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Take me to your leader: Reporting structures and equity in academic gynecologic oncology
YGYNO-977898; No. of pages: 6; 4C: Gynecologic Oncology xxx (xxxx) xxx
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Take me to your leader: Reporting structures and equity in academic gynecologic oncology Sarah M. Temkin a,⁎, Lisa Rubinsak b, Michelle F. Benoit c, Linda Hong d, Uma Chandavarkar e, Christine A. Heisler f, Laurel K. Berry g, B.J. Rimel h, William P. McGuire i a
Anne Arundel Medical Center, 2003 Medical Parkway, Suite 301, Annapolis, MD 21401, United States of America Karmanos Cancer Institute, Wayne State University, United States of America Kaiser Permanente Washington, United States of America d Loma Linda University School of Medicine, United States of America e Banner MD Anderson Cancer Center, United States of America f University of Wisconsin School of Medicine, United States of America g Wake Forest Baptist Health, Winston-Salem, United States of America h Cedars-Sinai Medical Center, United States of America i Virginia Commonwealth University, Richmond b c
H I G H L I G H T S • Women are under-represented in academic medicine leadership relevant to gynecologic oncologists • Women and surgical departmental leadership were associated with benefits for gynecologic oncology divisions • Gynecologic oncologists are under-represented in cancer center leadership.
a r t i c l e
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Article history: Received 9 March 2020 Accepted 29 March 2020 Available online xxxx Keywords: Gynecologic oncology leadership Academic medicine Cancer centers
a b s t r a c t Objective. Gynecologic oncology includes increasing percentages of women. This study characterizes representation of faculty by gender and subspecialty in academic department leadership roles relevant to the specialty. Methods. The American Association of Medical Colleges accredited schools of medicine were identified. Observational data was obtained through institutional websites in 2019. Results. 144 accredited medical schools contained a department of obstetrics and gynecology with a chair; 101 a gynecologic oncology division with a director; 98 a clinical cancer center with a director. Women were overrepresented in academic faculty roles compared to the US workforce (66 vs 57%, p b 0.01) but underrepresented in all leadership roles (p b 0.01). Departments with women chairs were more likely to have N50% women faculty (90.2 vs 9.8%, p b 0.01); and have larger faculties (80.4 vs 19.6% N20 faculty, p = 0.02). The cancer center director gender did not correlate to departmental characteristics. A surgically focused chair was also associated with N50% women faculty (85.7 vs 68.3%, p = 0.03); faculty size N20 (85.7 vs 61.4%, p b 0.01); and a woman gynecologic oncology division director (57.6 vs 29.4%, p b 0.01; 68.4 vs 31.7%, p b 0.01) and gynecologic oncology fellowship (50 vs 30.4%, p b 0.01; 59.1 vs 32%, p b 0.01). Gynecologic oncology leadership within cancer centers was below expected when incidence and mortality to leadership ratios were examined (p b 0.01, p b 0.01). Conclusion. Within academic medical schools, women remain under-represented in obstetrics and gynecology departmental and cancer center leadership. Potential benefits to gynecologic oncology divisions of inclusion women and surgically focused leadership were identified. © 2020 Elsevier Inc. All rights reserved.
1. Introduction ⁎ Corresponding author. E-mail addresses: [email protected] (S.M. Temkin), [email protected] (L. Rubinsak) , [email protected] (M.F. Benoit), [email protected] (L. Hong), [email protected] (U. Chandavarkar), [email protected] (C.A. Heisler), [email protected] (L.K. Berry), [email protected] (B.J. Rimel).
Diversity within organizations has been demonstrated to improve both quality and financial outcomes within healthcare systems [1,2]. In addition, within academic medicine, representative leadership is critical to the equitable distribution of resources [3]. Gynecologic oncology
https://doi.org/10.1016/j.ygyno.2020.03.031 0090-8258/© 2020 Elsevier Inc. All rights reserved.
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
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S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
is a unique subspecialty of medicine in that physicians provide both surgical and medical care for women with malignancies of the female genital tract. This distinctive care model arose through obstetrics and gynecology as a response to a perceived neglect of women with cancers of the ovary, uterus, cervix, vagina and vulva. Historically, within academic medical centers, the departmental home for gynecologic oncologists is within a department of obstetrics and gynecology. However, successful academic oncology practices that include high quality clinical and research activities within academic centers require cancer center resources and infrastructure in addition to departmental support [4]. For gynecologic oncology, balancing support may be challenging as obstetrics and gynecology departmental priorities tend towards maternity care and reproductive health; cancer centers typically are dominated by medical, radiation and surgical oncologists. Because support from cancer center leadership in addition to departmental advocacy is necessary for an academic gynecologic oncology practice to thrive, conflicting priorities of administrative leadership may pose unique challenges specific to this specialty. First, although the majority of trainees in obstetrics and gynecology have been women since the 1990's and the field has been comprised of a majority of women for over a decade, women have remained significantly under-represented in leadership roles in departments of obstetrics and gynecology [5]. Second, academic obstetrics and gynecology leadership is heavily weighted towards maternal–fetal medicine, many of whom provide little or no surgical or cancer care [6]. We undertook this study in order to examine how the attributes of leadership in departments of obstetrics and gynecology and affiliated cancer centers affect academic gynecologic oncology divisional characteristics. Specifically, we question whether gender and subspecialty training of department chairs and cancer center directors are associated with the relative size, gender distribution of faculty and presence of a gynecologic oncology fellowship within gynecologic oncology divisions in academic medical centers. 2. Methods The Association of American Medical Colleges list of Accreditation Council for Graduate Medical Education (ACGME) accredited schools of medicine (https://members.aamc.org/) was used to identify 154 accredited academic institutions. Publicly available data were reviewed using the administrative roster displayed on their Institutional Web sites. One reviewer (ST) compiled all information regarding leadership infrastructure related to gynecologic oncology including: department of obstetrics and gynecology leadership, faculty size and gender composition; division of gynecologic oncology leadership size and gender composition; presence of an accredited fellowship; the presence of an affiliated clinical cancer center; and clinical expertise of the director. Apparent gender was inferred for each faculty member in accordance with given name, pronoun used in their bio and, in most cases, accompanying or Web-sought and found photograph. Surgical focus of department chairs was determined by review of their online biography. Subspecialists in gynecologic oncology, female pelvic medicine and reconstructive surgery (urogynecology) or specialists in obstetrics and gynecology with descriptors of surgical expertise were considered to have a surgical focus. Maternal fetal medicine, reproductive endocrinologists or specialists in obstetrics and gynecology without mention of surgery in the biography were considered to have a reproductive health focus. Disease site focus of the cancer center director was similarly inferred by review of their bio and a review of publications when necessary. This review was completed by primary reviewer (ST) between July 15 and July 31, 2019. A second reviewer confirmed all data (LH, MB, UC, LB) between August 1 and 15, 2019. Discrepancies were resolved by consensus. Data collected for this study were all from publicly available Web sites and were recorded in aggregate quantitative, anonymized fashion. This study is therefore exempt from institutional review board review.
Institutional leadership characteristics were summarized into categorical variables and presented as frequency and proportions. ACOG workforce data was used to as expected rates of gender in obstetrics and gynecology [7]. Ratios of disease site incidence and mortality to leadership were calculated using 2019 estimates of incidence and mortality from the SEER and compared to expected rates [8]. Chi-squared testing was used to evaluate observed versus expected rates. All statistical analysis was performed using JMP version 14. SAS Institute Inc., Cary, NC, 1989–2019 with p value b0.05.
3. Results Of 154 accredited medical schools, 144 contain an obstetrics and gynecology department with a chair; 101 listed gynecologic oncology division with a director; 98 listed clinical cancer centers with a director. Faculty size and gender composition was able to be determined in 143 medical schools.
4. Gender and leadership in gynecologic oncology Women were overrepresented in academic obstetrics and gynecology faculty roles compared to the number of practicing obstetrician gynecologists in the United States (66 vs 57%, p b 0.01); but not within GO divisions (55 vs 57%). Women were significantly (p b 0.01) underrepresented in all leadership roles (Fig. 1). Thirty-five percent of chairs of departments of obstetrics and gynecology, 38% of gynecologic oncology division directors and 48% of gynecologic oncology fellowship directors were women. Departments of obstetrics and gynecology with women chairs were more likely to have N50% women gynecologic oncology faculty (90.2 vs 9.8%, p b 0.01); and have faculties numbering N20 (80.4 vs 19.6%, p = 0.02) (Table 1). Gynecologic oncology division directors who are women were associated with divisions containing more than half women gynecologic oncology faculty (Table 2). The cancer center director gender did not correlate to obstetrics and gynecology or gynecologic oncology faculty or leadership characteristics.
5. Department of obstetrics and gynecology leadership subspecialty leadership Within departments of obstetrics and gynecology, chair subspecialty was more commonly reproductive-health focused (70.8%) including maternal fetal medicine specialists (39.6%); specialists in obstetrics and gynecology (20.1%); and reproductive endocrinology (11.1%), compared to surgically focused – gynecologic surgeons (13.9%) or gynecologic oncologists (15.3%). The number of gynecologic oncologists acting as department chairs was not statistically different compared to the number of gynecologic oncologist faculty in medical schools (9.6%). A surgically focused chair was associated with N50% women faculty (85.7 vs 68.3%, p = 0.03); and faculty size N20 (85.7 vs 61.4%, p b 0.01) (Table 3). Departments with a surgically focused chair or gynecologic oncologist chair were more likely to have a woman gynecologic oncology division director (57.6 vs 29.4%, p b 0.01; 68.4 vs 31.7%, p b 0.01 respectively), and gynecologic oncology fellowship (50 vs 30.4%, p b 0.01; 59.1 vs 32%, p b 0.01 respectively). Women and gynecologic oncologist chairs represented 8 of 144 (5.6%) department Chairs. This was not statistically different than the 5.2% of women gynecologic oncologists that make up academic obstetrics and gynecology faculty. Because women chairs tended to lead larger departments and departments with higher percentages of women, 9.9% of gynecologic oncologists employed as faculty (11.6% of women gynecologic oncology faculty) report to women gynecologic oncologists at the chair level.
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
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Fig. 1. Percentage of women in faculty and leadership positions compared to US obstetrician gynecologist workforce data (*indicates differs from expected) p b 0.01).
6. Cancer center subspecialty leadership Men outnumbered women in cancer center leadership and comprised 85 (86.7%) of cancer center directors. The majority of cancer center directors were trained as medical oncologists (n = 58, 59.2%); 14 (14.3%) PhDs without a medical degree; 10 (10.2%) surgical oncologists; 5 (5.1%) pediatric oncologists; 2 (2%) gynecologic oncologists; 9 had other training. The training included pathology, behavior health, ear nose and throat specialist, radiation oncology, endocrinology,
psychology and pulmonology. Ninety cancer center directors had a specific disease site focus. From most common to least common the disease sites of interest were as follows: hematologic (22, 24.4%); gastrointestinal (21, 23.3%); breast (16, 17.8%); thoracic (9, 10%); genitourinary (6, 6.7%); pediatrics (5, 5.6%); sarcoma (3, 3.3%); gynecologic (3, 3.3%);
Table 2 Characteristics of academic institutions based on gynecology oncology division director gender. Woman GO Division Director Man GO (n = 39, 38.6%) Division Director (n = 62, 61.4%)
Table 1 Characteristics of academic institutions based on chair gender.
OBG department size n (%)a b20 faculty N20 faculty OBG department gender n (%)a b50% women N50% women GO fellowship n (%) Yes No GO division size n (%)a b 3 faculty 3 or more faculty GO division gendera b50% women N50% women NCI Cancer Center n (%) Yes No OBG Chair Specialty n (%) Generalist MFM REI GYN surgeon GO
Woman OBG Department Chair (n = 51, 35.7%)
Man OBG Department Chair (n = 93, 64.3%)
10 (19.6%) 41 (80.4%)
35 (38%) 57 (62%)
p Value
0.02
0.19 18(35.3%) 33 (64.7%)
43(46.7%) 49(53.2%) 0.10
28 (54.9%) 23 (45.1%)
64 (68.8%) 29 (31.2%)
17 (33.3%) 34 (66.7%)
45 (48.9%) 47 (51.1%)
0.07 b0.01
5 (9.8%) 46 (90.2%)
32 (34.8%) 60 (65.2%)
24(47.1%) 27 (52.9%)
33 (35.4%) 60 (64.5%)
0.17
0.08 13 (26%) 15 (30%) 3 (6%) 11(22%) 8 (16%)
16 (17.2%) 41 (44.1%) 13 (14.0%) 9 (9.7%) 14 (15.1%)
OBG, Obstetrics and Gynecology. GO, Gynecologic Oncology. NCI, National Cancer Institute. MFM, Maternal Fetal Medicine. REI, Reproductive Endocrinology. GYN, gynecology. Bold values statistically significant at p b 0.05 values. a For one program faculty size and gender composition were unable to be determined.
OBG department size n (%) a b20 faculty N20 faculty OBG department gender n (%) a b50% women N50% women GO fellowship n (%) Yes No GO division size n (%) a b 3 faculty 3 or more faculty GO division gender n (%) a b 50% women N50% women NCI Cancer Center n (%) Yes No OBG Chair Specialty n (%) Generalist MFM REI GYN surgeon GO
p Value 0.80
6 (15.8%) 32 (84.2%)
11 (17.7%) 51 (82.3%)
5 (13.2%) 33 (86.8%)
11 (17.7%) 51 (82.3%)
19 (48.7%) 20 (51.3%)
29 (46.8%) 33 (53.2%)
0.54
0.86 8 (21.1%) 30 (78.9%)
14 (22.6%) 48 (77.4%)
4 (10.5%) 34 (89.5%)
31 (50%) 31 (50%)
b0.01
19 (48.7%) 20 (51.3%)
34 (54.8%) 28 (45.2%)
0.55 0.02
5 (29.2%) 11 (12.8%) 4 (10.3% 6 (15.4%) 13 (33.3%)
7 (11.3%) 33 (53.2%) 8 (12.9%) 8 (12.9%) 6 (9.7%)
OBG, Obstetrics and Gynecology. GO, Gynecologic Oncology. NCI, National Cancer Institute. MFM, Maternal Fetal Medicine. REI, Reproductive Endocrinology. GYN, gynecology. Bold values statistically significant at p b 0.05 values. a For one program faculty size and gender composition were unable to be determined.
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
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S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
Table 3 Characteristics of academic institutions based on obstetrics and gynecology chair specialty.
OBG department size n (%) b20 faculty N20 faculty OBG department gender n (%) b50% women N50% women OBG chair gender n (%) Woman Man GO fellowship n (%) Yes No GO division size n (%) b 3 faculty 3 or more faculty GO division gender n (%) b50% women N50% women GO division director gender Man Woman NCI Cancer Center n (%) Yes No
Surgical specialty (n = 42, 29.4%)
Non-surgical specialtya (n = 101, 70.6%)
6 (14.3%) 36 (85.7%)
39 (38.6%) 62 (61.4%)
6 (14.3%) 36 (85.7%)
32 (31.7%) 69 (68.3%)
0.03
19 (45.2%) 23 (54.8%)
31 (30.7%) 70 (69.3%)
0.10
21 (50%) 21 (50%)
31(30.4%) 71 (69.6%)
0.03
13 (30.9%) 29 (69.1%)
49 (48.5%) 52 (51.5%)
0.05
15 (35.7%) 27 (64.3%)
46 (45.5%) 55 (54.5%)
0.28
14 (42.4%) 19 (57.6%)
48 (70.6%) 20 (29.4%)
b0.01
20 (47.6%) 22 (52.4%)
37 (36.3%) 65 (63.7%)
p Value b0.01
0.21
OBG, Obstetrics and Gynecology. GO, Gynecologic Oncology. NCI, National Cancer Institute. MFM, Maternal Fetal Medicine. REI, Reproductive Endocrinology. GYN, gynecology. Bold values statistically significant at p b 0.05 values. a For one department chair specialty was unable to be determined.
skin (1, 1.1%); and central nervous system (0, 0%). Medical oncologists focused on hematologic malignancies were most prevalent as cancer center directors (n = 18, 20%). Of NCI designated cancer centers, one director was a gynecologic oncologist. One additional academic cancer center director, a radiation oncologist, had a clinical focus on gynecology. Cancer center director gender, specialty or disease focus were not associated with characteristics of the gynecologic oncology division. When incidence to leadership ratios were examined, gynecologic cancer ranked 9th of 11 disease sites. Gynecologic cancers were 9th in mortality to leadership ratio (Fig. 2). These leadership ratios were below expected rates (p b 0.01, p b 0.01). 7. Conclusions Health care organizations have been slow to adopt and promote diversity in leadership despite the well described benefits [2]. Although women make up the majority of the health care workforce they remain underrepresented in chair positions and in other managerial roles [9,10]. These data suggest that women in departmental leadership may benefit gynecologic oncology divisions. Departments with women chairs were larger, had more gender balanced faculty and were more likely to have women gynecologic oncology division directors. Gynecologic oncology divisions with women directors were also more likely to have gender balance. Women surgeons consistently report a lack of mentoring as an obstacle to professional advancement and much more commonly than men (40% women vs. 13% male faculty) [11,12]. Women physicians also prefer gender concordant mentoring relationships which is often difficult in surgical specialties with striking gender disparities, but feasible in gynecologic oncology [13]. These data suggest that having women in leadership may provide more opportunities for mentorship for women faculty thereby allowing retention and advancement. Similar to previous publications, these data confirmed an overrepresentation of reproductive health focused chairs of obstetrics and gynecology [6]. Several beneficial characteristics of gynecologic oncology
divisions correlated to having surgeons in departmental leadership positions. Divisions led by surgeons had both larger faculty and greater gender representation within the division more closely aligned to that of practicing gynecologic oncologists. They were more likely to have gynecologic oncology training programs. Beyond gender, representativeness of medical specialties within departments and schools of medicine is likely to impact allocation of resources and physicians perceived support. Because obstetrics and gynecology is the only department both medical and surgical care around an organ site, as two specialties (obstetrics and gynecology) are combined into one, the clinical expertise of department chairs is acutely important for gynecologic surgeons. Female gynecologic oncologists are the only women surgeons who may report to non-surgeons at the chair level within the academic medical center model. Finally, these findings demonstrate an underrepresentation of gynecologic expertise within cancer center leadership. Representation of cancer center directors with a focus on gynecologic cancer was low as was leadership roles of gynecologic oncologists within cancer center structures. Clinical cancer centers within academic medical centers are distinct enterprises dedicated to the integration of subspecialists related to cancer care and research [4]. The most common academic cancer center structure is the “Matrix Cancer Center,” which benefit academic oncologists through the integration of clinical cancer care with bench to bedside research. However, this structure may reduce the influence and subsequent benefit of smaller divisions and less common disease sites. Resource control for these divisions may be diminished as the responsibility of management of oncology faculty is outsourced to respective departments. In contrast to departments like medicine or surgery which contain a critical mass of faculty participating in cancer center activities, most departments of obstetrics and gynecology contain 2 or fewer gynecologic oncologists compared to the departmental average size of 34 [14]. This may compound a resource allocation disadvantage for gynecologic oncologists when a department chair is not an oncologist. Without cancer center or departmental leadership advocating for gynecologic cancer research, there is a risk of augmenting existing gaps in research funding. Nationally, less research funding is directed towards gynecologic cancers than other disease sites [15]. This is particularly concerning as the needs of gynecologic cancer patients are great. Ovarian cancer is typically diagnosed at a late stage where treatment is rarely curative; endometrial cancer incidence and mortality continue to rise in the United States [16]; and cervical cancer and endometrial cancer continue to have some of the largest racial and socioeconomic disparities of cancer disease sites [16,17]. Novel therapies for these diseases are desperately needed yet the availability of federally funded clinical trials for gynecologic malignancies has declined in the last decade [18]. There are limitations to this report. Gender, specialty training and disease site focuses were not self-reported. Institutional web sites may have been out of date. Leadership in academic medicine shifts frequently and there has been increasing attention to promotion and recruitment of women into chair positions. Part time or job share positions were not able to be identified. We were unable to assess the time spent in faculty or leadership positions. Longer term limits among men may tilt the balance of leadership towards a disproportionately male leadership. For example, among the 2145 permanent clinical department chairs serving at U.S. medical schools in 2019, the average term length was 8.7 years for men and 6.1 years for women [19]. This analysis may not have captured a culture change towards diversity in academic departments of obstetrics and gynecology. Women may have recently inherited divisions or departments that had been previously managed by men. Employees, including physicians, who feel included within an organization have higher levels of organizational commitment, job satisfaction and lower turnover [20]. In 2009 accreditation guidelines of the Liaison Committee on Medical Education (LCME) made
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
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Fig. 2. (A) Incidence to leadership ratios of major cancer disease sites; (B) Mortality to leadership ratios of major cancer disease sites calculated.
diversity an expectation within medical schools. The endorsed institutional standard stated that “each medical school must have policies and practices to achieve appropriate diversity among its students, faculty, staff, and other members of its academic community.” Yet efforts to improve faculty diversity have not yet generated an academic physician workforce representative of diversity in the United States. This lack of progress has been most pronounced in leadership and higher academic rank [21]. These data additionally demonstrate women gynecologic oncologists remain rare in the ranks of departmental leadership despite a growing proportion of women in the field. Gynecologic oncologists have expertise in both medical and surgical oncology care making them uniquely poised for cancer center leadership. However, they are underrepresented in cancer center leadership which may further diminish organizational resources allocated towards cancer care dedicated to treating malignancies of the female reproductive tract. Attention to these physicians and their practices could help ensure that women with gynecologic cancer receive equitable care with equivalent access to novel therapies. Inclusion of gynecologic oncologists in cancer center activities, committees and leadership should be a priority.
Funding There was no funding used in preparation of this manuscript.
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Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Take me to your leader: Reporting structures and equity in academic gynecologic oncology Sarah M. Temkin a,⁎, Lisa Rubinsak b, Michelle F. Benoit c, Linda Hong d, Uma Chandavarkar e, Christine A. Heisler f, Laurel K. Berry g, B.J. Rimel h, William P. McGuire i a
Anne Arundel Medical Center, 2003 Medical Parkway, Suite 301, Annapolis, MD 21401, United States of America Karmanos Cancer Institute, Wayne State University, United States of America Kaiser Permanente Washington, United States of America d Loma Linda University School of Medicine, United States of America e Banner MD Anderson Cancer Center, United States of America f University of Wisconsin School of Medicine, United States of America g Wake Forest Baptist Health, Winston-Salem, United States of America h Cedars-Sinai Medical Center, United States of America i Virginia Commonwealth University, Richmond b c
H I G H L I G H T S • Women are under-represented in academic medicine leadership relevant to gynecologic oncologists • Women and surgical departmental leadership were associated with benefits for gynecologic oncology divisions • Gynecologic oncologists are under-represented in cancer center leadership.
a r t i c l e
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Article history: Received 9 March 2020 Accepted 29 March 2020 Available online xxxx Keywords: Gynecologic oncology leadership Academic medicine Cancer centers
a b s t r a c t Objective. Gynecologic oncology includes increasing percentages of women. This study characterizes representation of faculty by gender and subspecialty in academic department leadership roles relevant to the specialty. Methods. The American Association of Medical Colleges accredited schools of medicine were identified. Observational data was obtained through institutional websites in 2019. Results. 144 accredited medical schools contained a department of obstetrics and gynecology with a chair; 101 a gynecologic oncology division with a director; 98 a clinical cancer center with a director. Women were overrepresented in academic faculty roles compared to the US workforce (66 vs 57%, p b 0.01) but underrepresented in all leadership roles (p b 0.01). Departments with women chairs were more likely to have N50% women faculty (90.2 vs 9.8%, p b 0.01); and have larger faculties (80.4 vs 19.6% N20 faculty, p = 0.02). The cancer center director gender did not correlate to departmental characteristics. A surgically focused chair was also associated with N50% women faculty (85.7 vs 68.3%, p = 0.03); faculty size N20 (85.7 vs 61.4%, p b 0.01); and a woman gynecologic oncology division director (57.6 vs 29.4%, p b 0.01; 68.4 vs 31.7%, p b 0.01) and gynecologic oncology fellowship (50 vs 30.4%, p b 0.01; 59.1 vs 32%, p b 0.01). Gynecologic oncology leadership within cancer centers was below expected when incidence and mortality to leadership ratios were examined (p b 0.01, p b 0.01). Conclusion. Within academic medical schools, women remain under-represented in obstetrics and gynecology departmental and cancer center leadership. Potential benefits to gynecologic oncology divisions of inclusion women and surgically focused leadership were identified. © 2020 Elsevier Inc. All rights reserved.
1. Introduction ⁎ Corresponding author. E-mail addresses: [email protected] (S.M. Temkin), [email protected] (L. Rubinsak) , [email protected] (M.F. Benoit), [email protected] (L. Hong), [email protected] (U. Chandavarkar), [email protected] (C.A. Heisler), [email protected] (L.K. Berry), [email protected] (B.J. Rimel).
Diversity within organizations has been demonstrated to improve both quality and financial outcomes within healthcare systems [1,2]. In addition, within academic medicine, representative leadership is critical to the equitable distribution of resources [3]. Gynecologic oncology
https://doi.org/10.1016/j.ygyno.2020.03.031 0090-8258/© 2020 Elsevier Inc. All rights reserved.
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
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S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
is a unique subspecialty of medicine in that physicians provide both surgical and medical care for women with malignancies of the female genital tract. This distinctive care model arose through obstetrics and gynecology as a response to a perceived neglect of women with cancers of the ovary, uterus, cervix, vagina and vulva. Historically, within academic medical centers, the departmental home for gynecologic oncologists is within a department of obstetrics and gynecology. However, successful academic oncology practices that include high quality clinical and research activities within academic centers require cancer center resources and infrastructure in addition to departmental support [4]. For gynecologic oncology, balancing support may be challenging as obstetrics and gynecology departmental priorities tend towards maternity care and reproductive health; cancer centers typically are dominated by medical, radiation and surgical oncologists. Because support from cancer center leadership in addition to departmental advocacy is necessary for an academic gynecologic oncology practice to thrive, conflicting priorities of administrative leadership may pose unique challenges specific to this specialty. First, although the majority of trainees in obstetrics and gynecology have been women since the 1990's and the field has been comprised of a majority of women for over a decade, women have remained significantly under-represented in leadership roles in departments of obstetrics and gynecology [5]. Second, academic obstetrics and gynecology leadership is heavily weighted towards maternal–fetal medicine, many of whom provide little or no surgical or cancer care [6]. We undertook this study in order to examine how the attributes of leadership in departments of obstetrics and gynecology and affiliated cancer centers affect academic gynecologic oncology divisional characteristics. Specifically, we question whether gender and subspecialty training of department chairs and cancer center directors are associated with the relative size, gender distribution of faculty and presence of a gynecologic oncology fellowship within gynecologic oncology divisions in academic medical centers. 2. Methods The Association of American Medical Colleges list of Accreditation Council for Graduate Medical Education (ACGME) accredited schools of medicine (https://members.aamc.org/) was used to identify 154 accredited academic institutions. Publicly available data were reviewed using the administrative roster displayed on their Institutional Web sites. One reviewer (ST) compiled all information regarding leadership infrastructure related to gynecologic oncology including: department of obstetrics and gynecology leadership, faculty size and gender composition; division of gynecologic oncology leadership size and gender composition; presence of an accredited fellowship; the presence of an affiliated clinical cancer center; and clinical expertise of the director. Apparent gender was inferred for each faculty member in accordance with given name, pronoun used in their bio and, in most cases, accompanying or Web-sought and found photograph. Surgical focus of department chairs was determined by review of their online biography. Subspecialists in gynecologic oncology, female pelvic medicine and reconstructive surgery (urogynecology) or specialists in obstetrics and gynecology with descriptors of surgical expertise were considered to have a surgical focus. Maternal fetal medicine, reproductive endocrinologists or specialists in obstetrics and gynecology without mention of surgery in the biography were considered to have a reproductive health focus. Disease site focus of the cancer center director was similarly inferred by review of their bio and a review of publications when necessary. This review was completed by primary reviewer (ST) between July 15 and July 31, 2019. A second reviewer confirmed all data (LH, MB, UC, LB) between August 1 and 15, 2019. Discrepancies were resolved by consensus. Data collected for this study were all from publicly available Web sites and were recorded in aggregate quantitative, anonymized fashion. This study is therefore exempt from institutional review board review.
Institutional leadership characteristics were summarized into categorical variables and presented as frequency and proportions. ACOG workforce data was used to as expected rates of gender in obstetrics and gynecology [7]. Ratios of disease site incidence and mortality to leadership were calculated using 2019 estimates of incidence and mortality from the SEER and compared to expected rates [8]. Chi-squared testing was used to evaluate observed versus expected rates. All statistical analysis was performed using JMP version 14. SAS Institute Inc., Cary, NC, 1989–2019 with p value b0.05.
3. Results Of 154 accredited medical schools, 144 contain an obstetrics and gynecology department with a chair; 101 listed gynecologic oncology division with a director; 98 listed clinical cancer centers with a director. Faculty size and gender composition was able to be determined in 143 medical schools.
4. Gender and leadership in gynecologic oncology Women were overrepresented in academic obstetrics and gynecology faculty roles compared to the number of practicing obstetrician gynecologists in the United States (66 vs 57%, p b 0.01); but not within GO divisions (55 vs 57%). Women were significantly (p b 0.01) underrepresented in all leadership roles (Fig. 1). Thirty-five percent of chairs of departments of obstetrics and gynecology, 38% of gynecologic oncology division directors and 48% of gynecologic oncology fellowship directors were women. Departments of obstetrics and gynecology with women chairs were more likely to have N50% women gynecologic oncology faculty (90.2 vs 9.8%, p b 0.01); and have faculties numbering N20 (80.4 vs 19.6%, p = 0.02) (Table 1). Gynecologic oncology division directors who are women were associated with divisions containing more than half women gynecologic oncology faculty (Table 2). The cancer center director gender did not correlate to obstetrics and gynecology or gynecologic oncology faculty or leadership characteristics.
5. Department of obstetrics and gynecology leadership subspecialty leadership Within departments of obstetrics and gynecology, chair subspecialty was more commonly reproductive-health focused (70.8%) including maternal fetal medicine specialists (39.6%); specialists in obstetrics and gynecology (20.1%); and reproductive endocrinology (11.1%), compared to surgically focused – gynecologic surgeons (13.9%) or gynecologic oncologists (15.3%). The number of gynecologic oncologists acting as department chairs was not statistically different compared to the number of gynecologic oncologist faculty in medical schools (9.6%). A surgically focused chair was associated with N50% women faculty (85.7 vs 68.3%, p = 0.03); and faculty size N20 (85.7 vs 61.4%, p b 0.01) (Table 3). Departments with a surgically focused chair or gynecologic oncologist chair were more likely to have a woman gynecologic oncology division director (57.6 vs 29.4%, p b 0.01; 68.4 vs 31.7%, p b 0.01 respectively), and gynecologic oncology fellowship (50 vs 30.4%, p b 0.01; 59.1 vs 32%, p b 0.01 respectively). Women and gynecologic oncologist chairs represented 8 of 144 (5.6%) department Chairs. This was not statistically different than the 5.2% of women gynecologic oncologists that make up academic obstetrics and gynecology faculty. Because women chairs tended to lead larger departments and departments with higher percentages of women, 9.9% of gynecologic oncologists employed as faculty (11.6% of women gynecologic oncology faculty) report to women gynecologic oncologists at the chair level.
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
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Fig. 1. Percentage of women in faculty and leadership positions compared to US obstetrician gynecologist workforce data (*indicates differs from expected) p b 0.01).
6. Cancer center subspecialty leadership Men outnumbered women in cancer center leadership and comprised 85 (86.7%) of cancer center directors. The majority of cancer center directors were trained as medical oncologists (n = 58, 59.2%); 14 (14.3%) PhDs without a medical degree; 10 (10.2%) surgical oncologists; 5 (5.1%) pediatric oncologists; 2 (2%) gynecologic oncologists; 9 had other training. The training included pathology, behavior health, ear nose and throat specialist, radiation oncology, endocrinology,
psychology and pulmonology. Ninety cancer center directors had a specific disease site focus. From most common to least common the disease sites of interest were as follows: hematologic (22, 24.4%); gastrointestinal (21, 23.3%); breast (16, 17.8%); thoracic (9, 10%); genitourinary (6, 6.7%); pediatrics (5, 5.6%); sarcoma (3, 3.3%); gynecologic (3, 3.3%);
Table 2 Characteristics of academic institutions based on gynecology oncology division director gender. Woman GO Division Director Man GO (n = 39, 38.6%) Division Director (n = 62, 61.4%)
Table 1 Characteristics of academic institutions based on chair gender.
OBG department size n (%)a b20 faculty N20 faculty OBG department gender n (%)a b50% women N50% women GO fellowship n (%) Yes No GO division size n (%)a b 3 faculty 3 or more faculty GO division gendera b50% women N50% women NCI Cancer Center n (%) Yes No OBG Chair Specialty n (%) Generalist MFM REI GYN surgeon GO
Woman OBG Department Chair (n = 51, 35.7%)
Man OBG Department Chair (n = 93, 64.3%)
10 (19.6%) 41 (80.4%)
35 (38%) 57 (62%)
p Value
0.02
0.19 18(35.3%) 33 (64.7%)
43(46.7%) 49(53.2%) 0.10
28 (54.9%) 23 (45.1%)
64 (68.8%) 29 (31.2%)
17 (33.3%) 34 (66.7%)
45 (48.9%) 47 (51.1%)
0.07 b0.01
5 (9.8%) 46 (90.2%)
32 (34.8%) 60 (65.2%)
24(47.1%) 27 (52.9%)
33 (35.4%) 60 (64.5%)
0.17
0.08 13 (26%) 15 (30%) 3 (6%) 11(22%) 8 (16%)
16 (17.2%) 41 (44.1%) 13 (14.0%) 9 (9.7%) 14 (15.1%)
OBG, Obstetrics and Gynecology. GO, Gynecologic Oncology. NCI, National Cancer Institute. MFM, Maternal Fetal Medicine. REI, Reproductive Endocrinology. GYN, gynecology. Bold values statistically significant at p b 0.05 values. a For one program faculty size and gender composition were unable to be determined.
OBG department size n (%) a b20 faculty N20 faculty OBG department gender n (%) a b50% women N50% women GO fellowship n (%) Yes No GO division size n (%) a b 3 faculty 3 or more faculty GO division gender n (%) a b 50% women N50% women NCI Cancer Center n (%) Yes No OBG Chair Specialty n (%) Generalist MFM REI GYN surgeon GO
p Value 0.80
6 (15.8%) 32 (84.2%)
11 (17.7%) 51 (82.3%)
5 (13.2%) 33 (86.8%)
11 (17.7%) 51 (82.3%)
19 (48.7%) 20 (51.3%)
29 (46.8%) 33 (53.2%)
0.54
0.86 8 (21.1%) 30 (78.9%)
14 (22.6%) 48 (77.4%)
4 (10.5%) 34 (89.5%)
31 (50%) 31 (50%)
b0.01
19 (48.7%) 20 (51.3%)
34 (54.8%) 28 (45.2%)
0.55 0.02
5 (29.2%) 11 (12.8%) 4 (10.3% 6 (15.4%) 13 (33.3%)
7 (11.3%) 33 (53.2%) 8 (12.9%) 8 (12.9%) 6 (9.7%)
OBG, Obstetrics and Gynecology. GO, Gynecologic Oncology. NCI, National Cancer Institute. MFM, Maternal Fetal Medicine. REI, Reproductive Endocrinology. GYN, gynecology. Bold values statistically significant at p b 0.05 values. a For one program faculty size and gender composition were unable to be determined.
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
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S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
Table 3 Characteristics of academic institutions based on obstetrics and gynecology chair specialty.
OBG department size n (%) b20 faculty N20 faculty OBG department gender n (%) b50% women N50% women OBG chair gender n (%) Woman Man GO fellowship n (%) Yes No GO division size n (%) b 3 faculty 3 or more faculty GO division gender n (%) b50% women N50% women GO division director gender Man Woman NCI Cancer Center n (%) Yes No
Surgical specialty (n = 42, 29.4%)
Non-surgical specialtya (n = 101, 70.6%)
6 (14.3%) 36 (85.7%)
39 (38.6%) 62 (61.4%)
6 (14.3%) 36 (85.7%)
32 (31.7%) 69 (68.3%)
0.03
19 (45.2%) 23 (54.8%)
31 (30.7%) 70 (69.3%)
0.10
21 (50%) 21 (50%)
31(30.4%) 71 (69.6%)
0.03
13 (30.9%) 29 (69.1%)
49 (48.5%) 52 (51.5%)
0.05
15 (35.7%) 27 (64.3%)
46 (45.5%) 55 (54.5%)
0.28
14 (42.4%) 19 (57.6%)
48 (70.6%) 20 (29.4%)
b0.01
20 (47.6%) 22 (52.4%)
37 (36.3%) 65 (63.7%)
p Value b0.01
0.21
OBG, Obstetrics and Gynecology. GO, Gynecologic Oncology. NCI, National Cancer Institute. MFM, Maternal Fetal Medicine. REI, Reproductive Endocrinology. GYN, gynecology. Bold values statistically significant at p b 0.05 values. a For one department chair specialty was unable to be determined.
skin (1, 1.1%); and central nervous system (0, 0%). Medical oncologists focused on hematologic malignancies were most prevalent as cancer center directors (n = 18, 20%). Of NCI designated cancer centers, one director was a gynecologic oncologist. One additional academic cancer center director, a radiation oncologist, had a clinical focus on gynecology. Cancer center director gender, specialty or disease focus were not associated with characteristics of the gynecologic oncology division. When incidence to leadership ratios were examined, gynecologic cancer ranked 9th of 11 disease sites. Gynecologic cancers were 9th in mortality to leadership ratio (Fig. 2). These leadership ratios were below expected rates (p b 0.01, p b 0.01). 7. Conclusions Health care organizations have been slow to adopt and promote diversity in leadership despite the well described benefits [2]. Although women make up the majority of the health care workforce they remain underrepresented in chair positions and in other managerial roles [9,10]. These data suggest that women in departmental leadership may benefit gynecologic oncology divisions. Departments with women chairs were larger, had more gender balanced faculty and were more likely to have women gynecologic oncology division directors. Gynecologic oncology divisions with women directors were also more likely to have gender balance. Women surgeons consistently report a lack of mentoring as an obstacle to professional advancement and much more commonly than men (40% women vs. 13% male faculty) [11,12]. Women physicians also prefer gender concordant mentoring relationships which is often difficult in surgical specialties with striking gender disparities, but feasible in gynecologic oncology [13]. These data suggest that having women in leadership may provide more opportunities for mentorship for women faculty thereby allowing retention and advancement. Similar to previous publications, these data confirmed an overrepresentation of reproductive health focused chairs of obstetrics and gynecology [6]. Several beneficial characteristics of gynecologic oncology
divisions correlated to having surgeons in departmental leadership positions. Divisions led by surgeons had both larger faculty and greater gender representation within the division more closely aligned to that of practicing gynecologic oncologists. They were more likely to have gynecologic oncology training programs. Beyond gender, representativeness of medical specialties within departments and schools of medicine is likely to impact allocation of resources and physicians perceived support. Because obstetrics and gynecology is the only department both medical and surgical care around an organ site, as two specialties (obstetrics and gynecology) are combined into one, the clinical expertise of department chairs is acutely important for gynecologic surgeons. Female gynecologic oncologists are the only women surgeons who may report to non-surgeons at the chair level within the academic medical center model. Finally, these findings demonstrate an underrepresentation of gynecologic expertise within cancer center leadership. Representation of cancer center directors with a focus on gynecologic cancer was low as was leadership roles of gynecologic oncologists within cancer center structures. Clinical cancer centers within academic medical centers are distinct enterprises dedicated to the integration of subspecialists related to cancer care and research [4]. The most common academic cancer center structure is the “Matrix Cancer Center,” which benefit academic oncologists through the integration of clinical cancer care with bench to bedside research. However, this structure may reduce the influence and subsequent benefit of smaller divisions and less common disease sites. Resource control for these divisions may be diminished as the responsibility of management of oncology faculty is outsourced to respective departments. In contrast to departments like medicine or surgery which contain a critical mass of faculty participating in cancer center activities, most departments of obstetrics and gynecology contain 2 or fewer gynecologic oncologists compared to the departmental average size of 34 [14]. This may compound a resource allocation disadvantage for gynecologic oncologists when a department chair is not an oncologist. Without cancer center or departmental leadership advocating for gynecologic cancer research, there is a risk of augmenting existing gaps in research funding. Nationally, less research funding is directed towards gynecologic cancers than other disease sites [15]. This is particularly concerning as the needs of gynecologic cancer patients are great. Ovarian cancer is typically diagnosed at a late stage where treatment is rarely curative; endometrial cancer incidence and mortality continue to rise in the United States [16]; and cervical cancer and endometrial cancer continue to have some of the largest racial and socioeconomic disparities of cancer disease sites [16,17]. Novel therapies for these diseases are desperately needed yet the availability of federally funded clinical trials for gynecologic malignancies has declined in the last decade [18]. There are limitations to this report. Gender, specialty training and disease site focuses were not self-reported. Institutional web sites may have been out of date. Leadership in academic medicine shifts frequently and there has been increasing attention to promotion and recruitment of women into chair positions. Part time or job share positions were not able to be identified. We were unable to assess the time spent in faculty or leadership positions. Longer term limits among men may tilt the balance of leadership towards a disproportionately male leadership. For example, among the 2145 permanent clinical department chairs serving at U.S. medical schools in 2019, the average term length was 8.7 years for men and 6.1 years for women [19]. This analysis may not have captured a culture change towards diversity in academic departments of obstetrics and gynecology. Women may have recently inherited divisions or departments that had been previously managed by men. Employees, including physicians, who feel included within an organization have higher levels of organizational commitment, job satisfaction and lower turnover [20]. In 2009 accreditation guidelines of the Liaison Committee on Medical Education (LCME) made
Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031
S.M. Temkin et al. / Gynecologic Oncology xxx (xxxx) xxx
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Fig. 2. (A) Incidence to leadership ratios of major cancer disease sites; (B) Mortality to leadership ratios of major cancer disease sites calculated.
diversity an expectation within medical schools. The endorsed institutional standard stated that “each medical school must have policies and practices to achieve appropriate diversity among its students, faculty, staff, and other members of its academic community.” Yet efforts to improve faculty diversity have not yet generated an academic physician workforce representative of diversity in the United States. This lack of progress has been most pronounced in leadership and higher academic rank [21]. These data additionally demonstrate women gynecologic oncologists remain rare in the ranks of departmental leadership despite a growing proportion of women in the field. Gynecologic oncologists have expertise in both medical and surgical oncology care making them uniquely poised for cancer center leadership. However, they are underrepresented in cancer center leadership which may further diminish organizational resources allocated towards cancer care dedicated to treating malignancies of the female reproductive tract. Attention to these physicians and their practices could help ensure that women with gynecologic cancer receive equitable care with equivalent access to novel therapies. Inclusion of gynecologic oncologists in cancer center activities, committees and leadership should be a priority.
Funding There was no funding used in preparation of this manuscript.
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Please cite this article as: S.M. Temkin, L. Rubinsak, M.F. Benoit, et al., Take me to your leader: Reporting structures and equity in academic gynecologic oncology, Gynecologic Oncology, https://doi.org/10.1016/j.ygyno.2020.03.031