Business and financial communities have recently acknowledged that gender disparities in both compensation and leadership are commonplace. However, the presence of gender disparity in the medical field, particularly in the fields of neurology and clinical neurophysiology, has been less commonly recognized. In this article, we explore the unique challenges faced by female physicians and discuss underlying reasons these obstacles continue to exist. We then build on these challenges to discuss strategies and techniques that can be used at the individual, institutional, and national level to combat these disparities. We also provide examples of strategies used by the American Clinical Neurophysiology Society (ACNS), an international society for all clinical neurophysiologists, which has acknowledged its own gender disparities and instituted measures that have led to significant improvements in gender equity.
DATA ON PHYSICIAN GENDER DISPARITY
In 2017, the number of female medical students exceeded the number of male students enrolled in medical school for the first time in US history.1 Despite the increased number of female medical students, gender disparity in hiring, promotion, compensation, leadership roles, and the presence of sexual harassment continue in the medical field. The underrepresentation of women in top leadership positions can be readily seen in academic medicine where women account for only 22% of full professor positions, 18% of department chairs, and 17% of medial school deans.2 Women are less likely to achieve these ranks even after controlling for age, years after residency, number of publications, grants, clinical trials, and total Medicare payments.3,4 Therefore, it may not be surprising that no women have held presidential leadership positions in 10 major medical specialty societies in the last decade.5 Although academic productivity can be influenced by many factors including personal choices for work–life balance, these choices do not account for the significant disparity in leadership roles, career advancement, or compensation.
At a time when the field of neurophysiology has seen enormous growth, gender disparity in leadership and compensation remain. Over the last two decades, this growth in our field has included the incorporation of neurophysiologic intraoperative monitoring as standard practice during surgical procedures in which the central nervous system is at risk and continuous EEG monitoring has increased in use greater than 10-fold.6,7 For the last several years, 40% to 50% of graduates from clinical neurophysiology fellowships, as well as related fellowship programs in neuromuscular medicine and epilepsy, have been female.8 Unfortunately, despite the growth in our field and the increasing number of women entering the fields of neurology and clinical neurophysiology, women remain underrepresented in national leadership positions, awards, conference presentations, publications, and many other markers of academic success.9–12 Of 1,712 academic neurologists at 29 top-ranked medical schools, only 30.8% were women. After controlling for number of years since medical school graduation, women accounted for 43.3% of assistant professors, 30.2% of associate professors, and only 13.8% of professors.9 At all academic levels, male neurologists had more academic publications than women, but there were no major differences between men and women for other activities, such as educational leadership, clinical activity, or book authorship.
Gender discrimination has been experienced by as many as 66% of women physicians in some reports, and gender disparities persist despite increasing efforts by universities and medical centers to improve inclusivity and diversity.13,14 This is particularly prominent among mid-career women physicians who often become marginalized at the same institutions that appear to promote diversity. A study by Carnes and Bigby in 2007 first described this phenomenon as “Jennifer fever,” in which mid-career female physicians are seen as more threatening to their colleagues as they advance in their career and less likely to be supported in their advancement.15 In their early careers, these same female physicians are not seen as competition for advancement and would be trained and mentored. However, later on, attitudes within a department or among peers begin to shift as the advancement of female physicians in mid-career is often seen as increasingly more threatening to their male counterparts because of competition for promotion, leadership positions, and funding.
Why Physician Gender Equity Matters: Effect on Patient Care and Communication
Diversity increases productivity, and organizations and teams with women in leadership positions are more successful.16,17 With increasing numbers of female physicians, one would expect changes to occur in regard to patient care. In fact, a broad perspective that includes female physicians at all levels of patient care has been associated with improved patient outcomes. Female physicians are generally more inclined to demonstrate patient-centered attitudes and behaviors than their male counterparts.18–23 This difference can be observed as early as medical school, where female medical students are more likely to provide patient-centered communications than male medical students.13,15–17 Patient-centered communication skills have been shown to be preferred by patients and can increase physician–patient rapport and improve patient's health outcomes as well as emotional well-being.20,21,23 Female physicians have been shown to outperform male physicians in many specific types of patient-centered communication including more positivity in both verbal and nonverbal communications, greater empathy, better active listening, and a greater focus on preventative medicine compared with male physicians.18,19,22,24,25 These trends in patient-centered communications may help explain why female physicians are less likely to be the subject of either isolated or recurrent malpractice claims than male physicians.26,27 As a consequence of patient-centered communication style, female physicians also typically engage in longer clinic visits, with the average clinic visit for female physicians lasting 10% longer (an average of 2.2 minutes) than clinic visits for their male colleagues.19,28 However, in some cases, these patient-centered forms of communication may be considered a disadvantage because they may be seen as stereotypical of female roles and underlie implicit biases. This may help explain lower physician ratings of women physicians despite better patient outcomes.
Despite these effects on improved patient-centered communication, multiple studies suggest that female physicians are evaluated more harshly by patients than their male colleagues. In a review of over 53,000 online physician ratings, female physicians were consistently rated more negatively in all domains (helpfulness, punctuality, staff, and knowledge).29 Other studies have suggested that some of these differences may center on the way that female physician's patient-centered language is perceived.30 The findings of these studies demonstrate an undercurrent of implicit bias. These biases are based on cultural norms of traditional gender roles and can undermine career advancement for women. A study using video-taped, scripted actors simulating physicians found that male actors whose scripts contained patient-centered language were consistently rated higher than female actors with identical scripts.31 Other studies have found that male medical students who use patient-centered language on an Objective Structured Clinical Evaluation (OSCE) receive more positive ratings than female students who use equally patient-centered language.32 These studies suggest that patient-centered behaviors in female physicians are less likely to be attributed to professional competence and more likely to be attributed to stereotypical female behavior. In this way, the communication skills of female physicians can be undervalued and underappreciated by patients.28
A gender-diverse physician workforce may also improve patient outcomes, especially in environments in which there are gender gaps in health care. For example, outcomes for women with acute myocardial infarction are worse than those for men,33 potentially related to sex differences in clinical presentation of myocardial infarction. In a database of over 500,000 Florida patients with myocardial infarction admitted from the emergency department between 1991 and 2010, female patients had higher mortality when treated by male physicians (mortality increased by 1.52%), whereas male and female patients treated by female physicians had similar outcomes (baseline mortality 11.9%).34 Perhaps more importantly, the increased mortality for female patients was attenuated when they were treated by male physicians who either had prior experience treating female myocardial infarction patients or who worked in an environment where there were more female physicians. The reasons for the findings are not clear, but they support the notion that diverse teams enhance patient care and outcomes.
CHALLENGES TO PHYSICIAN GENDER EQUITY
Inclusion Without Equity: Workplace Discrimination and Organizational Bias
Many organizations attribute improvement in equity with increasing numbers of women in a department or institution. However, there can be a disconnect between the increased numbers of women and their shared experiences in the workplace.35 In organizations where gender disparity continues despite equal numbers of women, there is a bias that permeates the culture and this organizational bias is most difficult to change.36,37 Female physicians face challenges in their interactions with other healthcare and workplace professionals. In one survey, over 51% of female physicians believed that they had experienced workplace discrimination from co-workers (26%) or supervisors and administrators (38%).38 However, few studies have systematically addressed the ways that workplace discrimination occurs among medical professionals. Women are less likely to negotiate their contracts than their male colleagues, and when they do, they are more likely to be viewed negatively.39 The few studies available on this suggest that female physicians are often introduced or described in a less positive way than their male colleagues when negotiating. Female physicians are statistically less likely to be selected as grand round speakers at all levels of training and, when they are selected, are less likely to be introduced by their full title than their male colleagues.40,41
Implicit bias can permeate organizations and undermine the ability of women to advance in their careers. One example of this form of implicit bias can occur in evaluation letters for promotion. Promotion letters on average for female faculty candidates are 16% shorter than letters for male faculty and tend to be less favorable.42 Male faculty were more than twice as likely to be referred as “future leaders” and their letters were four times as likely to contain references to their leadership positions and their research.42,43 In contrast, letters written about female faculty were almost six times more likely to contain references to their personal life and were almost twice as likely to contain “doubt raising” language.43
From February to April, 2017, ACNS members were asked to voluntarily participate in an anonymous salary survey that was administered via Survey Monkey. The goal of the survey was to identify various factors that influenced compensation for neurophysiologists. A total of 175 members completed the survey (125 self-identifying males and 50 self-identifying females). Participants were asked to record their total annual compensation by selecting 1 of 5 salary categories (sorted from low to high). For analysis, category 1 was labeled “low,” categories 2 to 4 were combined and labeled “medium,” and category 5 was designated “high.”
Salary differences by gender were evaluated using Pearson χ2 test. Females had a lower proportion of salaries in the high category compared with males when analyzing the total sample (Table 1, A). In addition, there was also a trend toward higher proportion of females with lower salaries when segregating the sample by practice type (academic and nonacademic), although such difference failed to meet statistical significance, possibly because of limited sample size (Table 1, B and C). To protect confidentiality of this small sample size, data were analyzed in aggregate format. Therefore, salary data are presented in the form of ranges instead of actual dollar amounts, hence limiting analyses to categorical tests. The small sample size also did not allow for further analysis of variables that might influence salary including age, years of practice and geographic region. Larger, more robust studies are needed to better evaluate how neurophysiologists are compensated and understand factors that contribute to differences in salary.
TABLE 1. -
Salary Ranges: Not Controlled for Age, Years of Practice, and Geographic Region
|A. All participants (175)
| Males (n = 125)
| Females (n = 50)
|B. Academic practice (94)
| Males (n = 69)
| Females (n = 25)
|C. Nonacademic practice (81)
| Males (n = 56)
| Females (n = 25)
The 2019 Medscape Physician Compensation Report revealed that female physicians overall earn 25% less than male physicians ($51,000), with the greatest disparities seen in surgical and medical subspecialties.44 For neurologists, the gender pay gap is $56,000 (24%), increased from $37,000 in 2015.44 This is one of the largest gaps in any medical specialty. Women neurologists spend an average of 4 more hours per week in patient care activities (39 vs. 35), and 1 more hour on paperwork and administration (18 vs. 17). This is compounded by the additional time spent on average in caregiver activities. These additional hours spent may contribute to not only the potential for burnout but less time which can be devoted to leadership roles, research engagement or networking, all important for promotion resulting in increased compensation. When we look at results of a limited survey among ACNS members in 2017, these salary differences held consistent for private practice positions as well.
There are many possible causes for disparities in compensation, including lack of salary transparency, differences in negotiating styles between women and men, implicit bias, and unequal work hours because of family needs and work–life balance. Although some public institutions publish salaries for all faculty, in most institutions, compensation packages are complex and negotiated individually based on type of work tasks (mix of research, patient care, educational activities, and administration), productivity, experience and skills, and merit. Women may be less successful in negotiating salary and resources than their male colleagues. In some cases, they may not try to negotiate at all because of lack of knowledge about contracts, desire to avoid conflict or appearing aggressive, or poor negotiating skills. When women do negotiate, they tend to use other female colleagues, who are themselves often underpaid, as benchmarks for salary and other support. Women may also perform greater amounts of uncompensated or inadequately compensated work (e.g., administrative or educational tasks) that do not lead to career advancement. Finally, because women often start at a lower salary, annual pay increases will also lag, leading to additional lifetime earning disparities.
Health, Maternity, and Family
Pregnancy and starting a family may be even more challenging for women in medicine than for women in other professions. Twenty-four percent of female physicians are diagnosed with infertility, and 8.5% of female physicians will require treatment for infertility.45,46 Furthermore, female physicians are more likely to experience miscarriages than women in the general population and are more likely to experience at least one pregnancy that is diagnosed as “high risk.”47 Miscarriage and high-risk pregnancies have both been associated with an increased risk of physician burnout.48 The American Academy of Pediatrics and the American Pediatric Society have both publicly endorsed a minimum of 12 weeks of maternity leave for new mothers.49 Multiple studies have demonstrated that longer paid maternity leave is associated with lower perinatal, neonatal, and postnatal mortality rates as well as a lower incidence of maternal hospitalizations and maternal depression.49–51 Women with shorter maternity leave are almost twice as likely to experience problems with stress management.52 However, the mean length of maternity leave at the top 12 American medical schools is only 8.6 weeks.51 Furthermore, one third of the top 12 medical schools in the United States require that maternity leave be taken through disability coverage and/or sick benefits, and most of the family leave policies surveyed had constraints that implied that their benefits were at the discretion of departmental leadership.46 These discretionary leave policies may lead to an adverse perception of women who take the full amount of leave available, thereby discouraging women from taking their full allowable time off.53 In a survey of over 5,800 female physicians, 32% said that they experienced discrimination because of pregnancy or maternity leave.54 Women who choose to breastfeed after they return to work face additional barriers, with 44% of female physicians saying that they experienced discrimination as a consequence of breastfeeding.55
Within the home, female physicians also have more household responsibilities than male physicians. On average, female physicians spend 8.5 hours per week more than male physicians on household responsibilities. Some of this difference may reflect the fact that 45% of male physicians have spouses who work part-time or are not employed, whereas only 14% of women have spouses who work part time or are not employed.54,56 Women are also more likely to report that family responsibilities interfere with work-related activities.53 Seventy-eight percent of department chairs also identified taking care of children and family as a major barrier to the advancement of female physicians.54 Women are often left out of leadership and administrative decisions because of part-time work or family leave.55,56 The need to balance work and family responsibilities can have adverse effects on the relationships and marriages of female physicians. Female physicians are more likely to report conflicts with their partner or spouse's career (53% vs. 41%) and are more likely to report recent work–home conflicts (62% vs. 49%) than male physicians.57 Although physicians have a slightly lower incidence of divorce than other professions in the United States with a lifetime incidence of 24%, female physicians have a significantly increased risk of divorce compared with male physicians (odds ratio 1.51).58 For female physicians, the risk of divorce was correlated with working longer hours. Interestingly, for male physicians, the opposite relationship was seen: male physicians who reported working >60 hours per week had a markedly lower incidence of divorce than male physicians who worked <39 hours per week (odds ratio 0.59).58
Wellness and Burnout
Burnout is an area of growing concern for both male and female physicians at all levels of training. Its symptoms include depersonalization, emotional exhaustion, and a decreased sense of personal accomplishment.59 A survey of 7,288 physicians in the United States found that 46% of physicians experience one or more symptoms of burnout, which substantially exceeds the rate of burnout in the general population.59 The incidence of burnout varies significantly depending on physician specialty. Neurologists have been found to have the third highest rate of burnout of all specialties (behind only emergency medicine and general internal medicine).59 Approximately 60% of neurologists acknowledge at least one symptom of burnout,60 and 73% of neurology residents have one or more symptoms of burnout.61 Although the majority of studies have not found a difference between the incidence of burnout between male and female physicians, evidence suggests that male and female physicians may experience burnout in different ways.57,59 Multiple studies suggest that female physicians are slightly more likely to develop emotional exhaustion, particularly at earlier stages of burnout, whereas male physicians are more likely to develop depersonalization, particularly when burnout first develops.62–64 At least one study has also suggested that male physicians are less likely to experience a reduced sense of personal accomplishment when experiencing burnout.64 However, it should be noted that although multiple studies have documented a difference in the incidence of emotional exhaustion, depersonalization, or personal achievement among other groups of physicians, a recent study failed to find a significant difference in the incidence of these symptoms between male and female neurologists.63 However, this study did find other ways in which the experience of burnout differs between male and female neurologists. Female neurologists are more likely to experience an increase in burnout as the number of weekends they work increases; for each additional weekend worked, the risk of burnout increases by 3%.63 Surveyed about causes of burnout, female neurologists are also more likely to acknowledge that family commitments add to the burden of their work and are more likely to express concerns about work–life balance.63
STRATEGIES TO ADDRESS GENDER DISPARITIES
Although there are numerous publications on gender bias, there are few longitudinal studies showing changes over time, and few interventions have been demonstrated to be efficacious. This section will provide an overview of inventions which have been effective in other fields, as well as suggested strategies for neurology and clinical neurophysiology.
Institutional Training to Identify and Overcome Biases
It is important to be aware of implicit as well as cultural bias and counter these biases to avoid encouraging stereotypical notions about female behavior.65,66 When institutions include training to identify and overcome biases, it raises the visibility of women neurologists as leaders regardless of their academic position within the organization.67,68 Implicit bias also affects physician–patient interactions. In a study involving over 900 participants from the American Academy of Radiology, slightly over 50% of female physicians indicated that they were treated unfairly or disrespected at work in the past year because of their gender. A significant percentage indicated that offensive language had also been used.69 These interactions may involve patients or other colleagues. When colleagues speak up about unfair treatment and advocate for other colleagues who are being discriminated against, it provides a more productive environment where greater networking is possible.
Organizational culture can be changed by inclusive leadership. When leadership is inclusive, hiring practices and competencies are based on fairness in the selection process.70–72 Although many institutions have developed diversity training programs, these programs may have negative consequences when used without other institutional interventions.73 Studies have shown that without additional interventions that change the culture or environment in which discrimination occurs, “an illusion of fairness” can be created such that when discrimination occurs, it is less likely to be recognized.74 In order for diversity programs to be effective, other institutional strategies are needed to change the culture so that discrimination is less likely to occur in the first place, and if it does occur, it can be recognized and countered.
Changes to Professional Organizations and National Scientific Meeting Structure
Given the underrepresentation of women in scientific meetings and societies, in 1995 the National Institute of Health (NIH) released a policy stating “organizers of scientific meetings should make a concerted effort to achieve appropriate representation of women, racial/ethnic minorities, and persons with disabilities, and other individuals who have been traditionally underrepresented in science in all NIH sponsored and/or supported meetings.” Twenty-five years later, women continue to be underrepresented as speakers, course chairs, and committee members.12,40 When course chairs are predominately men, the selection of speakers will be based on their networking environment who are predominately men. When course and committee chairs are gender equitable, more women are selected as speakers. Setting clear objectives to improve gender diversity is critical. Examples of such goals include 50% representation of female neurologists in speaking roles at national meetings in the next 3 years. Another clear objective would be increasing the number of women neurologists in leadership positions for a given organization to 50% in the next 3 to 5 years. These goals promote measurable cultural change as opposed to abstract aims without clear outcome measures.
Transparency in Academic Hiring and Promotion
Search committees should include an equitable number of women representing both clinical and research pathways so that women are part of the selection and voting process for new hires. Search committees should also promote a diverse applicant pool and track the number of women in leadership positions throughout the institution. A goal of 50% of the selection committee comprising women would be a clear outcome measure for success. Similarly, having women comprise 50% of leadership roles in academic departments can be an objective measure of gender parity in the promotion of female neurologists.
Several institutional strategies can be established to foster promotion of female neurologists to leadership levels. This can counter the “meritocracy myth,” where promotion is said to be based on merit only while studies have shown that implicit bias often counters achievement based on merit.75,76 Creating transparency regarding what is needed for academic promotion is essential to fostering advancement of women at all levels. This can be facilitated by skills building courses on creating a dossier, effective communication and achieving what is needed for promotion at both department and institutional levels.77–83 Given the history of lack of transparency, it is not surprising that many women physicians have indicated that they did not understand what was needed for promotion.4,84 Women have often cited they were told they were not ready for promotion to a higher academic rank; for example, that more publications or additional scholarly activities were needed, despite meeting institutional requirements for promotion.84 Fortunately, there are now several national leadership programs that include information on what is typically needed for academic promotion helping reduce this hurdle. Once the promotion process is understood and transparent, women physicians can advocate for their promotion more effectively.
Women may be less likely than men to nominate themselves for promotion, leadership positions, or awards.85 Departments should therefore have committees to ensure that women are put forward for promotion at appropriate time points. Nominating and search committees should ensure that an adequate number of female candidates are considered for each new position or award. Professional organizations may need to target outreach efforts to women who are eligible for leadership or awards.
Measurement of outcomes is essential to achieving meaningful improvement in equity. Individual institutions may voluntarily create periodic reports on diversity and inclusion, and the Association of American Medical Colleges publishes annual reports of faculty by rank and gender.2 In 2018, the promotion gap was as wide in neurology as in other medical specialties. Among more than 6,000 academic neurologists, 48% of assistant professors were women, whereas only 21% of full professors were women.2 This pattern of diminishing percentages of women at each higher rank holds true for unrepresented minority women as well. Unfortunately, these reports do not allow tracking at individual institutions and therefore do not facilitate root cause analyses of disparities. Attrition, or women leaving the institution, or even the field of medicine itself, may not be tracked. The New York Stem Cell Foundation (NYSCF), through its Initiative on Women in Science and Engineering, developed an institutional Report Card to measure commitment to gender equity and to encourage institutions to promote gender equality.86 The reports collect data on numbers of faculty by gender, rank, and minority; promotions; external speakers; and institutional policies on gender. The NYSCF incorporated the Report Card into its grant awards process, which may help to catalyze longitudinal measurement and drive change. Similar efforts could be undertaken nationally in neurology departments, and Report Cards could be developed for neurology professional associations.
Transparency in Compensation
Professional organizations should advocate for salary transparency. The American Academy of Neurology has developed an annual Neurology Compensation and Productivity Report, which provides information on salary, work relative value units, and race/ethnicity by region and practice setting. Organizations should also educate members about compensation and resources as part of career development activities. Workshops on negotiating, building networks, and developing leadership skills can all enable women to come to the compensation table on an equal footing with their male colleagues.
In individual departments, the factors on which salary is based should be transparent and equitable. For example, a standard base salary could be established for each academic rank, with the possibility of bonus payments if well-defined and transparent productivity metrics are met. Individual work activities should be clearly defined and credited to each neurologist's salary, such as salary and staff support for administrative (e.g., division or lab director), educational (e.g., residency or fellowship program director), or other institutional or departmental roles. Salaries should be reviewed annually to ensure that gender disparities do not exist.
Mentorship and Sponsorship Programs
Many institutions have created programs to teach leadership skills or better negotiation skills but an argument here is that there is a movement to “fix the women” making the female leader more like a man. Several problems are inherent in that approach. First, as studies have shown, women do not lead in the same way as men do and that may be an asset. Having another perspective, another style is advantageous to a team and institution. Second, this argument implies that the reason why women are not promoted is that they are lacking in leadership skills rather than acknowledging the systemic and cultural biases that have created challenges to the promotion of women to leadership positions. Finally, women leaders who demonstrate agentic leadership characteristics, or conventionally male traits such as ambition, self-confidence, and decisiveness, are often viewed as less likeable than male leaders with the same leadership qualities and are less likely to succeed.85
Mentoring programs for women have been shown to improve their ability for career advancement.87 Having mentors that inspire, have achieved a level of success, and are female (hence “look like you”) allows one to see an attainable path forward despite challenges that women neurologists navigate.88 Mentors provide guidance, advice, and shared experience but this does not necessarily translate directly into promotion. However, mentor relationships are low risk and require little investment.
Sponsors may provide advantages compared with traditional mentors by providing opportunities for career advancement and networking, both acknowledged to be critical for academic success. For many women physicians, having a female sponsor is particularly important.89 In contrast to mentorship, sponsorship provides advocacy and opportunity with the sponsor taking personal responsibility for the success of the protégé. Effective sponsors are established in their careers and well connected. Sponsorship is not without risk, however, and can involve the sponsor putting their reputation on the line. However, the effective protégé reciprocates with loyalty and successful academic performance that can mutually benefit the sponsor as well as the protégé. A 2016 study from Johns Hopkins University School of Medicine based on interviews of 23 faculty explored how sponsorship functions in academic medicine and found that although women are more likely to need additional support to be successful, they are less likely to seek sponsorship opportunities.89 In fact, other studies suggest that women are overmentored but undersponsored. Therefore, senior faculty who have achieved success should be willing to provide specific opportunities for advancement to junior female faculty who show potential, whereas junior faculty can benefit by actively seeking out sponsors. In turn, the protégé can “pay it forward” by becoming effective sponsors after they have achieved a level of success.
Child and Elder Care Programs
It has long been established that women are largely responsible for the care of children and elderly parents, despite the fact that they may also be the primary breadwinner of the family. Creating child and elder care programs so that neurologists are supported in their work as well as social networking time allows physicians to be more effective in their careers. When institutions and departments provide fair and transparent mechanisms for family leave, maternity/paternity and elder care, it eliminates bias when leave is taken. Leave policies should establish equitable compensation and provide incentives for physicians to take advantage of family leave when it is needed. Subsidizing onsite child care and allowing flexible work hours can also allow more adaptability in work schedules.
Capitalizing on Women's Strengths in a Changing Health Care Environment
Women physicians often possess strong communal qualities, such as attentiveness, excellent interpersonal communication, and collaboration, which can be assets in health care environments. Because they use more patient-centered communication, women may be particularly well-suited to identify and address health disparities and gaps in care coordination.90 In the team-based model of health care delivery, health care providers, patients, and families establish shared goals and coordinate high-quality care to improve patient satisfaction and outcomes.91 To lead these teams, female neurologists should cultivate their transformational leadership skills—serving as a role model, gaining team members' trust and confidence, innovating toward stated future goals, and mentoring and empowering team members.85 Transformational styles are considered to be more effective in leadership of modern organizations.
CULTURAL CHANGE IS POSSIBLE: THE ACNS
Similar to other specialty societies, the ACNS has long suffered from a paucity of females in leadership roles despite increasing number of female members. Review of data from 2011 to 2016 on the percentage of committee chairs who were female remained consistent at 20% to 25%. Since ACNS' inception in 1946, there have only been 6 female presidents over the course of 74 years. In 2015, ACNS created a Gender and Inclusivity Taskforce, with a goal of increasing the number of qualified female speakers and session moderators at ACNS annual meetings. Numerous studies have observed that the presence of at least one female organizer or moderator in a session leads to an increase in the number of female speakers (14.6% vs. 37.5%, P < 0.0001) and a decrease in the number of sessions without female speakers (8.1% vs. 47.1%, P < 0.0001).67–69 As a result of the work of the Taskforce, female physicians were appointed as cochairs of the ACNS Program Committee, the ACNS Continuing Medical Education Committee, and the ACNS Course Committee. This led to an enhanced awareness of gender inclusivity, which ultimately resulted in an increase in the percentage of female moderators from 12.1% in 2014 to 30.6% in 2019, and the percentage of female speakers from 13.9% in 2014 to 30.0% in 2019 (Fig. 1). The number of sessions without any female speakers decreased from 56.4% in 2014 to 28.0% in 2019 (Fig. 2). Concurrently, the number of women on the ACNS Leadership Council increased to 43.8%, and the Society will be under female leadership for 2020 and 2021, the first time in ACNS history in which there will be back-to-back female presidents. Although more work is needed, ACNS has established processes for gender inclusivity with clear metrics for success. These metrics include increasing female leadership and increasing percent of women serving as committee and course chairs to 50%.
The authors understand that disparities of various types exist in the workplace. However, the focus of this article is on gender disparity in compensation and promotion to leadership roles for female neurologists and clinical neurophysiologists. This gender disparity remains despite improvements in workplace policies over the last several decades and hampers productivity, affecting patient care and contributing to burnout. Apparent in the AMA survey, the Academy of Neurology survey and the latest survey of American Clinical Neurophysiology Society members in 2017 is that implicit biases remain and dedicated actions to end disparity of all kinds are needed in the field of clinical neurophysiology. These include dedicated workplace childcare, transparency in promotion, hiring and compensation, and mentoring and sponsoring programs for female neurologists. As with all institutions, cultural change may be slow, but the benefits of gender diversity are far reaching and provide greater perspective, productivity, and enhanced global networking.
The authors thank Drs. Yafa Minazad, Leonardo Bonilha, Debra Briggs, David Burdette, Marc Nuwer, and Ezequiel Gleichgerrcht for their assistance in the design and data analysis of the 2017 salary survey.
1. Association of American Medical Colleges. More women than men enrolled in U.S. medical schools in 2017. 2017. Available at: https://news.aamc.org/press-releases/article/applicant-enrollment-2017/
. Accessed September 14, 2018.
2. Association of American Medical Colleges. Faculty Roster: U.S. Medical School Faculty. 2018. Available at: https://www.aamc.org/data-reports/faculty-institutions/report/faculty-roster-us-medical-school-faculty
. Accessed December 1, 2019.
3. Bennett CL, Raja AS, Kapoor N, et al. Gender differences in faculty rank among academic emergency physicians in the United States. Acad Emerg Med 2019;26:281–285.
4. Carr PL, Raj A, Kaplan SE, Terrin N, Breeze JL, Freund KM. Gender differences in academic medicine: retention, rank, and leadership
comparisons from the National Faculty Survey. Acad Med 2018;93:1694–1699.
5. Silver JK, Ghalib R, Poorman JA, et al. Analysis of gender equity
of physician-focused medical specialty societies, 2008–2017. JAMA Intern Med 2019;179:433–435.
6. Hill CE, Blank LJ, Thibault D, et al. Continuous EEG is associated with favorable hospitalization outcomes for critically ill patients. Neurology
7. James WS, Rughani AI, Dumont TM. A socioeconomic analysis of intraoperative neurophysiological monitoring during spine surgery: national use, regional variation, and patient outcomes. Neurosurg Focus 2014;37:E10.
8. Specialty training statistics [FREIDA online website]. 2019. Available at: https://freida.ama-assn.org/Freida/#/
. Accessed July 12, 2019.
9. McDermott M, Gelb DJ, Wilson K, et al. Sex differences in academic rank and publication rate at top-ranked US neurology
programs. JAMA Neurol 2018;75:956–961.
10. Pakpoor J, Liu L, Yousem D. A 35-year analysis of sex differences in neurology
11. Silver JK, Bank AM, Slocum CS, et al. Women physicians underrepresented in American Academy of Neurology
recognition awards. Neurology
12. Silver JK. Understanding and addressing gender equity
for women in neurology
13. Davis T, Goldstein H, Hall D, et al. Women and children first? Gender equity
in paediatric medicine. Arch Dis Child 2019. doi: 10.1136/archdischild-2018-316586.
14. Hofler LG, Hacker MR, Dodge LE, Schutzberg R, Ricciotti HA. Comparison of women in department leadership
in obstetrics and gynecology with those in other specialties. Obstet Gynecol 2016;127:442–447.
15. Kaatz A, Carnes M. Stuck in the out-group: Jennifer can't grow up, Jane's invisible, and Janet's over the hill. J Womens Health (Larchmt) 2014;23:481–484.
17. Rock D, Grant H. Why diverse teams are smarter. 2016. Available at: https://hbr.org/2016/11/why-diverse-teams-are-smarter
. Accessed December 1, 2019.
18. Bertakis KD, Azari R. Patient-centered care: the influence of patient and resident physician gender and gender concordance in primary care. J Womens Health (Larchmt) 2012;21:326–333.
19. Bertakis KD, Franks P, Epstein RM. Patient-centered communication in primary care: physician and patient gender and gender concordance. J Womens Health (Larchmt) 2009;18:539–545.
20. Blanch-Hartigan D, Hall JA, Roter DL, Frankel RM. Gender bias in patients' perceptions of patient-centered behaviors. Patient Educ Couns 2010;80:315–320.
21. Krupat E, Rosenkranz SL, Yeager CM, Barnard K, Putnam SM, Inui TS. The practice orientations of physicians and patients: the effect of doctor-patient congruence on satisfaction. Patient Educ Couns 2000;39:49–59.
22. Laidlaw TS, Kaufman DM, MacLeod H, van Zanten S, Simpson D, Wrixon W. Relationship of resident characteristics, attitudes, prior training and clinical knowledge to communication skills performance. Med Educ 2006;40:18–25.
23. Shah R, Ogden J. “What's in a face?” The role of doctor ethnicity, age and gender in the formation of patients' judgements: an experimental study. Patient Educ Couns 2006;60:136–141.
24. Bienstock JL, Martin S, Tzou W, Fox HE. Medical students' gender is a predictor of success in the obstetrics and gynecology basic clerkship. Teach Learn Med 2002;14:240–243.
25. Haidet P, Dains JE, Paterniti DA, et al. Medical student attitudes toward the doctor-patient relationship. Med Educ 2002;36:568–574.
26. Hall JA, Roter DL, Blanch DC, Frankel RM. Observer-rated rapport in interactions between medical students and standardized patients. Patient Educ Couns 2009;76:323–327.
27. Wiskin CM, Allan TF, Skelton JR. Gender as a variable in the assessment of final year degree-level communication skills. Med Educ 2004;38:129–137.
28. Jiang S. Pathway linking patient-centered communication to emotional well-being: taking into account patient satisfaction and emotion management. J Health Commun 2017;22:234–242.
29. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796–804.
30. Roter DL, Hall JA, Aoki Y. Physician gender effects in medical communication: a meta-analytic review. JAMA 2002;288:756–764.
31. Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Annu Rev Public Health 2004;25:497–519.
32. Lurie N, Slater J, McGovern P, Ekstrum J, Quam L, Margolis K. Preventive care for women. Does the sex of the physician matter? N Engl J Med 1993;329:478–482.
33. Mehta LS, Beckie TM, DeVon HA, et al. Acute myocardial infarction in women: a scientific statement from the American Heart Association. Circulation 2016;133:916–947.
34. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci USA 2018;115:8569–8574.
35. Kang SK, Kaplan S. Working toward gender diversity and inclusion in medicine: myths and solutions. Lancet 2019;393:579–586.
36. Burgess DJ, Joseph A, van Ryn M, Carnes M. Does stereotype threat affect women in academic medicine? Acad Med 2012;87:506–512.
37. Levine RB, Lin F, Kern DE, Wright SM, Carrese J. Stories from early-career women physicians who have left academic medicine: a qualitative study at a single institution. Acad Med 2011;86:752–758.
38. Coombs AA, King RK. Workplace discrimination: experiences of practicing physicians. J Natl Med Assoc 2005;97:467–477.
39. Bowles HR, Babcock L, Lai L. Social incentives for gender differences in the propensity to initiate negotiations: sometimes it does hurt to ask. Organ Behav Hum Decis Process 2007;103:84–103.
40. Boiko JR, Anderson AJM, Gordon RA. Representation of women among academic grand rounds speakers. JAMA Intern Med 2017;177:722–724.
41. Files JA, Mayer AP, Ko MG, et al. Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias. J Womens Health (Larchmt) 2017;26:413–419.
42. Trix F, Psenka C. Exploring the color of glass: letters of recommendation for female and male medical faculty. Discourse Soc 2003;14:191–220.
43. Hoffman A, Grant W, McCormick M, Jezewski E, Matemavi P, Langnas A. Gendered differences in letters of recommendation for transplant surgery fellowship applicants. J Surg Educ 2019;76:427–432.
44. Kane L. Medscape physician compensation report 2019. New York: Medscape, 2019. Available at: https://www.medscape.com/slideshow/2019-compensation-overview
. Accessed December 1, 2019.
45. Gyorffy Z, Dweik D, Girasek E. Reproductive health and burn-out among female physicians: nationwide, representative study from Hungary. BMC Womens Health 2014;14:121.
46. Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and childbearing among American female physicians. J Womens Health (Larchmt) 2016;25:1059–1065.
47. Staehelin K, Bertea PC, Stutz EZ. Length of maternity leave and health of mother and child: a review. Int J Public Health 2007;52:202–209.
48. Jou J, Kozhimannil KB, Abraham JM, Blewett LA, McGovern PM. Paid maternity leave in the United States: associations with maternal and infant health. Matern Child Health J 2018;22:216–225.
49. American Academy of Pediatrics. Major pediatric associations call for congressional action on paid leave. 2015. Available at: https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/FAMILYLeaveAct.aspx
. Accessed August 14, 2019.
50. Dagher RK, McGovern PM, Dowd BE. Maternity leave duration and postpartum mental and physical health: implications for leave policies. J Health Polit Policy Law 2014;39:369–416.
51. Riano NS, Linos E, Accurso EC, et al. Paid family and childbearing leave policies at top US medical schools. JAMA 2018;319:611–614.
52. Bohnet I. What works: gender equality by design. Cambridge: Harvard University Press, 2016.
53. Jolly S, Griffith KA, DeCastro R, Stewart A, Ubel P, Jagsi R. Gender differences in time spent on parenting and domestic responsibilities by high-achieving young physician-researchers. Ann Intern Med 2014;160:344–353.
54. Yedidia MJ, Bickel J. Why aren't there more women leaders in academic medicine? The views of clinical department chairs. Acad Med 2001;76:453–465.
55. Halley MC, Rustagi AS, Torres JS, et al. Physician mothers' experience of workplace discrimination: a qualitative analysis. BMJ 2018;363:k4926.
56. Adesoye T, Mangurian C, Choo EK, Girgis C, Sabry-Elnaggar H, Linos E. Perceived discrimination experienced by physician mothers and desired workplace changes: a cross-sectional survey. JAMA Intern Med 2017;177:1033–1036.
57. Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg 2009;250:463–471.
58. Ly DP, Seabury SA, Jena AB. Divorce among physicians and other healthcare professionals in the United States: analysis of census survey data. BMJ 2015;350:h706.
59. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377–1385.
60. Busis NA, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurologists in 2016. Neurology
61. Levin KH, Shanafelt TD, Keran CM, et al. Burnout, career satisfaction, and well-being among US neurology
residents and fellows in 2016. Neurology
62. Houkes I, Winants Y, Twellaar M, Verdonk P. Development of burnout over time and the causal order of the three dimensions of burnout among male and female GPs. A three-wave panel study. BMC Public Health 2011;11:240.
63. LaFaver K, Miyasaki JM, Keran CM, et al. Age and sex differences in burnout, career satisfaction, and well-being in US neurologists. Neurology
64. Purvanova RK, Muros JP. Gender differences in burnout: a meta-analysis. J Vocational Behav 2010;77:168–185.
65. Geagea A, Mehta S. Advancing women in academic medicine: ten strategies to use every day. Can J Anaesth 2020;67:9–12.
66. Harrison R. Athena SWAN is an ugly duckling. London: THE, 2018. Available at: https://www.timeshighereducation.com/opinion/Athena-swan-ugly-duckling
. Accessed December 1, 2019.
67. Bates C, Gordon L, Travis E, et al. Striving for gender equity
in academic medicine careers: a call to action. Acad Med 2016;91:1050–1052.
68. Lautenberger DM, Dandar VM, Raezer CL, Sloane RA. The state of women in academic medicine: the pipeline and pathways to leadership
2013–2014. Washington: Association of American Medical Colleges, 2014.
69. Pandharipande PV, Mercaldo ND, Lietz AP, et al. Identifying barriers to building a diverse physician workforce: a national survey of the ACR membership. J Am Coll Radiol 2019;16:1091–1101.
71. Silver JK. Diversity and inclusion are core leadership
competencies: a primer for busy leaders. Becker's Hospital Review. 2017. Available at: https://www.beckershospitalreview.com/hospital-management-administration/diversity-and-inclusion-are-core-leadership-competencies-a-primer-for-busy-leaders.html
. Accessed December 1, 2019.
72. Sukhera J, Milne A, Teunissen PW, Lingard L, Watling C. The actual versus idealized self: exploring responses to feedback about implicit bias in health professionals. Acad Med 2018;93:623–629.
73. Dobbin F, Kalev A. Why diversity programs fail. 2016. Available at: https://hbr.org/2016/07/why-diversity-programs-fail
. Accessed December 1, 2019.
74. Kaiser CR, Major B, Jurcevic I, Dover TL, Brady LM, Shapiro JR. Presumed fair: ironic effects of organizational diversity structures. J Pers Soc Psychol 2013;104:504–519.
75. Castilla EJ. Gender, race, and meritocracy in organizational careers. Am J Sociol 2008;113:1479–1526.
76. Castilla EJ, Benard S. The paradox of meritocracy in organizations. Administrative Sci Q 2010;55:543–676.
77. Gender imbalance in science journals is still pervasive. Nature 2017;541:435–436.
78. Butkus R, Serchen J, Moyer DV, Bornstein SS, Hingle ST. Achieving gender equity
in physician compensation and career advancement: a position paper of the American College of Physicians. Ann Intern Med 2018;168:721–723.
79. Filardo G, da Graca B, Sass DM, Pollock BD, Smith EB, Martinez MA. Trends and comparison of female first authorship in high impact medical journals: observational study (1994–2014). BMJ 2016;352:i847.
80. Grisham S. Medscape physician compensation report 2017. New York: Medscape, 2017. Available at: https://www.medscape.com/slideshow/compensation-2017-overview-6008547
. Accessed July 2, 2019.
81. Jagsi R, Motomura AR, Griffith KA, Rangarajan S, Ubel PA. Sex differences in attainment of independent funding by career development awardees. Ann Intern Med 2009;151:804–811.
82. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med 2016;176:1294–1304.
83. Raj A, Carr PL, Kaplan SE, Terrin N, Breeze JL, Freund KM. Longitudinal analysis of gender differences in academic productivity among medical faculty across 24 medical schools in the United States. Acad Med 2016;91:1074–1079.
84. Helitzer DL, Newbill SL, Morahan PS, et al. Perceptions of skill development of participants in three national career development programs for women faculty in academic medicine. Acad Med 2014;89:896–903.
85. Eagly AH, Carli LL. Women and the labyrinth of leadership
. Harv Bus Rev 2007;85:62–146.
86. Beeler WH, Smith-Doody KA, Ha R, et al. Institutional report cards for gender equality: lessons learned from benchmarking efforts for women in STEM. Cell Stem Cell 2019;25:306–310.
87. Carr PL, Gunn C, Raj A, Kaplan S, Freund KM. Recruitment, promotion, and retention of women in academic medicine: how institutions are addressing gender disparities. Womens Health Issues 2017;27:374–381.
88. Steinke J. Adolescent girls' STEM identity formation and media images of STEM professionals: considering the influence of contextual cues. Front Psychol 2017;8:716.
89. Ayyala MS, Skarupski K, Bodurtha JN, et al. Mentorship is not enough: exploring sponsorship and its role in career advancement in academic medicine. Acad Med 2019;94:94–100.
90. Shpiner DS, Di Luca DG, Cajigas I, et al. Gender disparities in deep brain stimulation for Parkinson's disease. Neuromodulation 2019;22:484–488.
91. Coleman K, Wagner EH, Ladden MD, et al. Developing emerging leaders to support team-based primary care. J Ambul Care Manage 2019;42:270–283.