INTRODUCTION

The USA is a unique and diverse society with representation of people from different ethnic and racial backgrounds. US census data for 2018 showed that there were 76.6% white people, 13.4% African Americans and 5.8% Asians.¹ These statistics were disproportionate with the data on medical school enrolments by the Association of American Medical Colleges (AAMC).² According to AAMC, there were 21% Asian people, 5.4% Hispanic, 5.4% African American and 55.7% white people in a total enrolment of 19 553 students. This report also shows a slightly decrease in the enrolment of female students (47.3%) in medical schools compared with the proportion of 51% women in the general population of the USA.²

Considering the current population demographics and increasing diversity of the general population, there is a need for the diversification of healthcare professionals to provide culturally and linguistically appropriate care. It is critically important, especially in the context of estimates that more than half of US citizens will be members of minority groups by 2050.³ These disparities in healthcare affect access to quality care, patient satisfaction and health-related outcomes. Health-related disparities in the healthcare workforce also impact the mission and obligations of protecting, restoring and improving the health of all Americans.³

Gender and/or racial disparities continue to exist in medical specialties, editorial boards of medical journals and professional societies.^{4 5} This under-representation of faculty also adversely impacts the mentoring, recruitment and retention of minority students in addition to health-related outcomes.⁶ An interesting term ‘bamboo ceiling’ has been used to describe the specific challenges and barriers that the Asian American community face in rising to the upper echelons of leadership and corporate positions.⁷

Affirmative action and similar policies have resulted in a proportionate gender and racial representation in medical school enrolment and early careers in academic medicine. While the number of women and minorities has increased due to a change of policies, their concentration at the lower ranks of academic disciplines shows that more research work is needed to assess the career path and associated needs-based assessment at every academic rank and leadership position. This disparity is more apparent for leadership positions in medical schools since the under-represented minorities (URMs) occupy only 13% of medical school leadership positions.²

Several medical organisations such as the AAMC, National Medical Association (NMA) and American Medical Association (AMA) are working together to ensure the representation of the URMs in medical and professional fields.⁸ Although there has been an increase in medical students and faculty from URMs, the percentage has not changed relative to the number of positions.

The future of the neurology workforce and ethnic diversity is an important concern of the American Academy of Neurology (AAN). Despite all these efforts, URMs comprise a minority in academic neurology.⁹ Studies have highlighted the ethnic and/or gender disparity in faculty ranks including cardiology,¹⁰ emergency medicine,¹¹ radiation oncology,¹² psychiatry,^{13 14} dermatology,¹⁵ gastroenterology,¹⁶ ophthalmology,¹⁷ haematology¹⁸ and medical school faculty.¹⁹ However, the data for neurology are few and limited. Our objective was to investigate the trends in the representation of gender and racial groups in academic neurology faculty positions across the USA for over 12 years.

RESULTS

Faculty positions

Over the 12-year period there was a significant increase in total academic faculty positions of neurology from 4137 in 2006 to 6140 in 2017, with an increase in chairpersons from 110 to 129, professors from 1017 to 1442, associate professors from 1585 to 2719, assistant professors from 868 to 1213, instructors from 470 to 495 and others from 87 to 142 (figure 1). From 2006 to 2017 the increase in all faculty positions was gradual but the number of instructors increased initially and then decreased (table 1).

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Figure 1

Trend in academic positions from 2006 to 2017.

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Table 1

Positions in academic faculty of neurology

The increase was highest at the level of assistant professor with an increase of 1134 positions, followed by the positions of professor, associate professor, others, instructor and chairpersons with increases of 425, 345, 55, 25 and 19, respectively.

Racial distribution

In all academic faculty positions over the 12-year period, white people were predominant followed by Asians, Hispanics, African Americans, Multiple races-Hispanics, Multiple races-non-Hispanics, Unknown, Native Hawaiians and American Indians (figure 2). Moving down the ladder from chairperson to instructors, white people comprised a decreased proportion. There was a simultaneous increase in the proportion of Asians, Hispanics and African Americans. The racial distribution for each faculty position is described below.

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Figure 2

Racial and gender representation in academic neurology: 12-year average.

Chairperson

With regard to leadership in academic neurology (ie, department chair), white physicians comprised a higher proportion in all years although over time this decreased from 86.4% to 79.8%. Asians, Hispanics and Multiple race-non-Hispanics increased from 6.4% to 9.3%, from 0.9% to 3.1% and from 1.8% to 4.7%, respectively, whereas there was no change for the other racial categories (figure 3).

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Figure 3

Racial distribution at position of Chairperson over a period of 12 years.

Professor

From 2006 to 2017, at the level of professor, white physicians decreased from 87.4% to 81.6% while Asian and Hispanic physicians increased from 7.1% to 10.5% and from 0.7% to 2.1%, respectively (figure 4).

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Figure 4

Racial distribution at position of Professor over a period of 12 years.

Associate professor

From 2006 to 2017, at the rank of associate professor, white physicians decreased significantly from 81.1% to 68.3% whereas Asian and Hispanic physicians and those of unknown race increased from 10.3% to 19.0%, from 1.6% to 3.1% and from 2.1% to 3.5%, respectively. Physicians of other races did not show any change (figure 5).

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Figure 5

Racial distribution at position of Associate Professor over a period of 12 years.

DISCUSSION

Our study has highlighted significant racial and gender disparities over a period of 12 years in academic faculty of neurology positions. Although the total number of positions has increased and the field has become more diverse, white physicians have a higher proportion in all positions, especially at the higher tiers of academics.²⁰ But over a period of 12 years, as described by Merchant et al,²¹ the proportion of white physicians in total academic positions has decreased with a simultaneous increase in Asians and other minorities, as corroborated by our study. The absolute decrease in the percentage of white chairpersons was 7% in 12 years. At this rate, it will take more than 40 years for other races to have proportional representation in academic positions. Also, there is a higher percentage of Asians when moving down the academic ladder, with 9.3% in the position of chairperson and 22.0% at the level of an instructor in 2017.

For many years, challenges in ameliorating racial disparity in medicine and neurology have remained constant.²² These differences in proportion can be attributed to both extrinsic and intrinsic factors. Powers et al ²³ described extrinsic factors as financial support, mentorship, role models and educational opportunities. The intrinsic factors are community service, intellectual curiosity and altruism. Impediments to educational progress and training are poor education, lack of mentorship, systemic racism and stereotyping. URMs are also affected by hiring, promotions and compensation bias. There is a need for greater enrolment of URMs in MD/PhD programmes to address this racial disparity.²⁴ Similar racial disparity has been corroborated by other studies. Fisher et al ²⁵ in their meta-analysis of 23 articles reported that URMs comprised a small proportion of tenured faculty in academic neurology with the highest percentage being white people. They described tenure as related to higher salaries, leadership and a comfortable working environment.

It has been shown that the performance of groups of people working across multiple tasks is positively correlated with the proportion of diverse individuals. Numerous studies have also shown that groups perform better than the best individuals, and groups with more differing viewpoints and perspectives achieve the very best results.^{26 27} The Institute of Medicine report suggested that a more diverse workforce allows for improved access to care, facilitates better communication with patients, and improves patient-centred care concerning healthcare decision-making.²⁸ Another metric of quality in healthcare is to improve the 'cultural competence' of physicians, which has been shown to result in better health outcomes for the patient and the health system.²⁹

The gender differences in neurology faculty positions are also consistent with the existing literature.^{30 31} Men occupy a higher proportion of leadership roles such as chairperson and professors, and this trend did not change significantly over a period of 12 years. Overall, the proportion of women increased at all academic levels, but this increase was more at the instructor and assistant professor levels rather than at the leadership role of the chairperson. Carr et al ³² followed 1273 faculty members from 24 medical schools in the USA for 17 years to identify predictors of advancement, leadership and retention as a faculty member. After 17 years of longitudinal follow-up, the authors reported that women were not able to attain higher ranks in academic positions and they found low productivity, measured by the number of publications, as an explanatory reason.

Various other factors may also explain this paucity of women including lack of leadership roles and mentors, reluctance to go into senior positions, family priorities, uncomfortable working environment and not having female colleagues.^{17 33} However, there is a high need for gender and ethnic diversity in an academic setting to bring a diversity of thought, experience and background of personal experience. This is important in the backdrop of several legislations to protect the discrimination and address these disparities including Title VII of the federal Civil Rights Act and Equal Pay Act pro.^{34 35}

Another less obvious challenge that perpetuates the problem is that appointment and promotion to leadership positions in academia are primarily based on an individual’s academic performance. When selecting for leadership positions there is little consideration for an individual’s role or track record in advocacy for equity, diversity and inclusion. After appointment to leadership positions, these individuals are expected to ensure equal opportunity and affirmative action which has resulted in increased recruitment of women and minorities. The bottleneck of barriers to entry has therefore been replaced with barriers to promotion and leadership positions, since those selected for leadership positions may not have an innate interest, understanding or expertise in equity, diversity and inclusion.

Ely and Meyerson described the framework for improving women’s leadership in academics.³⁶ The first consideration was to highlight the skills that women are lacking so that institutes can take initiatives on that. The second approach is to address the barriers that create a difference in women’s progress. The third approach is to increase the visibility of women’s work and their rational skills, and the fourth is to assess the challenges in a different culture.^{37 38}

There can be several explanations for these findings, and the best way is to find the root cause is by interviewing URMs in different academic settings of neurology. Mahoney et al ³⁹ included 36 minorities faculty in their survey and found four major causes for this disparity: (1) personal commitment and institutional pressure; (2) gap between implementation and intention to increase diversity; (3) reacting to discrimination; and (4) providing minorities with mentors. There are several logistic reasons for increasing URMs in an academic setting at all rank levels. First, it will make URMs more comfortable in the working environment; second, it will help in patients’ outcomes to understand and explain the disease; third, it will include different experiences and cultural approaches; and last, it will help URMs to find mentorship and advance in medicine.⁴⁰

There are some limitations to our study. We did not look at bibliometric factors of the faculty that can affect their rank. Other confounders include specialty choice, academic interest and personal preference. Gender bias, particularly in leadership, may be due to female preference, age, experience and family priority to work in private clinics than in academics. As our study was only related to neurology, we did not find that this faculty rank difference is due to graduating from a non-US medical school. Finally, our study did not explore the combined effects of being both a gender and racial minority, such as female Hispanic or female African American/Black individuals.

CONCLUSION

Despite an increase in the proportion of minorities in the US population, URMs in the academic faculty of neurology are still under-represented. Further studies are needed to find the cause for this difference, which will help to bring more diversity to the faculty.