The proportion of women entering physician-scientist training programs has increased steadily over the past 20 years such that, for the last few years, nearly 50% of the trainees enrolled in M.D.-Ph.D. programs have been women [1]. There is a gender-diversity problem in the physician-scientist work force, but it is not a recruitment problem. It is, rather, a retention problem: Several studies, including one published in September 2008 in The Journal of the American Medical Association (JAMA), have found that substantially more women than men drop out before completing their M.D.-Ph.D. degrees [1, 2, 3].

The JAMA study also found that women who complete their M.D.-Ph.D. training are less likely than male graduates to pursue academic medicine. Women still comprise only 34% of medical school faculty [4], a category that includes clinical instructors as well as medical-faculty researchers. And a study in The New England Journal of Medicine found that in six prominent medical journals, only 19% of senior authors with M.D.s were women [5].

So although half of matriculants into M.D.-Ph.D. programs are women, the percentage of graduates who engage in teaching the next generation drops and is even smaller for those who teach, see patients, and conduct research--the classic definition of "academic medicine."

Of those who do choose to pursue careers in academic medicine, the percentage of women advancing drops at each step. The 2007–08 Women in U.S. Academic Medicine: Statistics and Benchmarking Report found that, of the 34% of faculty members who are women, 40% are assistant professors, 29% are associate professors, and only 17% are full professors [4]. The higher up you go in academic medicine, the fewer women you find.

As female enrollment in medical school and M.D.-Ph.D. programs reaches or approaches parity, questions about retention should focus more on the training and postgraduate fronts: Why are fewer women than men finishing M.D.-Ph.D. programs? Why are fewer female graduates choosing careers in academic medicine? And what can we do about this pre- and postgraduate attrition?

Finding balance

To succeed as a clinician-researcher, a physician-scientist uses his or her mastery of both clinical practice and basic science research in parallel, often drawing on both skill sets to find advances in the diagnosis, treatment, and prevention of human disease. Integrating these skills along the continuum from laboratory research to the practice of medicine is a constant challenge for trainees; they seek to allocate their time and talents to maximize their contribution to medical science. This challenge starts during physician-scientist training and continues on through postdoctoral training and/or residency and fellowship programs.

Moreover, it is of course desirable--for men and women--to maintain satisfying personal lives while meeting these professional challenges. This challenge tends to affect women differently--and often times more profoundly--than men. Women who want to have children and enter an M.D.-Ph.D. program (or an M.D. program with additional research training) must consider that they are committing to at least 7 years of graduate-level education--and factor in the possibility that they may have to wait to have children. Women who choose to have children during training often try to plan their pregnancies during a "less intense" year that ideally will also include medical leave after the delivery and family leave for the early months of their child's life. This may affect her choice of medical specialty--opting, perhaps, for a field that offers enough flexibility to allow time with family and time off when needed. With so many variables, it's no wonder women physician-scientists sometimes feel they need to choose between their personal and professional lives.

The role of bias

In her 2002 editorial in Nature Medicine, Nancy Andrews, now the Dean of Medicine at Duke University, noted that women physician-scientists may feel as though they must "outcompete" and "overachieve" relative to their male counterparts to attain equal standing [6]. This, she wrote, may be due to bias harbored by male colleagues toward their female counterparts. And aside from any real prejudice, the historical record of medicine as a male-dominated profession can drive women physicians and physician-scientists to perceive bias, push themselves too hard--and burn out much earlier than their male colleagues, or sacrifice their careers in part or entirely. Such intense competition also creates counterproductive tension in training programs and in the workplace.

An undercurrent of historical bias against female faculty members may also slow advancement. "The fact that women are capable of contributing to the nation's scientific and engineering enterprise but are impeded in doing so because of gender and racial/ethnic bias and outmoded 'rules' governing academic success is deeply troubling and embarrassing," wrote the authors of a 2007 report on women in academic science and engineering issued by the National Academies [7]. The authors also point out that women face unnecessary barriers to hiring and promotion in research universities and that this, consequently, deprives the United States of an essential source of talent.

Institutions have come a long way, but as the National Academies report suggests, there's a long way to go. Institutions need to take additional steps to more effectively recruit, hire, and retain the talented women that matriculate into and graduate from M.D.-Ph.D. programs in the United States. Measures that could be taken include providing child-care services for predoctoral trainees and offering more part-time opportunities for recent graduates, residents, fellows, and new faculty [8]. Perhaps the most important step for the future is to establish accountability when it comes to issues of recruitment and retention of women in the physician-scientist work force: Identify shortcomings, set new goals, and develop solutions to meet them as quickly as possible.

Promoting equality equally

As the National Academies report noted, institutional changes are essential. But holding those institutions accountable must coincide with individual efforts: Women pursuing physician-scientist careers should insist on equal treatment. Women should strive to be responsible advocates of equality, both for themselves and for future women physician-scientists. In particular, women physician-scientist trainees should critically evaluate the resources available at a particular institution prior to matriculation and throughout their training, and, once there, carefully consider each putative case of gender discrimination. If the resources seem scarce, then women should work with peers to establish them.

Another key component must be the inclusion of male trainees and faculty members in the process. Both men and women need to address issues of equality during and between each career step to ensure the equal representation of women. Men are often aware of the problems and witness the different challenges men and women face during training, but they lack a mechanism to offer suggestions and solutions to correct them. Women should seek input from their male colleagues as they work toward addressing the issues we discuss here.

Networking

A key issue in the retention of women in the trainee pipeline and beyond is ensuring they have support from peers and mentors [9]. Social networks specifically for physicians and physician-scientists, both in the form of online peer groups and through professional organizations, provide opportunities for women to connect with others for ideas, solutions, and inspiration. Organizations such as the American Physician Scientists Association and the American Medical Women's Association, for example, provide venues for collaboration and the formation of supportive professional relationships. The American Medical Association, as well as the American Medical Student Association (AMSA), also has several groups and initiatives aimed at addressing the concerns of women in their roles as physicians and physician-researchers. M.D.-Ph.D. programs are usually very small, so such organizations and social networks provide opportunities for women to meet people at other institutions, discuss areas of common concern, and learn from others' successes and failures.

All physician-scientists and trainees need strong mentors, and the field in particular needs strong women mentors to address questions and concerns among female trainees, graduates, and early-career clinical faculty. As noted earlier, there are fewer high-ranking women faculty members at academic medical centers, so finding established women physician researchers to serve as mentors can be difficult. National organizations, however, and existing resources such as the previously named organizations can help women along the physician-scientist career path identify successful mentors who can answer questions and offer support.

An intrinsic asymmetry

A key word for women preparing for careers as physician-scientists in the 21st century is "initiative." Women must take the initiative to clearly evaluate their academic institutions and to offer constructive criticism to pave the way for the next generation of female physician-scientists. Through action committees and strong social networks, women can find support, seek mentorship opportunities, and implement changes that support the female physician-researcher. Gathering information and documenting current trends can provide factual evidence that such change is necessary and provide insight into the best means of troubleshooting the problems.

Physician-scientist training is a long, winding road, but it is navigated by some of the best and brightest people, both men and women. The fact that men and women tend to navigate this system differently means that there is an intrinsic asymmetry--but asymmetry need not become inequality. It is important that institutions strive for parity while making every effort to retain every capable person who pursues such a career. Physician-scientists are known for their ability to conduct translational research--working out complicated problems, developing solutions, and applying them to a population in need. It is time to apply a translational approach to the very people who are trained to practice it, by turning ideas into real-world solutions for the problems faced during M.D.-Ph.D. training in order to retain women in academic careers as physician-scientists. 

References

1. D. A. Andriole, A. J. Whelan, and D. B. Jeffe, Characteristics and Career Intentions of the Emerging MD/PhD Workforce. The Journal of the American Medical Association 300, 1165-1173 (2008).

2. Recommendations for Revitalizing the Nation's Physician-Scientist Workforce (Association of Professors of Medicine Physician-Scientist Initiative, Washington, D.C., 2008).

3. J. Bickel et al., Increasing Women's Leadership in Academic Medicine: Report of the AAMC Project Implementation Committee. Academic Medicine 77, 1043-1061 (2002).

4. Women in U.S. Academic Medicine: Statistics and Benchmarking Report, 2007-2008 (Association of American Medical Colleges, Washington, D.C., 2008).

5. R. Jagsi et al., The "Gender Gap" in Authorship of Academic Medical LiteratureA 35-Year Perspective. The New England Journal of Medicine 355, 281-287 (2006).

6. N. C. Andrews, The other physician-scientist problem: Where have all the young girls gone? Nature Medicine 8, 439-441 (2002).

7. Beyond Bias and Barriers: Fulfilling the Potential of Women in Academic Science and Engineering (Committee on Maximizing the Potential of Women in Academic Science and Engineering, National Academy of Sciences, National Academy of Engineering, and Institute of Medicine, National Academies Press, 2007).

8. R. A. Harrison and J. L. Gregg, A Time for Change: An Exploration of Attitudes Toward Part-Time Work in Academia Among Women Internists and Their Division Chiefs. Academic Medicine 84, 80-6 (2009).

9. M. Singer, Beyond Bias and Barriers. Science 314, 893 (2006).

Coming Soon: A Network Just for You, Whoever You Are

Next month, Science Careers and the new Clinical and Translational Science Network will start to roll out a tool to help get you plugged in to the clinical and translational science community. You will be able to set up a professional profile, join groups belonging to our nine affiliated professional societies, discuss career issues, arrange to give a talk at a neighboring lab, establish a research collaboration, or locate a mentor or a protégé in your field of scientific interest. This isn't just another time-wasting online network; it's an online tool for establishing career-relevant relationships with real-world implications.

And we're already developing a group dedicated to the issues faced by women in academic medicine. Stay tuned to learn how to sign up!

James M. Pauff is a 5th year M.D.-Ph.D. trainee in the Medical Scientist Program at The Ohio State University, and he is the president of the American Physician Scientists Association. He is currently finishing medical school training.

Misty Richards is a 4th year M.D.-Ph.D. trainee at Albany Medical College, and she is the national student president-elect of the American Medical Women's Association. She is currently working in Tokyo, Japan, on a Fulbright Scholarship.

10.1126/science.caredit.a0900015