Historically, otolaryngology has been a male dominated field with women representing only 1.5% of otolaryngologists in the early 1980s. However, more women are entering medical school each year. In the US, 55% of medical school matriculants in 2021-2022 identified as a woman while only 34.7% of residents and 18.3% of active otolaryngologists did so.1–3 Even though the number of women entering medical careers is increasing each year, there is a gap in representation of women within leadership roles.
In 2021, women represented 17.9% (N=569) of professors, 28.8% of associate professors (N=577), 40.4% of assistant professors (N=948), and 74.1% (N=216) of instructors at medical schools in the United States.4 This shows that with increasing leadership responsibility, the proportion of women decreases. Suurna and Leibbrandt support this, as they found the proportion of female physicians to negatively correlate with higher academic ranking.5 More specifically, in 2020 Epperson et al. found that women represented 14.7% of fellowship directors in otolaryngology.6
Our study aims to understand if there are any changes to this previous data and if the number of women represented in director positions of ACGME accredited fellowships in otolaryngology is representative.
The need for approval of this study was waived by the ethical review board at the University at Buffalo (#0000439). The list of ACGME accredited fellowship directors in pediatric otolaryngology programs was obtained at https://aspo.us/page/fellowshipdetails on January 4th 2022. A similar list for accredited neurotology fellowships was obtained at https://www.americanneurotologysociety.com/neurotology-fellowship-program-information on the same date. Gender and year of residency graduation of the program director was determined by searching the individual’s departmental webpage, Doximity page (https://www.doximity.com/), the American Academy of Otolaryngology membership directory, and personal knowledge of the person by the senior author. Scopus H-index was obtained at https://www.scopus.com/authid/ between January 4th-10th, 2022.
Data analysis was conducted using SPSS version 27 (IBM Corporation, Armonk, NY). Descriptive statistics and non-parametric analyses were conducted when appropriate.
A total of 32 PedOto (including 1 Canadian program) and 26 NOto fellowships were included, with 15 (25.9%) female and 43 (74.1%) male FDs (Table 1). There were 12 female PedOto fellowship directors (37.5% of PedOto) and 3 NOto fellowship directors (11.5% of NOto) (Figure 1). Mean years since residency graduation was 16.2 (95% CI 13.1-19.4) for PedOto and 22.8 (95% CI 18.7-27.0) for NOto (P=.005) (Table 2). Mean years since residency graduation was 11.8 (95% CI 9.7-13.9) for women and 21.7 (95% CI 18.6-24.9) for men (P<.001). All fellowship directors had an average of 19.2 years of experience. Years of experience ranged from 7-19 years for women and 4-41 years for men. The mean H-index was 15.9 (95% CI 10.4-21.5) for PedOto and 25.8 (95% CI 21.0-30.5) for NOto (P=.005), with 11.1 (95% CI 7.6-14.5) for women and 23.6 (95% CI 18.9-28.3) for men (P=.002) (Table 3).
There is an obvious discrepancy in the representation of women within ACGME-recognized otolaryngology fellowship leaders. The phenomenon of the ‘leaky pipeline’ describes the lack of retention of women in the workforce, specifically with increasing promotion, responsibility, and leadership and is one that is encountered in other professional fields as well. When looking at academia and medicine as a whole, there is a well-established pattern of women inhabiting roles that are on the lower rung of the ladder. Even within medical school faculty, after accounting for age, years of experience, specialty and measures of research productivity, women are still significantly less likely to be full professors.7
Review of current literature and our findings brought forth an important question: where are the senior women in these spaces? Analysis of general surgery residency directors found that women were appointed to their positions at a younger age than their male counterparts, with fewer years between appointment and residency graduation.8 Within otolaryngology leadership roles, which accounts for chairs, residency directors, and fellowship directors, only 15.3% of positions are held by women.6,9 Furthermore, Epperson et al. noted that these women had significantly fewer years in practice, lower h-indices compared to their male counterparts, and even fewer had more than 20 years of experience.6 In another study, productivity differences between academic otolaryngologists at different stages of their respective careers showed that men had significantly higher h-indices and had been publishing for more years than women, specifically in the early and mid-stages of their careers. Even though there was no established difference between h-indices within the late career stage, the total number of women in this cohort was low with very few women having greater than 16 years of practice.10 Additionally, Diehl and colleagues wrote a recent article on how age hinders women’s careers. When women are young they are perceived as inexperienced; however, as they age they are seen as outdated. On the other hand, men are perceived as more valuable as they age in leadership roles.11 This lends more support to our claim that senior women are underrepresented among leadership roles. Our analysis of pediatric and neurotology fellowships further corroborates these discrepancies. Both specialties have a significant disparity in the number of women fellowship directors and a significantly less number of years since residency graduation, indicating once again that senior women faculty are being looked over in these spaces.
Identifying the causes behind these inequities is imperative before solutions can be suggested. Domestic responsibilities among heterosexual couples, especially those with children, have historically been unequally divided with women having to take on a larger role in the home. A recent survey among surgical trainees and faculty at an academic center revealed that women faculty took on the primary role in childcare planning, meal planning and grocery shopping. The same study found that women were less likely to be on a tenure track.12 Female physicians tend to be less advanced in their specialty of choice, pursue senior academic or hospital positions less often, and instead apply to more part-time positions. Add in the role of parenthood, the negative effects are further enhanced on career advancement.13 To add fuel to the fire, there is a well-established pay disparity within otolaryngology. In the 2020 Doximity Physician Compensation Report, otolaryngology has the highest gender wage gap of all medical and surgical specialties. The gap is 22.1% after accounting for age, experience, faculty rank, and research productivity.14,15 Interestingly, a study analyzing all surgical fellowship directors found a negative correlation between subspeciality compensation and female representation.16 Is the pay gap discouraging women from pursuing executive positions?
Female representation alone is important for trainees - female otolaryngology residents have made it clear that having female attendings, coworkers, career mentors and research mentors was an important factor when ranking programs.17 It is imperative to address these discrepancies, whether that encompasses hiring experienced women, instituting tenure pathways for women in otolaryngology, or lending additional support to address the above-mentioned lifestyle inequalities. It is apparent that we are not valuing a critical population that has broken the glass ceiling and paved the way for young women. Having senior women on the stage provides a source of invaluable mentorship for young trainee’s and helps contribute to diversity and equity.
ACGME Otolaryngology FDs do not reflect the gender distribution of academic otolaryngologists today, especially senior women. Initiatives need to be taken to encourage retention of women in otolaryngology.