Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence

Summary

Women are under-represented in academic medicine. We reviewed the empirical evidence focusing on the reasons for women's choice or rejection of careers in academic medicine. Using a systematic search, we identified 52 studies published between 1985, and 2015. More than half had methodological limitations and most were from North America. Eight main themes were explored in these studies. There was consistent evidence for four of these themes: women are interested in teaching more than in research; participation in research can encourage women into academic medicine; women lack adequate mentors and role models; and women experience gender discrimination and bias. The evidence was conflicting on four themes: women are less interested in research than men; women lose commitment to research as their education and training progress; women are deterred from academic careers by financial considerations; and women are deterred by concerns about work–life balance. Inconsistency of findings across studies suggests significant opportunities to overcome barriers by providing a more enabling environment. We identified substantial gaps in the scientific literature that could form the focus of future research, including shifting the focus from individuals' career choices to the societal and organisational contexts and cultures within which those choices are made; extending the evidence base to include a wider range of countries and settings; and testing the efficacy of interventions.

Introduction

Since Elizabeth Blackwell became the first woman to receive a medical degree in the USA in 1849 and the first to be recorded on the medical register in the UK in 1859, societies on both sides of the Atlantic have achieved gender equity in admissions to medical schools, but women remain significantly under-represented in academic medicine.1, 2, 3 Women constituted 40% of admissions to medical schools in 1980 in the UK and in 1992 in the USA, and by 2013 constituted 55% of students entering medical schools in the UK and 47% in the USA.4, 5, 6 However, despite increases in the percentage of women faculty from 21% in 2004, to 28% in 2014, in the UK,⁷ and from 30% in 2004, to 38% in 2014, in the USA,³ gender equity in academic medicine has not yet been achieved. The disadvantages of fewer women choosing careers in academic medicine include a waste of intellectual capital,⁸ and a potential lack of diversity in the research agenda and future health practices.9, 10 Given international concern about the need to revitalise academic medicine and its leadership,¹¹ a better understanding of how to enhance the recruitment and optimal contributions of women in academic roles might improve the likelihood of accomplishing academic medicine's missions.

In the past decade, gender equity in science, technology, engineering, mathematics, and medicine has received significant attention in policy. In the USA, the National Science Foundation has launched the ADVANCE programme to increase the representation and advancement of women, promote gender equity, and develop a more diverse science and engineering workforce.¹² The Association of American Medical Colleges convened the Group on Women in Medicine and Science, which advocates for women's advancement and leadership through various initiatives, including a tool that enables medical schools to compare how well they advance women.³ The National Initiative on Gender, Culture and Leadership in Medicine: C-Change has benchmarked the culture and faculty perspectives on gender equity in US medical schools and internationally.¹³ The US National Institutes of Health has appointed the first Chief Officer for Scientific Workforce Diversity to “[lead] NIH's effort to diversify the national scientific workforce and expand recruitment and retention”.¹⁴

In the UK, several professional and scientific bodies, including the Medical School Council,¹⁵ the British Medical Association,¹⁶ the Royal College of Physicians,² and the Academy of Medical Sciences,17, 18 have reviewed the situation of women in academic medicine and suggested measures to improve it. Most notably, Professor Dame Sally Davies, the UK Government's Chief Medical Officer and Director General of the National Institute for Health Research, has challenged academic and clinical leaders to improve support for women's advancement in clinical academia through participation in the Athena SWAN Charter for Women in Science.¹⁹ The Charter encourages and recognises institutional commitment to advancing the careers of women in science, technology, engineering, mathematics, and medicine.²⁰

Our study extends two reviews about the career choice of academic medicine. We focus on women's choice or rejection of academic medicine during medical school and residency, whereas two previous reviews were based primarily on studies that did not report results by gender.21, 22 Straus and colleagues' review was based on international empirical studies from 1990 to 2005 (n=25),²¹ whereas Borges and colleagues' was restricted to US journals and included both opinion pieces and empirical studies from 1960 to 2006 (n=41).²² Neither review specifically investigated women's career choices during education and training. We have produced an interpretative synthesis of evidence based on eight theme summary statements, and within each statement we have analysed both supporting and refuting studies and assessed their methodological quality (panel).