of assistant professors endorsed promotion criteria as equitable. In fact, assistant professors fell squarely between associate and full professors in their perceptions and responses. Because of the wide age range among associate and full professors, we explored the relationship of age within these two ranks. Our results showed the older cohorts in both groups were less satisfied with their sense of belonging and pace of professional development than the younger groups. Older women in the associate professor group were the least satisfied with professional opportunities relative to any group (44% satisfied). We may interpret these findings in two different ways.

First, the findings may represent a positive trajectory; for example, they may reflect more equitable environments experienced by the younger faculty, as a result of greater education on harassment, discrimination, diversity and inclusion, and structural changes to our academic medical environments through identified values, professionalism councils, and reporting structures. Or, the findings could indicate a negative trend; perhaps early career women and younger mid-career faculty have not yet encountered the challenges and experiences of those in more senior ranks. For example, as junior faculty, career opportunities may seem abundant, but it is not until women faculty face barriers to promotion or are passed over for leadership positions that junior women see and experience the circumstances reported by women in more senior ranks. Further data, including longitudinal studies, are required to understand which of these explanations is correct. Possibly both explanations are true.

Recognizing that only half of women report satisfaction with the pace of their advancement, institutions should consider reviewing women's timelines for promotion, while evaluating available positions and candidate-identification processes to fill those positions. Many leadership roles, including positions on important committees, do not have formal search processes and, therefore, may exclude women and other underrepresented groups. Instituting formal processes may increase satisfaction with opportunities for early and mid-career women and increase the pace of advancement. In addition, while most women across all ranks report being appreciated by their supervisor, those in the highest ranks report not being encouraged in their career development. This finding is important as careers do not end when an individual becomes a full professor and indeed the individual will likely have decades more to contribute. These results indicate that improved career development for women moving into chair, senior-level positions, and executive c-suite positions is much needed—and underscore where a mentor could play a role in these senior career transitions.

Most women faculty (59%–74%) do not report having a formal mentor with the lowest rates among the highest ranks. Interestingly, men were more likely across all ranks to endorse having a formal mentor at their medical school or in their department while women are more likely to endorse having informal mentors internally and externally. Of those women who did not have a formal mentor, 41%–66% believe a formal mentor is important. This finding is very important for many reasons. First, the lack of formal mentorship in early and mid-career may have disproportional impact on women's careers. In addition, formal mentorship may lead to sponsorship, which is needed for career advancement. Finally, women appear to be utilizing informal mentors, which can be of great support but may not carry the weight of a formal mentor and may impact one's career development. Women may be using these informal mentors to assist with climate, harassment or bias issues, instead of career advice, which also has a different, less significant, impact on direct career advancement.

Career development programs targeted to the specific needs of women at different phases of their careers can be impactful in helping women to advance in their careers^2,26,27 and can serve as a means to peer mentorship as well.²⁶ It is incumbent upon our academic medical systems to develop intentional and targeted career development programs,²⁸ formal mentorship programs,²⁹ and opportunities for women at all ranks if we are to retain the top women in academic medicine.

The most concerning findings of this study are related to culture and climate. The perception that medical schools offer equal opportunities to faculty regardless of gender was endorsed very differently among women (range 57%–68%) and men (range 83.3%–85%). Another critical finding is related to the culture and climate of disrespect and fear that is experienced by so many women, across all ranks. The finding that only 48% (range of 40%–52%) of women feel that they can express their opinions without fear of retribution is sobering, unacceptable, and must be understood and addressed by our institutions. In comparison, slightly more than half of men at all ranks (54%, range 50%–58%), who responded to this survey endorsed being able to express their opinions without fear of retribution. While this 6% difference may seem small, the fact that almost half of faculty do not feel that they can express their opinions is an important finding that needs further exploration and understanding. In particular, it is not clear what types of issues men and women do not feel comfortable disclosing, which may be different among men and women given the reported rates of gender harassment in academic medicine.

In addition, more than a quarter of all women faculty in each rank do not feel respected in the workplace. Of those who do not feel respected, approximately one in five women identify gender as the source of disrespect, with race or ethnicity and age also identified as reasons for disrespect. Of note, it is striking that >80% of men faculty (84.4%–87.7%) report feeling respected in the workplace. Among women, only 68.6%–74.7% of women similarly report feeling respected in the workplace. The recent report by the AAMC, Understanding and Addressing Sexual Harassment in Academic Medicine,³⁰ and the NASEM³¹ report underscore that for many women the culture includes high instances of gender and sexual harassment, which impact their career choices and trajectories. The AAMC report found that for those who experience sexual harassment, there is lack of confidence in the schools' ability to address the issue and a feeling of lack of safety in reporting.³⁰ The findings in this study, along with those from the AAMC, suggest that these experiences lead women to be less engaged, less satisfied and, potentially, less likely to stay in academic medicine.

To ensure we retain the most exceptional talent in medicine, institutions must be intentional in developing institutional processes and policies that will impact change.^31,32 Many organizations train faculty about unconscious bias, harassment, and discrimination, but must go further with experiential training and honest dialog so that the climate of our organizations change and, in turn, experiences of women faculty improve. Women cannot work, much less excel, in organizations that do not provide equal opportunities, are not respectful of everyone and suppress the open expression of ideas and concerns, especially in the discipline of medicine and science. Academic medicine thrives when all voices and ideas are heard, which enables us to conduct the best science and care for patients.

Conclusion

This study reports the perceptions of >7,500 academic medicine women faculty exploring their views of satisfaction with their advancement, sense of belonging, respect, and equity—not as a monolithic group but as a diverse group of women who represent different generations, ranks, and experiences. The results of this study underscore the need to address issues of gender inequity and sexism for all women faculty. Furthermore, the study specifically identifies that men and women who are mid-career are the least satisfied with their work culture and climate but for women who are mid-career or later their lack of satisfaction is even greater and requires specific and nuanced attention. Institutional leaders and the academic medicine community must address and intentionally develop programs to support their career development and sense of belonging. Further research is needed to fully understand the ways that interventions may target the needs of women across the academic career trajectory. If we do not make changes to the systems in place, we will continue to lose the talent of women faculty at the highest levels of our organizations.

Footnotes

Authors' Contributions

All authors contributed to the conceptualization, methodology, visualization, writing, reviewing, and editing. V.D. and D.L. also contributed to the data curation and formal analysis.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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