Physician Diversity

How does the choice to subspecialize differ by gender?

Despite a rise in women enrolling in medical school over the past three decades, women in internal medicine remain less likely to pursue fellowship, says a recently published analysis of data from 1991–2016.

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The research, published in JAMA Internal Medicine, examines the gender breakdown in internal medicine (IM) residency programs and IM subspecialties. Researchers analyzed data published annually regarding internal medicine subspecialty choices.

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Women’s subspecialty share shrinks

There has been a significant uptick in female IM residents. In 1991, 30% of IM residents were women, a number that rose to 43% in 2016. Despite there being more female IM residents during the period studied, the percentage of women pursuing IM fellowships has actually fallen.

Of the 7,986 IM residents in subspecialty fellowships in 1991, 33.3% were women and 66.7% were men. In 2016, the percentages shifted—of the 19,868 residents in IM fellowships, 23.6% were women and 76.4% were men.

The study was written by Anna T. Stone, MD, Kelly M. Carlson, MD, Kathleen L. Morris, DO, and Mary Norine Walsh, MD—of the cardiology department at Indianapolis’ St. Vincent Hospital and Heart Center—along with Pamela S. Douglas, MD, at Duke University Medical Center’s cardiology department.

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Rise in 9 internal medicine subspecialties

The data reveal that nine IM subspecialties that existed in 1991 and 2016 saw a rise in the number of women:

  • Cardiovascular disease.
  • Endocrinology.
  • Gastroenterology.
  • Geriatric medicine.
  • Hematology and oncology.
  • Infectious disease.
  • Nephrology.
  • Pulmonary disease and critical care.
  • Rheumatology.

Looking at 2016 data within that group, women made up the largest percent of fellows in endocrinology (71.3%), geriatric medicine (67.9%) and rheumatology (60.2%).

Of the nine subspecialties that were around back in ’91, the three in which women made up the smallest percentage of the workforce in 2016 were cardiovascular disease (21.3%), pulmonary disease and critical care (32.6%), and gastroenterology (34%).

“Substantial differences between specialties remain,” the study says. “As compared with the other eight subspecialties, cardiology had the lowest percentage of women, which is an important issue that the cardiology profession should continue to address.”

The researchers did not list a gender breakdown for subspecialty fellowship programs that have come into being since 1991.

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Reasons for overall subspecialization drop

The research letter cites data from a 2012 JAMA study, “General Medicine vs. Subspecialty Career Plans Among Internal Medicine Residents.” Among other findings, that study revealed that women were about 10% more likely than men to pursue a career in general internal medicine without subspecializing.

In examining the drop in the share of women trained in internal medicine who choose to subspecialize, the research letter offers evidence to further support that 2012 data.

“Many factors are associated with the decisions of medical students in choosing an internal medicine residency, including their sex, educational experience, views of patient care, and lifestyle perceptions,” says the new JAMA Internal Medicine study. “Similar considerations apply to subspecialty training. Time with family has been the most highly rated factor in career choice for both men and women. As compared with men, women have assigned a greater importance to long-term patient relationships and family time and less to financial considerations.”