Application of Decomposition Analysis of Spatial Accessibility (DASA) in Health Services Research.

Withdrawal mapping is effective in showing the educational impact of residency programs and medical schools. It is often used for advocacy and education purposes, but it lacks grounding in the theoretical foundation of spatial accessibility research. This study proposes an improved technique called Decomposition Analysis of Spatial Accessibility, or DASA, to decompose spatial accessibility by applying the withdrawal mapping concept to the classical 2SFCA application. This study applies the DASA technique to three case studies with policy implications. The first case study details the contribution of Black surgeons to public access to the surgical workforce. The second case study details the contribution of international medical graduates from the original seven travel-ban countries. The third case study demonstrates the market competition between family physicians and general pediatricians. The study showcases the usefulness (particularly for workforce-planning for underserved populations) of the DASA technique in understanding subgroup contributions in spatial accessibility analyses.

Diversity of Department Chairs in Family Medicine at US Medical Schools.

BACKGROUND: As designated department leader, chairs need to be sensitive to diversity and inclusiveness for recruitment and retention of faculty and visibility to medical students and resident physicians. The purpose of this analysis is to describe diversity by sex and race/ethnicity of family medicine (FM) chairs as a beginning to understand trends. METHODS: This cross-sectional, observational study involved 2018 to 2020 data from the Association of American Medical Colleges Faculty Roster. We compared this data with other department chairs, faculty, medical school matriculants, and the US general population. RESULTS: There were 407 FM chair observations. While many FM chairs were White males, this was lower than all other clinical departments combined. The proportion of chairs who were under-represented minorities was highest in FM (16.7%) compared with all other departments The distributions of FM chairs who were Black, Asian, and Native American were comparable with the US population. The proportions of Hispanic FM chairs, FM faculty, and medical school matriculants lagged behind the population. CONCLUSION: Diversity of department chairs in FM is greater than many other clinical departments and more representative of the US general population. Attention by chairs to leadership development of females and recruitment of Hispanic faculty are priorities.

Trends in Cochlear Implantation in Texas: An Exploration of Outpatient Discharge Data, 2010 to 2017.

OBJECTIVES: To describe trends in cochlear implantation (CI) disparities in Texas using an all-payer database from 2010 to 2017. METHODS: Texas Outpatient Surgical and Radiological Procedure Data, a public use data file, was accessed to analyze outpatient CI cases for Texas. Variables analyzed include patient age, sex, race/ethnicity, and insurance status. Population data from the American Community Survey generated CI utilization rates by patient demographic characteristics. RESULTS: There were 6158 CI cases identified during the study period. The number of CI per year nearly doubled from 497 in 2010 to 961 in 2017. The majority of CI recipients were white (59.5%), male (51.9%), and privately insured (47.9%). All sub-populations statewide had more CI in 2017 compared to 2010, with the overall CI per 100 000 population increasing from 1.98 to 3.50 per 100 000 population. Patients over 75 demonstrated the greatest increase in the CI rate per 100 000 population, increasing from 4.60 in 2010 to 14.30 in 2017. Regarding race/ethnicity, all sub-populations noted an increase in the CI per 100 000 population, with white patients demonstrating the highest rate in 2017, at 4.36 CI per 100 000 population. Asian patients had a 502% increase in the CI rate (from 0.42 to 2.53), compared with 87.9%, 84.4%, and 69.2% increases for white, Black, and Hispanic populations, respectively. CONCLUSIONS: CI became more widespread between 2010 and 2017, benefiting certain populations more than others. Black and Hispanic populations had lower CI per 100 000 population than their white peers, while patients >65 years of age accounted for the greatest increase in CI.

Recent Trends in Faculty Promotion in U.S. Medical Schools: Implications for Recruitment, Retention, and Diversity and Inclusion.

PURPOSE: Faculty promotion is important for retention and has implications for diversity. This study provides an update on recent trends in faculty promotion in U.S. medical schools. METHOD: Using data from the Association of American Medical Colleges Faculty Roster, the authors examined trends in faculty promotion over 10 years. Promotion status for full-time assistant and full-time associate professors who started between 2000 and 2009 inclusive was followed from January 1, 2010 to January 1, 2019. The authors used bivariate analyses to assess associations and promotion rates by sex, race/ethnicity, department, tenure status, and degree type. RESULTS: The promotion rate for assistant professors was 44.3% (2,330/5,263) in basic science departments, 37.1% (17,232/46,473) in clinical science departments, and 33.6% (131/390) in other departments. Among clinical departments, family medicine had the lowest rate of promoting assistant professors (24.4%; 484/1,982) and otolaryngology the highest rate (51.2%; 282/551). Faculty members who were male (38.9%; 11,687/30,017), White (40.0%; 12,635/31,596), tenured (58.7%; 98/167) or tenure-eligible (55.6%; 6,653/11,976), and holding MDs/PhDs (48.7%; 1,968/4,038) had higher promotion rates than, respectively, faculty who were female (36.3%; 7,975/21,998), minorities underrepresented in medicine (URM; 31.0%; 1,716/5,539), nontenured (32.5%; 12,174/37,433), and holding other/unknown degrees (20.6%; 195/948; all P < .001). These differences were less pronounced among associate professors; however, URM and nontenured faculty continued to have lower promotion rates compared with White, Asian, or tenured faculty at the associate professor level. CONCLUSIONS: Promotion rates varied not only by faculty rank but also by faculty sex, race/ethnicity, department, tenure status, and degree type. The differences were more pronounced for assistant professors than associate professors. URM faculty members, particularly assistant professors, were promoted at lower rates than their White and Asian peers. More research to understand the drivers of disparities in faculty promotion seems warranted.

Full-Time Faculty in Clinical and Basic Science Departments by Sex and Underrepresented in Medicine Status: A 40-Year Review.

PURPOSE: To assess the changing diversity of faculty in specific clinical and basic science departments, stratified by sex and underrepresented in medicine (URM) status, at all Liaison Committee on Medical Education (LCME)-accredited medical schools. METHOD: In this retrospective, cross-sectional, observational study, the authors used data from the Association of American Medical Colleges Faculty Roster (data pulled in October 2019) to identify trends in clinical department faculty and in basic science department faculty by sex and URM status. They included full-time faculty at all LCME-accredited medical schools from 1979 to 2018. They compared the proportions of faculty across separate departments according to sex and URM status, and they used 2-independent-sample t test and simple linear regressions for statistical comparisons. RESULTS: The number of full-time faculty increased from 49,909 in 1979 to 175,326 in 2018. The largest increase occurred in clinical departments, where the number of faculty increased from 38,726 to 155,677 (a fourfold increase). The number of faculty in basic science departments increased from 11,183 to 19,649 (a 1.8-fold increase). The proportions of faculty who were non-URM females (compared with non-URM males, URM females, and URM males) increased the most-from 14.4% (5,595 of 38,726) to 37.6% (58,478 of 155,677) for clinical departments, and from 14.9% (1,669 of 11,183) to 33.0% (6,485 of 19,649) for basic science departments. Growth was steady but slow among URM faculty, especially for Black males; the absolute number of male URM faculty remained low in both basic science and clinical departments. The proportions of females and URM faculty were highest in the departments of obstetrics and gynecology, pediatrics, and family medicine. CONCLUSIONS: The substantial increase in faculty, especially in clinical departments, has led to greater diversity, but mostly among non-URM females. The rise of URM male and URM female faculty has been minimal.

Tenure Trends in Academic Emergency Medicine Departments in U.S. Medical Schools.

OBJECTIVE: The objective was to assess the long-term trends in tenure status stratified by sex and underrepresented in medicine (URM) status among emergency medicine (EM) department faculty in U.S. medical schools. METHODS: This study used the Association of American Medical Colleges Faculty Roster to study trends in tenure status of full-time faculty from 1989 to 2018. The numbers and proportions of faculty by tenure status were studied over the years and compared across sex and URM minority status. Two-independent-sample t-test and simple linear regression were used for statistical comparisons. RESULTS: The number of EM faculty increased from 177 in 1989 to 5,237 in 2018, with the majority of increase in nontenured (from 120 to 4,485) rather than tenured (from 24 to 198) or tenure track (from 28 to 548) faculty. The proportions of tenure-line faculty increased briefly from 1989 (29.4%) to 1994 (32.5%) and decreased since to 14.2% in 2018. The decreases were greater among men (from 34.5% to 14.9%) or non-URM (from 32.7% to 14.1%) than women (from 24.8% to 13.1%) or URM (from 30.2% to 15.3%). Compared to other academic departments, EM departments had the second lowest proportion of tenure-line faculty in 2018. CONCLUSION: Emergency medicine faculty size increased rapidly in the past 30 years, with the vast majority of growth in nontenured faculty, regardless of sex or URM status. This highlights the need to review career development and academic promotions for EM particularly among nontenured faculty.

US Dermatology Department Faculty Diversity Trends by Sex and Underrepresented-in-Medicine Status, 1970 to 2018.

Importance: Faculty diversity has important implications for improving the cultural competency and diversity of medical students and residents. However, dermatology is one of the least diverse fields in medicine. Objectives: To measure faculty diversity by sex, race, and ethnicity in academic dermatology departments in US medical schools and to evaluate how this representation compares with the diversity of the US population, medical students, department chairs, and faculty in other clinical departments. Design, Setting, and Participants: In this cross-sectional study, data from the Association of American Medical Colleges Faculty Roster were evaluated to differentiate full-time faculty by sex and designation as a minority underrepresented in medicine (URM; currently including black, Hispanic, American Indian/Alaska Native, Native Hawaiian, and Pacific Islander individuals). Trends in female and URM representation among academic dermatology departments were analyzed from 1970 to 2018. Main Outcomes and Measures: The numbers and proportions of US dermatology department faculty by sex, race, and ethnicity. Results: The number of full-time US dermatology department faculty increased from 167 in 1970 to 1464 in 2018. The number of female faculty increased from 18 (10.8%) in 1970 to 749 (51.2%) in 2018; the number of URM faculty grew from 8 (4.8%) in 1970 to 109 (7.4%) in 2018. Proportions of female and white dermatology department faculty were similar to the US population in 2018; however, like other clinical departments, the proportion of URM faculty was lower than in the general population. There was an inverse association between increasing faculty rank and the proportion of female faculty overall, but this was not the case among URM faculty. At every rank, there was a proportionately low number of URM faculty represented. Across all specialties, department chairs were least diverse, with white individuals representing 79.7% (n = 2856 of 3585) of all chairs in 2018 and women representing 19.4% (n = 694 of 3585) of all chairs. Conclusions and Relevance: Expansion of faculty in US dermatology departments over the past half century has led to greater female representation, now similar to that in the general population. Higher-ranking faculty is associated with lower diversity. Although dermatology department faculty diversity by sex, race, and ethnicity has partially improved over the past 49 years, continued attention to the lagging representation of URM faculty should be a priority for the field of academic dermatology.

Trends in Tenure Status in Academic Family Medicine, 1977-2017: Implications for Recruitment, Retention, and the Academic Mission.

PURPOSE: Tenure status has important implications for medical school faculty recruitment and retention and may affect educational quality, academic freedom, and collegiality. However, tenure trends in academic family medicine are unknown. This study aimed to describe trends in tenure status of family medicine faculty overall and by gender and status of minorities underrepresented in medicine (URM) in Liaison Committee on Medical Education-accredited medical schools. METHOD: Association of American Medical Colleges Faculty Roster data were used to describe trends in tenure status of full-time family medicine faculty, 1977 to 2017. Bivariate and trend analyses were conducted to assess associations and describe patterns between tenure status and gender, race, and ethnicity. Interdepartmental variations in tenure trends over the years were also examined. RESULTS: Among family medicine faculty, the proportions of faculty tenured or on a tenure track dropped more than threefold from 1977 (46.6%; n = 507/1,089) to 2017 (12.7%; n = 729/5,752). Lower proportions of women and URM faculty were tenured or on a tenure track than male and non-URM faculty, respectively. But the gaps among them were converging. Compared with other clinical departments, family medicine had the highest proportion of faculty (74.6%; n = 4,291/5,752) not on a tenure track in 2017. CONCLUSIONS: Proportion of tenure positions significantly decreased among family medicine faculty in U.S. medical schools. While gaps between male and female faculty and among certain racial/ethnic groups remained for family medicine tenure status, they have decreased over time, mainly because of a substantial increase in nontenured positions.

The Rise of Nontenured Faculty in Obstetrics and Gynecology by Sex and Underrepresented in Medicine Status.

OBJECTIVE: To assess the changing landscape in nontenured faculty, stratified by sex and underrepresented in medicine status, for obstetrician-gynecologists at all U.S. medical schools. METHODS: In this retrospective observational study, we used data from the Association of American Medical Colleges Faculty Roster to identify trends in career pathways of full-time faculty at all U.S. MD-granting medical schools from 1978 to 2017. Proportions of nontenured faculty were compared with other clinical departments, according to sex and race-ethnicity. Two-sample t-testing and simple linear regression were used for statistical comparisons. RESULTS: The number of full-time obstetrics and gynecology faculty increased from 1,688 to 6,347, with most being nontenured (from 535 to 4,951; 9.3-fold increase) rather than tenured (from 457 to 587; 1.3-fold increase) or tenure-eligible (from 397 to 514; 1.3-fold increase). The proportions of all faculty who were nontenured increased from 29.6% to 72.5% (a 2.5-fold increase; P<.010) for men and from 43.4% to 81.4% (a 1.9-fold increase; P<.01) for women. The proportion who were nontenured increased similarly for faculty who were underrepresented in medicine (from 27.4% to 83.5%; a 3.0-fold increase; P<.01) and for those who were not underrepresented in medicine (from 32.0% to 77.1%; a 2.4-fold increase; P<.01). Trends in the increased proportions of nontenured obstetrics and gynecology faculty were similar with those in other major clinical departments. CONCLUSIONS: The substantial rise in the number of obstetrics and gynecology faculty was largely among those who were nontenured, regardless of sex or underrepresented in medicine status. This finding signals the essential need for examining career development and academic accomplishment for promoting nontenured faculty.

The Racial and Ethnic Composition and Distribution of Primary Care Physicians.

Racial and ethnic minority physicians are more likely to practice primary care and serve in underserved communities. However, there are micro-practice patterns within primary care specialties that are not well understood. To examine the differences among primary care physician practice locations by specialty and race/ethnicity, a retrospective study was conducted on U.S. medical graduates who were direct patient care physicians in 2012. The group-specific contributions to primary care accessibility were decomposed by individual group of minorities underrepresented in medicine (URM). Results confirm significant differences not only in their distribution across underserved areas but also in their racial/ethnic composition by primary care specialties, with internist most diverse and family physicians least diverse. However, stratified analysis shows that within each primary care subspecialty, URM physicians were more likely to practice in underserved areas than their White peers regardless of specific specialties.

Relocation of Obstetrician-Gynecologists in the United States, 2005-2015.

OBJECTIVE: To examine recent trends in the relocation of obstetrician-gynecologists (ob-gyns) in the United States. METHODS: This longitudinal descriptive study analyzed relocation patterns of ob-gyns between the earliest reference point (2005) and most recently (2015). A physician's county location in a year was compared with his or her location during the previous year. Physician background and county characteristics came from three data resources (Association of American Medical Colleges databases, American Medical Association Physician Masterfile, American Community Survey). A multilevel logistic regression model was used to model factors associated with relocation for the entire period. RESULTS: An average of 2,446 (6.5%) of the 37,385 ob-gyns in practice moved per year. Approximately one third (32.1%) relocated (usually once or twice) during the 10 years with more than half (58.2%) remaining within their state. The odds of relocating were higher if the ob-gyns was young, male, black, or an international medical graduate. Relocations were predominantly to counties that were either urban or with a lower percentage of the population in poverty (less than 21.2%). Although the number of ob-gyns and women 18 years or older increased in most states, the population to ob-gyn ratio increased from 3,155 in 2006 to 3,293 in 2015. Net gains from relocations were most apparent in Florida, California, and Washington, whereas net losses were especially apparent in Michigan, Pennsylvania, Ohio, Illinois, and New York. CONCLUSION: Approximately one in every three ob-gyns in the United States moved at least once in the past 10 years to counties that were predominantly urban or with less poverty. Observing this trend might contribute to a better understanding about the uneven national distribution of ob-gyns.

Increasing Family Medicine Faculty Diversity Still Lags Population Trends.

BACKGROUND: Faculty diversity has important implications for medical student diversity. The purpose of this analysis is to describe trends in racial, ethnic, and gender diversity in family medicine (FM) departments and compare these trends to the diversity of matriculating medical students, the diversity of all medical school faculty, and the population in general. METHODS: We used the Association of American Medical Colleges Faculty Roster to describe trends in proportions of female and minorities under-represented in medicine (URM) in FM department full-time faculty in U.S. MD-granting medical schools. RESULTS: Among FM faculty, the proportions of female and URM faculty have grown more than 2-fold between 1980 and 2015. Increasing faculty rank was associated with lower diversity across the study period. FM departments had higher female and URM proportions than the average of all other specialties, but URM representation still lagged population trends. CONCLUSION: Although FM faculty diversity is growing over time, continued attention to URM representation should remain a priority.

Current and Future Status of Diversity in Ophthalmologist Workforce.

IMPORTANCE: Increasing the level of diversity among ophthalmologists may help reduce disparities in eye care. OBJECTIVE: To assess the current and future status of diversity among ophthalmologists in the workforce by sex, race, and ethnicity in the context of the available number of medical students in the United States. DESIGN, SETTING, AND PARTICIPANTS: Data from the Association of American Medical Colleges, the American Medical Association, and US Census were used to evaluate the differences and trends in diversity among ophthalmologists, all full-time faculty except ophthalmology, ophthalmology faculty, ophthalmology residents, medical school students, and the US population between 2005 and 2015. For 2014, associations of sex, race, and ethnicity with physician practice locations were assessed. MAIN OUTCOMES AND MEASURES: Proportions of ophthalmologists stratified by sex, race, and ethnicity between 2005 and 2015. RESULTS: Women and minority groups traditionally underrepresented in medicine (URM)-black, Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander-were underrepresented as practicing ophthalmologists (22.7% and 6%, respectively), ophthalmology faculty (35.1% and 5.7%, respectively), and ophthalmology residents (44.3% and 7.7%, respectively), compared with the US population (50.8% and 30.7%, respectively). During the past decade, there had been a modest increase in the proportion of female practicing ophthalmologists who graduated from US medical schools in 1980 or later (from 23.8% to 27.1%; P < .001); however, no increase in URM ophthalmologists was identified (from 7.2% to 7.2%; P = .90). Residents showed a similar pattern, with an increase in the proportion of female residents (from 35.6% to 44.3%; P = .001) and a slight decrease in the proportion of URM residents (from 8.7% to 7.7%; P = .04). The proportion of URM groups among ophthalmology faculty also slightly decreased during the study period (from 6.2% to 5.7%; P = .01). However, a higher proportion of URM ophthalmologists practiced in medically underserved areas (P < .001). CONCLUSIONS AND RELEVANCE: Women and URM groups remain underrepresented in the ophthalmologist workforce despite an available pool of medical students. Given the prevalent racial and ethnic disparities in eye care and an increasingly diverse society, future research and training efforts that increase the level of diversity among medical students and residents seems warranted.

Racial and Ethnic Differences Between Obstetrician-Gynecologists and Other Adult Medical Specialists.

OBJECTIVE: To compare racial and ethnic differences between obstetrician-gynecologists (ob-gyns) and other large groups of adult medical specialists who provide the predominant care of women. Whether physician diversity influences their practice locations in underserved areas was also sought. METHODS: This cross-sectional study reports an analysis of U.S. national data about racial and ethnic characteristics, gender, and specialty (obstetrics and gynecology, general internal medicine, family medicine, emergency medicine) of 190,379 physicians who came from three resources (Association of American Medical Colleges Student Records System, Association of American Medical Colleges Minority Physicians Database, American Medical Association Physician Masterfile). Underserved locations were identified as being rural, having 20% or more of the population living in poverty or being federally designated as areas of professional shortages or underserved populations. Bivariate measures of associations were performed to study the association between physician race and ethnicity and their practice location. RESULTS: Female physicians in all specialties were more likely than males to be nonwhite, and ob-gyns were most likely to be female (61.9%). Compared with other studied specialists, ob-gyns had the highest proportion of underrepresented minorities (combined, 18.4%), especially black (11.1%) and Hispanic (6.7%) physicians. Underrepresented minority ob-gyns were more likely than white or Asians to practice in federally funded underserved areas or where poverty levels were high. Native Americans, Alaska Natives, and Pacific Islanders were the ob-gyn group with the highest proportion practicing in rural areas. CONCLUSION: Compared with other adult medical specialists, ob-gyns have a relatively high proportion of black and Hispanic physicians. A higher proportion of underrepresented minority ob-gyns practiced at medically underserved areas.

A Diversity 3.0 Update: Are We Moving the Needle Enough?

Five years ago, in a previous Academic Medicine Commentary, the author asserted that the move toward health reform and a more equitable health system required a transformation of more than how we finance, deliver, and evaluate health care. It also required a new role for diversity and inclusion as a solution to our problems, rather than continuing to see it as just another problem to be fixed. In this update, the author assesses the collective progress made by the nation's medical schools and teaching hospitals in integrating diversity into their core strategic activities, as well as highlighting areas for continued improvement.The author identifies five new trends in diversity and inclusion within academic medicine: broader definitions of diversity to include lesbian, gay, bisexual, and transgender people and those who have disabilities; elevated roles for diversity leaders in medical school administration; growing use of a holistic approach to evaluating medical school applicants; recognition of diversity and inclusion as a core marker of excellence; and appreciation of the significance of subpopulations within minority and underrepresented groups.More work remains to be done, but institutional initiatives to foster and prioritize diversity and inclusion coupled with national efforts by organizations such as the Association of American Medical Colleges are working to build the capacity of U.S. medical schools and teaching hospitals to move diversity from a peripheral initiative to a core strategy for improving the education of medical students and, ultimately, the care delivered to all of our nation's people.

Measuring Diversity and Inclusion in Academic Medicine: The Diversity Engagement Survey.

PURPOSE: To produce a physician and scientific workforce that advances high-quality research and culturally competent care, academic medical centers (AMCs) must assess their capacity for diversity and inclusion and leverage opportunities for improvement. The Diversity Engagement Survey (DES) is presented as a diagnostic and benchmarking tool. METHOD: The 22-item DES consists of eight factors that connect engagement theory to inclusion and diversity constructs. It was piloted at 1 AMC and then administered at 13 additional U.S. AMCs in 2011-2012. Face and content validity were assessed through a review panel. Cronbach alpha was used to assess internal consistency. Confirmatory factor analysis (CFA) was used to establish construct validity. Cluster analysis was conducted to establish ability of the DES to distinguish between institutions' degrees of engagement and inclusion. Criterion validity was established using observed differences in scores for demographic groups as suggested by the literature. RESULTS: The sample included 13,694 respondents across 14 AMCs. Cronbach alphas for the engagement and inclusion factors (range: 0.68-0.85), CFA fit indices, and item correlations with latent constructs indicated an acceptable model fit and that items measured the intended concepts. Cluster analysis of DES scores distinguished institutions with higher, middle, and lower degrees of engagement and inclusion by their respondents. Consistent with the literature, black, Hispanic/Latino, female, and LGBTQ (lesbian, gay, bisexual, transgender, queer) respondents reported lower degrees of engagement than their counterparts. CONCLUSIONS: The DES is a reliable and valid instrument for assessment, evaluation, and external benchmarking of institutional engagement and inclusion.