In the debate over universal health care, little attention has been paid to medical schools and their faculty members, who are an essential element of the health-care work force and who play a prominent role in issues of inequitable access to medical care and spiraling medical costs. We depend on medical-school physicians and research scientists to educate the nation’s future physicians and to drive most development and innovation in U.S. medical care. But they are leaving academic medicine at unsustainably high rates. Compounding that attrition, 42 percent of faculty members in the field report burnout. That alarming rate of dissatisfaction is especially high among women, who constitute about a third of the nearly 130,000 medical-faculty members in America.
Over the past 25 years, steadily increasing numbers of women have graduated as physicians in sufficient numbers to be well represented today in senior and leadership positions in the nation’s academic medical centers. Yet women’s advancement in those centers has stalled. They rarely hold decision-making positions. For example, the average medical school has 35 female full professors, compared with 188 male counterparts. Only 8 percent of clinical-department chairpersons are women. By not realizing the full potential of women in academic medicine, we are squandering the public resources devoted to their training.
Medical schools also have great difficulty recruiting and retaining faculty members of color. Only 4 percent are Hispanic, and just 2 percent of those in other than historically black medical schools are African-American.
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Although numerous well-intentioned interventions over the past 30 years have sought to investigate women’s lack of advancement in medicine, they have relied largely on a skills-deficit explanatory model, suggesting that men are more successful because they receive more mentoring, have better negotiating skills, and so on.
Seeking a better understanding of the organizational culture in academic medicine, and especially why women and people of color do not advance, my colleagues and I conducted comprehensive interviews with medical faculty members in two research studies. Our subjects—both male and female, majority and underrepresented minority—were drawn from a variety of medical specialties and career stages. Because women and minority faculty members do not bear the responsibility for having created the dominant culture in academic medicine, it was easier for them to critically examine their experiences and articulate problems from an “outsider group” perspective.
Our interviews confirmed that medical faculty members, men and women alike, are stimulated by the opportunity to apply science to bring better medical care to patients. They are motivated by a social mission to care for all citizens, including those from underserved groups. They relish their autonomy and the variety of their work, and many find teaching to be profoundly rewarding. They spoke of the rewards of developing trust and relationships with patients.
Yet our interviews showed a sharp disconnect between the values of individual faculty members and the values of academic institutions of medicine. Many faculty members believed that their institution did not always share their altruistic motives. “I hear the same kind of business-speak as I heard in the private for-profit company,” one interviewee noted. As a result, faculty members perceive less meaningfulness in their work and often experience moral distress that not only prevents them from working at their highest potential but may also contribute to their leaving academe.
Interviewees described a culture in which people have difficulty relating to one another. Many faculty members complained of not being recognized as individuals beyond their professional role. The feeling that they could not bring their personal selves to work seemed to have a dehumanizing effect, suppressing the very qualities that allow doctors to show compassion and sensitivity to others. Women and underrepresented minority faculty members in particular spoke poignantly of their sense of isolation and invisibility: “Nobody cares what makes me tick here. I’m completely invisible—as a human, as a person. I go through most of my day with nobody recognizing me as a unique individual,” said one woman.
Respondents perceived that within their medical schools’ culture, individuals often made decisions and choices to benefit themselves rather than contribute to the common good: “People are scrambling up over one another, trying to find their way and find their niche and find their grants. ... Very nice, thoughtful people become very selfish and self-indulgent,” said one interviewee. The intensely competitive environment becomes a barrier to collaboration and leads to an inability to trust colleagues or leaders, and to an erosion of trust in the entire system.
If the existing academic culture is daunting for medical-school faculty members in general, it is even more so for women and underrepresented minority professors, who are subject to biases both conscious and unconscious. Women continue to be defined by gender-role expectations, and those who have authority are perceived as less likeable and less competent than their male counterparts. Although many white male professors dislike the culture of academic medicine, they are less alienated within the current system than others are, and they command higher salaries, receive more grants, and more easily gain promotion, status, and power. The men we interviewed were largely unaware of bias directed at women, just as white faculty members failed to notice the overt and covert racism and stereotyping experienced by faculty members of color.
Many of the women we interviewed—especially those in leadership positions—were able to be successful while maintaining the perspective of an outsider and attempting to change the system. Those strong but still vulnerable women often used their power to improve the situation of other faculty members. Women welcomed and sought leadership roles in which they perceived that they could make such improvements. Traditionally trained and reinforced leaders from within the organization may be unwilling or unable to contemplate and drive the necessary changes in medical schools. Some respondents questioned whether academic medicine can continue its tradition of attracting the best and brightest candidates. Perhaps the transformative leaders need to come in increasing numbers from among outsiders: women and people of color.
Even though today more medical leaders express a willingness to talk about diversity, their organizations and duties are not yet structured to foster those changes. By fostering high-quality workplace relationships, inviting diversity, and encouraging values-based mentoring for faculty members, schools of academic medicine can ensure a more inclusive, creative, and collaborative enterprise, one that is less individualistic and competitive. We need to cultivate environments where leaders, faculty members, and students can trust one another and develop awareness of self and others, curiosity about differences, tolerance for the unfamiliar, and continuous self-reflection.
Rather than initiating isolated diversity interventions, let us work on improving the overall culture of academic medicine. The consequences of not welcoming differences extend beyond the female and minority faculty members who are directly affected. The current culture suppresses divergent intellectual perspectives and discourages the openness and trust that are necessary for innovation and collaboration in research, education, and care for a diverse nation.
There is a parallel between the emotional detachment felt by medical-school faculty members and ineffective communication between doctors and their patients. If faculty members feel disconnected and cannot openly communicate among themselves, they are less likely to create good relationships with students and patients—regardless of their sex, race, career stage, or discipline.
