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ANNSURG-D-17-01419

ORIGINAL ARTICLE

Sex Differences in Faculty Rank Among Academic Surgeons

in the United States in 2014
Daniel M. Blumenthal, MD, MBA,  Regan W. Bergmark, MD,y Nikhila Raol, MD, MPH,z§
Jordan D. Bohnen, MD, MBA,ô Jean Anderson Eloy, MD,jj and Stacey T. Gray, MDy

Objective: The aim of this study was to evaluate sex differences in full
professorship among a comprehensive, contemporary cohort of US academic
surgeons.
Summary of Background Data: Previous work demonstrates that women
are less likely than men to be full professors in academic medicine, and in
certain surgical subspecialties. Whether sex differences in academic rank exist
across all surgical fields, and after adjustment for confounders, is not known.
Methods: A comprehensive list of surgeons with faculty appointments at US
medical schools in 2014 was obtained from Association of American Medical
Colleges (AAMC) faculty roster and linked to a comprehensive physician
database from Doximity, an online physician networking website, which
contained the following data for all physicians: sex, age, years since residency,
publication number (total and first/last author), clinical trials participation,
National Institutes of Health grants, and surgical subspecialty. A 20% sample
of 2013 Medicare payments for care was added to this dataset. Multivariable
regression models were used to estimate sex differences in full professorship,
adjusting for these variables and medical school-specific fixed effects.
Results: Among 11,549 surgeon faculty at US medical schools in 2014, 1692
(14.7%) were women. Women comprised 19.4% of assistant professors (1072/
5538), 13.8% of associate professors (404/2931), and 7.0% of full professors
(216/3080). After multivariable analysis, women were less likely to be full
professors than men (adjusted odds ratio: 0.76, 95% confidence interval: 0.6–
0.9).
Conclusion: Among surgical faculty at US medical schools in 2014, women
were less likely than men to be full professors after adjustment for multiple
factors known to impact faculty rank.
Keywords: faculty development, quality of life, sex differences in academic
rank, surgeon workforce
(Ann Surg 2018;xx:xxx–xxx)
From the Division of Cardiology, Massachusetts General Hospital, and Harvard
Medical School, Boston, MA; yDepartment of Otolaryngology, Massachusetts
Eye and Ear Infirmary and Department of Otolaryngology, Harvard Medical
School, Boston, MA; zDepartment of Otolaryngology-Head and Neck Surgery,
Emory University School of Medicine, Atlanta, GA; §Division of Pediatric
Otolaryngology, Children’s Healthcare of Atlanta, Atlanta, GA; ôDepartment
of Surgery, Massachusetts General Hospital, and Harvard Medical School,
Boston, MA; and jjDepartment of Otolaryngology–Head and Neck Surgery,
Department of Neurological Surgery, and Center for Skull Base and Pituitary
Surgery at the Neurological Institute of New Jersey, Rutgers New Jersey
Medical School, Newark, NJ.
Both Daniel M. Blumenthal and Regan W. Bergmark contributed equally.
Dr. Blumenthal reports research funding from the John S. LaDue Memorial
Fellowship at Harvard Medical School.
The authors declare no conflict of interests.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.annalsofsurgery.com).
Reprints: Daniel M. Blumenthal, MD, MBA, Division of Cardiology, Massachu-
setts General Hospital, Yawkey Building, Suite 5B, 55 Fruit Street, Boston,
MA 02114. E-mail: dblumenthal1@mgh.harvard.edu.
Copyright ß 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0003-4932/16/XXXX-0001
DOI: 10.1097/SLA.0000000000002662
S ex disparities in medicine—including in the availability of
medical training, hiring, and advancement—have improved sig-
nificantly over the past 50 years. Even so, these disparities remain
prevalent in academic medicine. For example, a recent analysis of
than 91,000 physicians with faculty appointments at US Medical
Schools found that women were less likely than men to be full
professors after adjustment for several measures of research and
clinical productivity known to influence the likelihood of promo-
tion.1 A follow-up analysis of 3800 US academic cardiologists
yielded similar results.2 Within the same specialty and same medical
school, female physicians earn less than their male counterparts, after
adjustment for several factors that impact physician salary.3
Sex disparities in academic surgery have also improved
somewhat over time; for example, the number of female residents
in general surgery doubled between 1999 and 2014, and the number
of women assistant professors increased nearly threefold over this
time.4 However, women remain underrepresented in academic sur-
gery at almost every level.5–8 For example, women comprise a
minority of trainees in all surgical fields, accounting for 38% of
all surgical residents and fellows, and 14% of neurosurgery and
orthopedic surgery trainees.5,9,10 In 2014, just 1% of chairs of
surgical departments at US Medical schools were women.10
Prior studies on sex disparities in surgery have several lim-
itations, including a focus on single surgical subspecialties or
surgical trainees, which limits efforts to compare disparities across
surgical fields4– 6,8,11–17; inconsistent adjustment for potential con-
founders of the relationship between surgeon sex and academic rank,
including measures of experience and clinical and research produc-
tivity; and use of noncontemporary data, which may limit how well
they reflect contemporary associations between sex and faculty rank
among academic surgeons.18–20 Therefore, we conducted a compre-
hensive, contemporary investigation of associations between surgeon
sex and academic rank among 11,549 surgeon faculty at US medical
schools in 2014. All analyses were conducted using data from
Doximity, an online networking website for physicians, and methods
identical to those employed in recent prior analyses of sex differences
in academic rank.1,2,21 We hypothesized that female surgeons would
be less likely than male surgeons to be full professors both before and
after adjustment for several factors that may influence academic
promotion.
METHODS
Data Sources
We analyzed data from a comprehensive cross-sectional data-
base of US physicians maintained by Doximity, a company that
provides an online networking service for US physicians. This
database included 1,029,088 US physicians as of July 7, 2015, when
data were provided for this study. The Doximity database includes all
physicians entered in the National Plan and Provider and Numeration
System (NPPES) National Provider Identifier (NPI) registry. These
physicians may register to use and activate their Doximity accounts;

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ANNSURG-D-17-01419
Blumenthal et al
24.0% of U.S. doctors (246,786 of 1,029,088) had registered by July
7, 2015.1,3 Physicians who lack active NPIs may self-register
with Doximity.
Doximity continuously gathers several data elements for all US
physicians in its database—including registered users and nonmem-
bers: age; sex; allopathic (MD) versus osteopathic (DO) training;
medical school and residency training names and locations; years
of medical school and residency graduations; primary board and
subspecialty certification; number of first author, last author, and total
publications; number of National Institute of Health (NIH) grants for
which the physician was a principle investigator (PI); and number of
clinical trials for which the physician was a PI or subinvestigator.
Doximity sources these data from multiple outlets, including The
American Board of Medical Specialties, state licensing boards,
PubMed, the NIH RePORT database, ClinicalTrials.gov, and through
collaborating hospitals and medical schools. A detailed explanation of
the database and validation of its accuracy has been published previ-
ously.1,3 We used publicly available Medicare claims data from 2013 to
calculate each physician’s Medicare revenue. We also denoted whether
surgeons were affiliated with medical schools ranked in the top 20 for
research by US News & World Report in 2013.22
Study Population
The study population included all US surgeons practicing
colon and rectal surgery, general surgery, neurosurgery, orthopedic
surgery, otolaryngology, plastic surgery, thoracic surgery, urology,
and vascular surgery who were assistant, associate, or full professors
at accredited US medical schools in 2014. Participating surgeons
were identified using the 2014 Association of American Medical
Colleges (AAMC) faculty roster—a comprehensive database of US
physician faculty that contains more than 160,000 physicians.23 Each
surgeon in the AAMC faculty roster was matched with his or her
Doximity profile. The human subjects review committee at Harvard
Medical School approved these data for study and waived
participant consent.
Data Validity
We evaluated dataset accuracy in 2 ways. First, given the
possibility that surgeons who had activated their Doximity accounts
might have edited the information in their profiles, thereby improv-
ing their accuracy, we compared surgeons with and without activated
Doximity accounts to determine whether systematic differences
between these groups in profile accuracy could have influenced
our findings. Second, in a prior study,1 we manually audited the
Doximity profiles of a random sample of 200 physicians with faculty
appointments at US medical schools by manually confirming faculty
rank (through review of institutional websites); publications in
PubMed; clinical trial participation through ClinicalTrials.gov;
and NIH funding through the NIH RePORT database.
Statistical Analysis
We first performed unadjusted comparisons of the character-
istics of men and women using 2-sided t tests and Chi-square tests.
Next, we estimated a multivariable logistic regression model to
predict the odds of full professorship as a function of physician
sex. This model adjusted for several covariates that could influence
academic advancement among surgeons and potentially confound
the relationship between sex and academic rank, including age, years
since residency completion, surgical subspecialty (binary variables
for colon and rectal surgery; general surgery; neurosurgery; ortho-
pedic surgery; otolaryngology; plastic surgery; thoracic surgery; and
vascular surgery); publication number (first author and last author,
and total), NIH grants (binary variable indicating whether a surgeon
2 | www.annalsofsurgery.com
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Annals of Surgery  Volume XX, Number XX, Month 2018
had ever been a principal investigator on an NIH grant), clinical trial
participation (binary variable), employment at medical school ranked
in the top 20 US medical schools for research by US News & World
Report,15,22 and 2013 Medicare reimbursements (a proxy for clinical
volume). This model also included a medical school-level fixed
effect variable, which enabled evaluation of sex differences in rank
among surgeons within the same medical school. We used robust
standard errors to account for correlations due to physician clustering
by medical school.
The primary outcome was the adjusted odds of full professor-
ship (vs associate and assistant professorship) among women relative
to men. We also computed the adjusted proportions of full profes-
sorship for men and women, as well as the absolute adjusted
difference in proportions, assuming population mean values for all
other model variables. We performed identical calculations for each
model variable to characterize associations between each covariate
and the probability of being a full professor. We considered a 2-tailed
P 0.05 to be statistically significant.
In secondary analyses, we re-estimated the multivariable
logistic regression model used for the primary outcome to evaluate
the odds of associate or full professorship (a combined outcome)
versus assistant professorship, and full professorship versus associate
professorship (omitting assistant professors). We calculated adjusted
proportions and adjusted differences in proportion for secondary
outcomes first as a function of physician sex, and then as a function of
the other model variables.
Two additional analyses evaluated how sex differences in
academic rank vary across medical schools. First, we stratified
our study population into 2 groups: those with appointments at
medical schools ranked in the top 20 for research by U.S. News
& World Report in 2013,15,22 and those with appointments at all other
medical schools. We then assessed for sex differences in academic
rank in each stratum, and across different surgical subspecialties.
Second, for each medical school, we used our primary multivariable
regression model to predict the difference in adjusted proportions of
full professorship between men and women if all surgeons in this
study cohort were affiliated with that medical school. We then
calculated the difference between the observed and predicted sex
differences in full professorship for each school, which we called the
‘‘full professorship gap.’’ More negative differences between
observed and predicted proportions correspond to a larger full
professorship gap. This method has been employed previously to
assess sex differences in full professorship.2
Data on 1 variable—the year of residency completion—were
missing for 1745 surgeons (13% of total sample). We therefore
compared the characteristics of surgeons who were and were not
missing these data (eTable 1, http://links.lww.com/SLA/B369).
Because this analysis confirmed that nonmissing data were similarly
distributed across these 2 cohorts, we excluded surgeons with
missing data from all analyses. All analyses were performed in
STATA, version 14.0 (STATA Inc., College Station, TX).
RESULTS
Characteristics of the Study Population
Our study included 11,549 surgeons with faculty appoint-
ments at US medical schools in 2014 (9.3% of 124,499 surgeons in
Doximity database), of whom 1692 (14.7%) were women. General
surgery, the largest subspecialty in this study, accounted for 34.1% of
the study sample (3940/11,549); the smallest subspecialty, colon and
rectal surgeons, represented 1.6% of all study surgeons (185/11,549;
Table 1). The proportion of female surgeons in each field ranged from
6.6% (thoracic surgery) to 25.4% (colon and rectal surgery; Table 2).
Overall, 26.7% of academic surgeons were full professors. Women
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Annals of Surgery  Volume XX, Number XX, Month 2018 Sex Differences in Faculty Rank in Surgery

TABLE 1. Characteristics of Study Population

All (n ¼ 11,549) Men (n ¼ 9857) Women (n ¼ 1692)
Count (%) Count (%) Count (%) P for Comparison by Sex
Faculty rank
Assistant professor 5538 (48.0) 4466 (45.3) 1072 (63.4) <0.001
Associate professor 2931 (25.4) 2527 (25.6) 404 (23.9) 0.124
Full professor 3080 (26.7) 2864 (29.1) 216 (12.8) <0.001
Age, mean years (SD) 50.7 (11.1) 51.6 (11.3) 45.6 (8.4) <0.001
Age groups, y
<40 1908 (16.5) 1457 (14.8) 451 (26.7) <0.001
40–44 2172 (18.8) 1736 (17.6) 436 (25.8)
45–49 1859 (16.1) 1551 (15.7) 308 (18.2)
50–54 1604 (13.9) 1393 (14.1) 211 (12.5)
55–59 1443 (12.5) 1285 (13.0) 158 (9.3)
60–64 1095 (9.5) 998 (10.1) 97 (5.7)
65þ 1468 (12.7) 1437 (14.6) 31 (1.8)
Years since residency, mean (SD) y 18.9 (11.8) 19.9 (12.0) 13.4 (8.5) <0.001
Subspecialtyz
Colon and rectal surgery 185 (1.6) 138 (1.4) 47 (2.8) <0.001
General surgery 3940 (34.1) 3145 (31.9) 795 (47.0) <0.001
Neurosurgery 992 (8.6) 910 (9.2) 82 (4.8) <0.001
Orthopaedic surgery 2193 (19.0) 1986 (20.1) 207 (12.2) <0.001
Otolaryngology (ENT) 1278 (11.1) 1036 (10.5) 242 (14.3) <0.001
Plastic surgery 617 (5.3) 524 (5.3) 93 (5.5) 0.76
Thoracic surgery 745 (6.5) 696 (7.1) 49 (2.9) <0.001
Urology 1101 (9.5) 980 (9.9) 121 (7.2) <0.001
Vascular surgery 498 (4.3) 442 (4.5) 56 (3.3) 0.03
Publications, mean (SD)
Total 23.1 (32.1) 24.4 (33.2) 15.8 (23.2) <0.001
First or last author 15.2 (26.6) 16.1 (27.6) 10.0 (18.8) <0.001
National Institutes of Health Grants
1 grant 730 (6.3) 629 (6.4) 101 (6.0) 0.52
Median no. for those with 1 grant (25–75 percentile) 3 (1–5) 3 (1–5) 2 (1–4)
Clinical Trial Investigator
1 trial 883 (7.6) 780 (7.9) 103 (6.1) 0.009
Median no. for those with 1 trial (25–75 percentile) 1 (1–2) 1 (1–2) 1 (1–1)
Top 20 medical school faculty§ 3327 (28.8) 2810 (28.5) 517 (30.6) 0.09
2013 Medicare Payments, mean (SD) 75,373 (96389.0) 80,766.5 (100461.0) 43,952.6 (58880.7) <0.001
Census region
Northeast 3253 (28.2) 2792 (28.3) 461 (27.2) <0.001
Midwest 2798 (24.2) 2368 (24.0) 430 (25.4)
South 3802 (32.9) 3272 (33.2) 530 (31.3)
West 1696 (14.7) 1425 (14.5) 271 (16.0)
SD indicates standard deviation; Y, years.
 2
P values reflect 2-sided t tests and X comparisons where appropriate.
P value for age reflects comparisons of age distributions.
yCalculations excluded 1745 surgeons for whom data on years since residency was not available.
zSurgical subspecialty was determined using data from the Association of American Medical Colleges’ Faculty Roster.
§Top 20 school signifies whether a surgeon was on faculty at a medical school ranked in the top 20 for research by U.S. News & World Report in 2013.

comprised 19.4% of assistant professors (1072/5538), 13.8% of Multivariable Analysis

associate professors (404/2931), and 7.0% of full professors (216/
3080; Table 1).
Compared with male surgeons, women surgeons were youn-
ger (mean age: 45.6 vs 51.6, P < 0.001), less experienced (mean
years since residency: 13.4 vs 19.9, P < 0.001), had fewer total
publications (15.8 vs 24.4, P < 0.001), and fewer first or last author
publications (10.0 vs 16.1, P < 0.001). Women and men had similar
rates of NIH funding (proportion with at least 1 NIH grant: 6.0% vs
6.4%, P ¼ 0.52), and women were less likely to be investigators on a
clinical trial (6.1% vs 7.9%, P ¼ 0.009). Women surgeons had lower
mean 2013 Medicare payments than men ($43,952.60 vs $80,766.50,
P < 0.001). In unadjusted analyses, women were more likely than
men to be assistant professors (62.4% vs 45.3%, P < 0.001) and less
likely to be full professors (12.8% vs 29.1%, P < 0.001).
After adjustment for age, years since residency, subspe-
cialty, total publications, first and last author publications, NIH
grant receipt, clinical trial participation, Medicare payments, and
being faculty at a top 20 research medical school, women were less
likely to be full professors than men [adjusted odds ratio (OR):
0.76; 95% confidence interval (95% CI): 0.6 – 0.9; adjusted differ-
ence in proportion: -3.0%, 95% CI: -5.0 to -1.0; Table 3]. Full
professorship was positively associated with age, years since
residency, total and first or last author publication number, NIH
grant funding, and clinical trial participation. After multivariable
adjustment, surgical subspecialty was not associated with the odds
of full professorship.
In secondary analyses, there were no significant sex dispar-
ities in the odds of full or associate professorship (vs assistant

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Blumenthal et al Annals of Surgery  Volume XX, Number XX, Month 2018

TABLE 2. Proportion of Women by Surgical Field and by DISCUSSION

Academic Rank In this study, a comprehensive, contemporary, database of
11,549 academic surgeon faculty at US medical schools in 2014 was
All Surgeons Men Women Women
(Count) (Count) (Count) (% of total)
used to investigate sex differences in academic rank among surgeons
from several surgical subspecialties. This database was developed
Subspecialty using validated physician-level data from Doximity, an online phy-
Colon and rectal surgery 185 138 47 25.4 sician networking site. This study found that women surgeons were
General surgery 3940 3145 795 20.2
significantly less likely than their male counterparts to be full
Neurosurgery 992 910 82 8.3
Orthopaedic surgery 2193 1986 207 9.4 professors after adjustment for several factors known to influence
Otolaryngology 1278 1036 242 18.9 academic rank, including age, experience (defined as years since
Plastic surgery 617 524 93 15.1 residency training), surgical specialty, publications, NIH grant fund-
Thoracic surgery 745 696 49 6.6 ing, clinical trials participation, and annual Medicare payment, and
Urology 1101 980 121 11.0 medical school affiliation. These results are consistent with prior
Vascular surgery 498 442 56 11.2 work on sex differences in academic medicine, including recent
Totaly 11549 9857 1692 14.7 analyses involving over 90,000 US academic physicians, and a
Academic Rank targeted investigation of sex disparities in academic rank among
Assistant Professors 5538 4466 1072 19.4
3800 US academic cardiologists.1,2
Associate Professors 2931 2527 404 13.8
Full Professors 3080 2864 216 7.0 This study is one of the largest and most contemporary
analyses to-date of sex disparities in academic rank among surgeon
No. indicates number. faculty at US medical schools. The study’s results are generally

Surgical subspecialty was determined using data from the Association of American
Medical Colleges’ Faculty Roster. consistent with prior work on this topic in surgery—including
ySum of all surgeons, male surgeons, and female surgeons, respectively, and specialty-specific evaluations in ophthalmology, neurosurgery, and
proportion of women surgeons among all surgeons. orthopedic surgery, and one study examining academic surgeons
generally—which have found that women are under-represented in
the upper echelons of academic surgery generally, and less likely to
be full professors than men in particular.4,6,7,13 One of this study’s
professor) between men and women (adjusted OR: 0.94, 95% CI: greatest strengths is that it mitigates substantial limitations of prior
0.8 – 1.1; eTable 2, http://links.lww.com/SLA/B369). However, in work on this topic, which include a focus on a surgical subspecialty,
multivariable analyses restricted to full and associate professors which limits generalizability, and, inadequate efforts to control for
only (eg, excluding assistant professors), women were signifi- potential confounders. All prior studies on this topic have assessed
cantly less likely to be full professors than men (adjusted OR: for sex disparities using either unadjusted data on rates of professor-
0.70; 95% CI: 0.6 – 0.85; absolute adjusted difference in propor- ship, or data adjusted only for publication number and/or H-index (a
tion: -6.3%; 95% CI: -9.7 to -2.8, eTable 3, http://links.lww.com/ measure of research impact).4,6,7,13 Adequate adjustment for factors
SLA/B369). known to influence academic rank independently of sex—including
Sizeable variation in sex differences in full professorship was age, experience, clinical productivity, NIH funding, participation in
observed across US medical schools (Fig. 1). The median absolute clinical trials, and medical school-level variations in promotion
school-specific full professorship gap was -3.1% (interquartile range, criteria—is critical for minimizing confounding by unmeasured
-3.3% to -2.8%). All medical schools in this analysis had significant, variables. This methodological rigor is a central and unique strength
negative full professorship gaps of this analysis and bolsters the validity of the study findings.
Potential explanations for the dearth of women in tenured and
Sex Differences in Full Professorship by Specialty academic surgical leadership positions include low rates of women
In adjusted analyses of sex differences in full professorship by entering surgical residencies4,24; The climb to break the glass ceiling
surgical subspecialty, significant sex differences in full professorship in surgery: trends in women progressing from medical school to
were observed in general surgery (OR: 0.68; 95% CI: 0.5–0.9; surgical training and academic leadership from 1994 to 2015 lack of
adjusted difference in proportion -4.0%; 95% CI: -7.0 to -1.1; effective mentorship for female surgeons25–27; inadequate support
Table 4). In addition, women were nonsignificantly less likely to for early-career female physician researchers28; unequal household
be full professors in all specialties other than vascular surgery. The and family obligations29,30; lack of established promotion tracks for
adjusted OR for full professorship among women relative to men was part-time surgeons or surgeons who take time off for child-rearing31–
0.66 among urologists (95% CI 0.35–1.3) and 0.45 among plastic 33
; and conscious or unconscious sex bias and discrimina-
surgeons (95% CI 0.2–1.2). tion.25,26,34,35 There have been concerns about sex differences in
decisions to pursue academic careers or to abandon academics before
Sex Differences in Full Professorship by Census becoming a full professor,24 although there are little data on those
Region and School Research Ranking topics. Women comprise approximately half of medical students but
Women were less likely than men to be full professors among just 14%—42% of surgical residents, depending on the surgical
academic surgeons in the Northeast census region (adjusted OR: field.5 Women surgical trainees are more likely than their male
0.52; 95% CI 0.3–0.8), but not among surgeons in the Midwest, counterparts to considering leaving residency training.24 Impor-
South, or Southwest regions. No significant sex disparities in rates of tantly, this study’s results should be viewed as hypothesis generating
full professorship were observed among surgeons affiliated with top given the retrospective, cross-sectional study design and the possi-
20 ranked research medical schools (adjusted OR: 1.03; 95% CI 0.8– bility of residual confounding of the relationship between surgeon
1.3; Table 4). However, among surgeons affiliated with a medical sex and academic rank. Specifically, that sex differences in rank
school ranked outside the top 20 for research, women were less likely persisted after adjustment for measures of academic and clinical
to be full professors (adjusted OR: 0.65; 95% CI: 0.5–0.8; adjusted productivity does not mean that these differences were the result of
difference in proportion: -4.4%, 95% CI: -6.9 to -1.9). unconscious or conscious sex bias.

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Annals of Surgery  Volume XX, Number XX, Month 2018 Sex Differences in Faculty Rank in Surgery

TABLE 3. Multivariable Analysis of Sex Differences in Full Professorship Among US Academic Surgeons in 2014
Full Professor (vs Assistant and Associate)
Odds Ratioy Absolute Difference in Proportionz
No./Total (%) of Professors Unadjusted Adjusted (95% CI) Unadjusted, % Adjusted, % (95% CI)
Sex
Men 2864 / 9857 (29.1) [Reference] [Reference]
Women 216 / 1692 (12.8) 0.36 0.76 (0.6–0.9) 16.3 3.0 (5.0 to -1.0)
Age groups, y
<40 17 / 1908 (0.9) [Reference] [Reference]
40–44 42 / 2172 (1.9) 2.19 0.93 (0.5–1.8) 1.0 0.3 (3.3 to 2.7)
45–49 264 / 1859 (14.2) 18.41 5.50 (3.3–9.3) 13.3 13.0 (9.8–16.2)
50–54 529 / 1604 (33.0) 54.74 12.5 (7.3–21.5) 32.1 23.4 (20.1–26.8)
55–59 673 / 1443 (46.6) 97.22 15.8 (9.0–27.9) 45.7 26.9 (23.1–30.7)
60–64 610 / 1095 (55.7) 139.90 17.0 (9.2–31.3) 54.8 28.0 (23.1–32.9)
65þ 945 / 1468 (64.4) 200.99 11.2 (5.8–21.5) 63.5 21.9 (16.7–27.0)
Years since residency (per 1 y) 1.13 1.10 (1.08–1.11) 1.7 1.0 (0.8–1.2)
Subspecialty§
Colon and Rectal Surgery 41 / 185 (22.2) [Reference] [Reference]
General Surgery 1050 / 3940 (26.6) 1.28 1.3 (0.7–2.2) 4.5 2.7 (3.4 to 8.8)
Neurosurgery 278 / 992 (28.0) 1.37 1.1 (0.6–1.9) 5.9 0.7 (5.4 to 6.8)
Orthopaedic Surgery 523 / 2193 (23.8) 1.10 0.90 (0.5–1.5) 1.7 1.4 (7.4 to 4.6)
Otolaryngology 327 / 1278 (25.6) 1.21 1.04 (0.6–1.9 3.4 0.4 (6.0 to 6.9)
Plastic surgery 155 / 617 (25.1) 1.18 1.2 (0.7–2.3) 3.0 2.2 (4.7 to 9.2)
Thoracic Surgery 225 / 745 (30.2) 1.52 1.1 (0.60–2.0) 8.0 0.7 (5.9 to 7.3)
Urology 335 / 1101 (30.4) 1.54 1.2 (0.7–2.2) 8.3 2.0 (4.6 to 8.5)
Vascular Surgery 146 / 498 (29.3) 1.46 1.2 (0.6–2.2) 7.2 1.7 (5.2 to 8.6)
Publications (per publication)
Total 1.03 1.02 (1.02–1.03) 0.4 0.3 (0.2–0.3)
First or last author 1.03 1.01 (1.01–1.01) 0.5 0.1 (0.1–0.1)
National Institutes of Health Grantô
No 2629 / 10,819 (24.3) [Reference] [Reference]
Yes 451 / 730 (61.8) 5.04 1.6 (1.3–2.1) 37.5 5.5 (2.5–8.4)
Clinical Trial Investigator
No 2666 / 10,666 (25.0) [Reference] [Reference]
Yes 414 / 883 (46.9) 2.65 1.7 (1.4–2.1) 21.9 6.1 (3.9–8.3)
Top 20 medical school faculty
No 2045 / 8222 (24.9) [Reference] [Reference]
Yes 1035 / 3327 (31.1) 1.36 1.1 (0.8–1.5) 6.2 0.9 (2.9 to 4.6)
2013 Medicare payment (per $10,000) 1.00 1.00 (1.00–1.00) 0.4 0.1 (0.1 to 0.0)
CI indicates confidence interval; y, years.

Factors associated with full professorship among faculty of all ranks.
yModel estimated the association between physician sex and faculty rank using odds ratios both before (eg, unadjusted) and after adjustment for age, years since residency, surgical
subspecialty, publications (total, first and last author), whether a surgeon had ever been a principal investigator on a National Institutes of Health grant award, whether a surgeon had ever
been a principal or coinvestigator on a clinical trial, whether a surgeon was a faculty member at a medical school ranked in the top 20 for research by US News & World Report in 2013,
each surgeon’s revenue from Medicare patients in 2013, and medical-school level fixed effects.
zModels used to calculate unadjusted and adjusted absolute differences in proportion were identical to those used to calculate unadjusted and adjusted odds ratios.
§Surgical subspecialty was determined using data from the Association of American Medical Colleges’ Faculty Roster.
ôGrant information was obtained from the National Institutes of Health RePORT grants database. Clinical trial information was obtained from ClinicalTrials.gov database.

Women surgeons had lower odds than men of being full
professors in all surgical subspecialties other than vascular surgery.
Although these differences were only statistically significant among
general surgeons, women surgeons in urology and plastic surgery had
two-thirds and one-half lower odds of full professorship than men,
respectively. Moreover, the confidence intervals for these ORs only
just crossed one, suggesting that the subspecialty-specific sample
sizes were insufficient to detect a significant difference in the odds of
full professorship between women and men.
In secondary analyses, odds of associate or full professorship
(vs assistant professorship) were similar among male and female
surgeons. However, among associate and full professors only (eg,
excluding assistant professors), women were significantly less likely
than men to be full professors. These results are consistent with those
of a recent study examining sex differences in academic rank among
US academic cardiologists, and parallel the outcomes of a larger
analysis of sex differences in academic rank across all medical and
surgical specialties.1,2 No conclusions about sex disparities in pro-
motion can be drawn from these findings because the study does not
account for surgeons who left each of these academic tiers in 2014.
Nonetheless, these results raise the possibility that sex disparities in
promotion may exist at one, or several, levels within the academic
surgery hierarchy. Longitudinal cohort studies are needed to identify
and characterize sex disparities in promotion.
Importantly, barriers to promotion for women academic sur-
geons may differ across the arc of their careers. Prior work has found
that women surgeons have lower academic productivity relative to
men earlier in their careers but equal or exceed the productivity of
their male counterparts later in their careers.11,36 Womens’ lower
early career productivity relative to men may stem from asymmetric
family obligations, lack of effective mentorship, and/or unequal
financial and institutional support for early female researchers.27,28

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CE: A.G.; ANNSURG-D-17-01419; Total nos of Pages: 8;
ANNSURG-D-17-01419
Blumenthal et al
FIGURE 1. Medical school variation in actual versus expected
sex differences in full professorship. Each green line corre-
sponds to the adjusted full professorship gap between female
and male surgeons at 1 of 131 US medical schools in this
analysis. Each medical school’s ‘‘adjusted full professorship
gap’’ equals the observed sex gap in full professorship at that
medical school minus the expected sex gap in full professorship
at that medical school. The observed sex gap in full professor-
ship is the absolute adjusted difference in the proportion of
women and men who are full professors at the medical school
(displayed in Table 3). The expected sex gap in full professor-
ship was calculated using the multivariable regression model
from the primary analysis to estimate the adjusted difference in
the proportions of female and male full professors for each
medical school as if all surgeons in this study were affiliated with
that medical school. Next, the ‘‘full professorship gap,’’ defined
as the difference between the observed and expected sex
differences in full professorship, was calculated for each school.
More negative full professorship gaps represent greater sex
disparities in full professorship. Full professorship gaps were
statistically significant for all medical schools.
This decreased early career productivity could potentially have
outsized consequences for womens’ academic careers by predispos-
ing to delays in promotion, declining interest in research, or even
attrition from academics.37 Although publication number was asso-
ciated with the odds of full professorship, adjusting for publications
did not mitigate observed sex disparities in academic rank.
We also found that female surgeons were significantly less
likely than male surgeons to be full professors at nontop ranked
research medical schools. However, among surgeon faculty at top
ranked research medical schools, women and men had similar odds
of full professorship. This finding was unexpected, and differs from
previous analyses that have not shown that medical school research
ranking modifies the association between sex and academic rank.
Additional research is needed to understand the implications and
causes of this finding.
Several steps can be taken to address sex inequities in aca-
demic rank in surgery departments. First, surgery departments must
acknowledge that sex disparities in academic rank exist both across
medical schools, and within their own institutions. This study
identified significant ‘‘full professorship gaps’’ in academic surgery
departments at all US medical schools, meaning that observed rates
of full professorship among women surgeons in these departments
were lower than expected based on their characteristics and clinical
and research productivity. These data raise the possibility that sex
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Annals of Surgery  Volume XX, Number XX, Month 2018
disparities in academic rank across academic surgery are pervasive.
Publishing annual department statistics on academic ranks and
promotion eligibility of all department members along with their
gender, race, and ethnicity may help department leadership to
identify and steps to ameliorate, persistent disparities.38 Other spe-
cific strategies for mitigating implicit sex bias in academic surgery
include developing systems and protocols for ensuring that compen-
sation plans are developed transparently and objectively; creating
sex-blind manuscript and grant review, and hiring and promotion
processes; explicitly and fairly distributing uncompensated teaching
and service responsibilities across faculty members; putting in place
equitable policies for taking leave and granting tenure extensions;
developing objective and transparent methods for evaluating success
and milestones for promotion; and educating physicians about
implicit sex bias.33,39 –42 Additional work is needed to comprehen-
sively evaluate the presence and impact of sex bias on promotion and
academic rank in surgery, and to identify the most effective strategies
for mitigating this bias. Comparative studies of medical schools
which have and have not instituted one or more of policies to address
implicit bias may help to clarify the relative efficacy of these policies.
In addition, future studies should seek to characterize several critical
determinants of promotion and academic rank, such as differences in
processes for promotion, salary setting, determination of ‘‘fringe’’
benefits (eg, space, equipment, and support staff), and performance
reviews across institutions, and associations between these processes
and academic rank.28
This study has limitations. First, the retrospective, cross-
sectional design limits the identification of causal mechanisms to
explain the study results, the assessment of sex differences in
promotion, or the ability to determine how rates of attrition from
academia influence sex differences in promotion and academic
rank. Future studies may be able to use this study’s findings to help
elucidate underlying causal mechanisms. Longitudinal studies are
necessary to assess promotion practices and understand how attri-
tion from academia influences sex differences in academic rank.
Second, while physicians on research tracks have been found to
advance more quickly than clinician-educators, information on
academic track was not available for analysis.33 However, control-
ling for research productivity—which will presumably be greater
among full time researchers than clinician-educators—and Medi-
care revenue, which will be greater among full time clinicians than
researchers, should help mitigate this potential source of confound-
ing. Third, we could not fully control for full versus part-time
employment status. Although women may be more likely to work
part time than men, controlling for measures of research and
clinical productivity should help to limit confounding due to this
factor. Even so, we were unable to control for clinical productivity
among patients with non-Medicare insurance, a limitation which
represents a source of potential residual confounding.2 Fourth, the
measures of clinical and research productivity used in this study do
not account for committee service, teaching responsibilities and
awards, and presentations, which may influence academic rank.
Nonetheless, because these factors likely have an outsized influ-
ence on promotion for nonresearchers, including clinician educa-
tors, who are more likely to be women, adjusting for them would
likely increase, not decrease, sex disparities in academic
rank.2,33,41 Fifth, these analyses do not control for leadership
positions, including department chairs, which may affect academic
rank. Sixth, these analyses do not control for surgeons’ career
priorities and interest in becoming full professors, which likely
differ across surgeons. Seventh, barriers to academic advancement
for women surgeons may change over time, and current academic
ranks, and sex differences in rank, may reflect past barriers to
advancement that have since been mitigated.
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ANNSURG-D-17-01419

Annals of Surgery  Volume XX, Number XX, Month 2018 Sex Differences in Faculty Rank in Surgery

TABLE 4. Sex Differences in Full Professorship Segmented by Surgical Subspecialty, Medical School Research Ranking, and US
Census Region
No. of Full Professors/Total (%)
Adjusted OR Absolute Adjusted Difference
Men Women (95% CI) in Proportion, % (95% CI)y
Subspecialtyz
Colon and Rectal Surgery 34 / 138 (24.6) 7 / 47 (14.9) 0.56 (0.1–2.6) 5.4 (18.9 to 8.1)
General Surgery 945 / 3145 (30.0) 105 / 795 (13.2) 0.68 (0.5–0.9) 4.0 (7.0 to -1.1)
Neurosurgery 269 / 910 (29.6) 9 / 82 (11.0) 0.78 (0.3–1.8) 2.8 (12.0 to 6.5)
Orthopaedic Surgery 501 / 1986 (25.2) 22 / 207 (10.6) 0.81 (0.5–1.4) 2.2 (8.0 to 3.6)
Otolaryngology 290 / 1036 (28.0) 37 / 242 (15.3) 0.91 (0.6–1.5) 1.0 (6.2 to 4.2)
Plastic Surgery 149 / 524 (28.4) 6 / 93 (6.5) 0.45 (0.2–1.2) 8.4 (17.9 to 1.2)
Thoracic Surgery 219 / 696 (31.5) 6 / 49 (12.2) 0.83 (0.25–2.75) 2.7 (20.5 to 15.0)
Urology 320 / 980 (32.7) 15 / 121 (12.4) 0.66 (0.35–1.3) 4.7 (11.8 to 2.4)
Vascular Surgery 137 / 442 (31.0) 9 / 56 (16.1) 1.63 (0.5–5.3) 6.2 (8.7 to 21.1)
Medical School Research Ranking§
Not top 20 1918 / 7047 (27.2) 127 / 1175 (10.8) 0.65 (0.5–0.8) 4.4 (6.9 to -1.9)
Top 20 946 / 2810 (33.7) 89 / 517 (17.2) 1.03 (0.80–1.3) 0.4 (2.6 to 3.4)
Census Regionô
Northeast 739 / 2792 (26.5) 36 / 461 (7.8) 0.52 (0.3–0.8) 6.2 (10.0 to -2.4)
Midwest 715 / 2368 (30.2) 64 / 430 (14.9) 0.87 (0.6–1.2) 1.5 (5.1 to 2.1)
South 905 / 3272 (27.7) 69 / 530 (13.0) 0.83 (0.6–1.2) 2.0 (5.7 to 1.6)
West 505 / 1425 (35.4) 47 / 271 (17.3) 1.02 (0.7–1.4) 0.2 (3.7 to 4.0)
CI indicates confidence interval; OR, indicates odds ratio.

Models estimated the association between physician ex and faculty rank using odds ratios adjusted for age, years since residency, surgical subspecialty, publications (total, first and
last author), whether a surgeon had ever been a principal investigator on a National Institutes of Health grant award, whether a surgeon had ever been a principal or coinvestigator on a
clinical trial, whether a surgeon was a faculty member at a medical school ranked in the top 20 for research by US News & World Report in 2013, each surgeon’s revenue from Medicare
patients in 2013, and medical-school level fixed effects.
yModels used to calculate adjusted absolute differences in proportion were identical to those used to calculate adjusted odds ratios.
zSurgical subspecialty was determined using data from the Association of American Medical Colleges’ Faculty Roster. Adjusted odds ratios and absolute adjusted differences in
proportions of female versus male full professors by surgical subspecialty.
§Adjusted odds ratios and absolute adjusted differences in proportions of female versus male full professors who are faculty at medical schools ranked outside of the top 20 for
research (eg, ‘‘not top 20’’), or in the top 20 for research (eg, ‘‘top 20’’) by US News & World Report in 2013.
ôAdjusted odds ratios and absolute adjusted differences in proportions of female versus male full professors by US Census region.

CONCLUSION 7. Tomei KL, Nahass MM, Husain Q, et al. A gender-based comparison of

Among 11,549 academic surgeon faculty at US medical
schools in 2014, women were less likely than men to be full
professors after adjustment for several factors known to influence
academic rank, including age, years of experience, surgical subspe-
cialty, medical school affiliation, and multiple measures of research
and clinical productivity. Future studies should focus on the mecha-
nisms underlying these sex disparities in academic rank, and strate-
gies for ameliorating them.
ACKNOWLEDGMENT
The authors would like to thank Andrew A. Olenski for his
contributions to this work.
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