Over the years, women have made great strides in clinical medicine; however, they still lag behind men in gaining academic equity.1,2 Women are also less represented than men in many medical specialties, including in positions of leadership and influence such as departmental chairs, directors of medical educational programs, conference speakers, and as members of clinical guideline committees and journal editorial boards.1–3
In recent years, research on academic equity and gender-parity in medicine has gained momentum. Many studies have explored the role of women in academic leadership, the challenges faced by them, and the strategies to improve their representation in academic medicine. However, there has been limited gender research in the clinical neurosciences, with few publications on the representation of women in leading academic roles in neuroanesthesiology and neurocritical care.4–6 While evaluating trends in authorship in academic anesthesiology, Miller et al4 observed that there was a higher percentage of women first authors in neuroanesthesiology-related articles (30.3%) compared with their overall representation in other specialties (24.8%). However, specific data regarding the representation of women as first authors of different article types in dedicated neuroanesthesiology and neurocritical care journals, which publish articles from a wide array of neuroscience academics worldwide, remains unknown.
We hypothesized that the proportion of women first authors in specialist neuroanesthesiology and neurocritical care journals would be ~30.0%, similar to that reported by Miller et al4 for neuroanesthesiology-related articles published in 2 general journals of anesthesiology. In this study, we evaluated the percentage of women first authors in different article types published during the last 5 years in journals dedicated to neuroanesthesiology and neurocritical care as the primary outcome. Secondary outcomes were the percentage of women as corresponding authors, and representation of women as first and corresponding authors by article type and country of affiliation.
We identified the 3 journals that are solely dedicated to publishing neuroanesthesiology and neurocritical care content. These are the Journal of Neurosurgical Anesthesiology (JNA), Neurocritical Care (NCC), and the Journal of Neuroanaesthesiology and Critical Care (JNACC). JNA is the official Journal of the Society for Neuroscience in Anesthesiology and Critical Care, NCC is the official Journal of the Neurocritical Care Society, and JNACC is the official journal of the Indian Society of Neuroanaesthesiology and Critical Care.
Original manuscripts published in these journals between July 1, 2015 and June 30, 2020 were included in this study. Articles were divided by type into 5 groups:
- Narrative Reviews.
- Special Articles, including Consensus Statements and Clinical Guidelines.
- Original Research Articles, including Clinical and Laboratory Investigations, Systematic Reviews and Meta-analyses.
- Clinical Reports, including Case Reports, Brief Reports and Short Reports of original research.
- Brief communications, including Correspondence, Point of View, Viewpoint, Letters to the Editor, Neuroimage, Practical Pearls, Closer look at Trials, Technology Notes, A Day in the Life of a Neurocritical Care trainee/fellow, Ethical Matters, Commentary and Current Opinion/Arguments and Concepts.
Not all article types are published by each of the 3 journals included in this study; further information about article types (according to the above categories) published in each journal is available in the Supplementary Material (Supplemental Digital Content 1: Table showing article type by journal, http://links.lww.com/JNA/A403). Invited Editorials and Commentaries, responses to Letters to the Editor, Journal Clubs, Reports of Conferences, Conference Abstracts, Letters commenting on published articles and replies to them, and a standard section on “Neurocritical Care Through History” by a single author (in NCC) were excluded from the data collection.
For each article identified for inclusion in the study, the following data were collected: date of publication (year and month), gender of first and corresponding author, article type, and country of affiliation of first and corresponding authors (considered as the country of origin of the article). The gender of the first and corresponding authors was determined from their names and, additionally, from various online search portals, including hospital and other organizational websites, Research Gate, LinkedIn, Google Scholar, Loop, Publons, Facebook, Doximity, Semantic Scholar, US Health, Medicare, and Health care. If author gender could not be determined following an extensive search, the article was excluded from the study. Articles with >1 first and/or corresponding authors were also excluded. For articles with a single author, this author was classified as both first and corresponding author.
Data collection was undertaken by 2 investigators (N.G. and S.B.), while a third (H.P.) cross-checked the data for any discrepancies. Details of articles published between July 1, 2015 and June 30, 2020 were recorded and stored using a standardized data collection tool in Microsoft Excel (Version 15.37; Microsoft Corporation, Redmond, WA).
Descriptive data are presented. For binary data (man or woman), first author, and corresponding author proportions were estimated. Bar graphs were constructed to characterize the association between first and corresponding author gender and article type. Line diagrams were used to depict overall gender proportions of first and corresponding authors in the 3 journals over the 5-year period of the study. Pie diagrams were used to report the countries of origin of most articles with women as first and corresponding author, and bar graphs were used to depict the representation of women first and corresponding authors from individual countries.
The 3 journals published 1196 articles between July 1, 2015 and June 30, 2020 that met our inclusion criteria: NCC, 640; JNA, 355; JNACC, 201. Of these articles, 32 were excluded (NCC, 28; JNA, 4) because we were unable to identify the gender of the first or corresponding author (4), there was >1 first and/or corresponding author (22), or both (6). Hence, 1164 manuscripts were included in the analysis; 612 were published in NCC, 351 were published in JNA, and 201 were published in JNACC.
Regarding the primary outcome, there was a lower proportion of women as first authors (403/1164; 34.6%) compared with men (761/1164; 65.4%) overall (Table 1). The proportion of women first authors ranged from 32.4% to 41.3% across the 3 journals, with JNACC having the highest proportion of women first authors (83/201; 41.3%), followed by JNA (122/351; 34.8%) and NCC (198/612; 32.4%). Similarly, only 29.6% (344/1164) of corresponding authors were women overall; JNACC had the highest proportion of the articles with women as corresponding author (75/201; 37.3%) followed by JNA (101/351; 28.8%) and NCC (168/612; 27.5%).
TABLE 1 -
Women First and Corresponding Authorship Across Journals
||Women First Author, N (%)
||Women Corresponding Author, N (%)
The Journal of Neurosurgical Anesthesiology
Journal of Neuroanaesthesiology and Critical Care
The proportions of women and men first authors by article type across all 3 journals are summarized in Figure 1. The proportion of women first authors was greatest for Special Articles (5/11; 45.5%), including Consensus Statements and Clinical Guidelines, followed by Clinical Reports (44/113; 38.9%) and Narrative Reviews (58/151; 38.4%); Original Research Articles had the lowest proportion of women as first author (198/597; 33.2%). Women corresponding authors were also more common in Special Articles and Clinical Reports (Fig. 2). Further information about authorship by article type is available in the Supplementary Material (Supplemental Digital Content 2: Table showing women first and corresponding author distribution by article type, http://links.lww.com/JNA/A404). The overall representation of women as first author and corresponding authors across the 3 journals was similar over the 5-year period of the study (Fig. 3).
The articles included in this study originated from 51 countries. The United States and India had the highest absolute number of articles with women as first and corresponding authors; 39% (159/403) of articles from the United States had women first authors, followed by 28.0% (111/403) from India, 6.0% (24/403) from Canada, 5.0% (20/403) from China and 3.0% (12/403) from Germany (Supplemental Digital Content 3: Pie chart showing countries with highest proportion of women first authors, http://links.lww.com/JNA/A405). Similarly, 43.0% (146/344) of articles from the United States had women corresponding authors, followed by 31.0% (107/344) from India, 5.0% (17/344) from Canada and 2.0% (7/344) each from China, Italy, South Korea, Japan, Germany and the United Kingdom (Supplemental Digital Content 4: Pie chart showing countries with highest proportion of women corresponding authors, http://links.lww.com/JNA/A406). When considering the proportion of women first authors from individual countries, the highest number of articles with women first authors were from China (20/35; 57.1%), followed by the Netherlands (7/14; 50.0%) and Canada (25/59; 42.4%) (Supplemental Digital Content 5: Bar chart showing women first authorship by individual country, http://links.lww.com/JNA/A407). The countries with the highest proportion of women as corresponding authors were India (107/272; 39.3%), followed by Italy (7/19; 36.8%) and the Netherlands (5/14; 35.7%) (Supplemental Digital Content 6: Bar chart showing women first authorship by individual country, http://links.lww.com/JNA/A408).
In this study, 34.6% of articles published in the 3 dedicated neuroanesthesiology and neurocritical care journals over the last 5 years included women as first authors. Men outnumbered women (65.4% vs. 34.6%, respectively) as first author across all article types, including Narrative Reviews, Consensus Statements, Clinical Guidelines, Original Clinical and Laboratory Research articles, Systematic Reviews and Meta-analyses, Case Reports, and Brief Communications. Of note, women had the lowest first authorship rates in Original Research Articles (33.2%) and Brief Communications (33.6%). A similar trend was observed in corresponding authorship, with men having higher representation compared with women across all article subtypes (70.4% vs. 29.6%, respectively). JNACC published the highest number of articles with women as first and corresponding authors, followed by JNA and NCC. Of the 51 countries of origin of the articles included in this study, the United States and India had the highest absolute number of articles with women as first and corresponding authors. However, articles from China had the highest proportion of women first authors, while articles from India had the highest proportion of women corresponding authors.
In recent years there has been a plethora of evidence confirming a lower representation of women in academic anesthesiology, pain medicine, critical care and clinical neuroscience, but with limited literature pertaining to women representation in neuroanesthesiology and neurocritical care academia.3–15 The findings of our study, which is an attempt to understand the representation of women first and corresponding authors in the academic subspecialty of neuroanesthesiology and neurocritical care, support those of a previous investigation that identified women first authors in 30.3% of neuroanesthesiology-related articles published in 2 leading anesthesiology journals with general content (Anesthesiology and Anesthesia and Analgesia).4 That study reviewed temporal trends in gender-based authorship of Original Research Articles published in 2002, 2007, 2012, and 2017, and identified women as first author in 24.8% of articles overall and as senior author in a dismal 15.6% of articles with no significant difference between the 2 journals. However, there was trend of increasing women first authorship, from 20.5% of articles in 2002 to 30.2% in 2017. Of particular interest, there was greater representation of women as first author in neuroanesthesiology-related manuscripts (30.3%) compared with articles overall (average 24.8%). Considering the lack of supportive data, the exact causes for the higher representation of women as first authors of neuroanesthesiology and neurocritical care articles is difficult to determine. However, it is possible that a greater emphasis is placed on research and subsequent publications during extended subspecialty training programs such as neuroanesthesiology and that this could lead to the higher proportions of women first authors in neuroanesthesiology and neurocritical care content. We observed a slightly higher representation of women first authors in neuroanesthesiology and neurocritical care articles compared with that in Miller et al4 study (34.6% vs. 30.3%). This might be related to our inclusion of journals dedicated to neuroanesthesiology and neurocritical care compared with the more general content of the journals investigated by Miller et al4 which include limited neuroanesthesiology and neurocritical care-related content. Furthermore, Miller et al4 reviewed articles published between 2002 and 2017 (and found an increasing trend in women first authorship over time), whereas we reviewed the 3 dedicated neuroanesthesiology and neurocritical care journals more recently (between 2015 and 2020).
In 2018, De Cassai and Correale7 reported an overall authorship by women of 36.9% to 39.3% for all original research papers published in 11 anesthesiology journals, and an unexpectedly higher percentage of women first authors (38.7% to 40.9%). Despite women being less well represented as first authors than men (19.0% vs. 81.0%) in articles published in the Canadian Journal of Anesthesia between 1954 and 2017, Flexman et al8 reported that an original article with a woman as first author resulted in 0.34 (95% confidence interval [CI]: 0.2-0.39; P<0.001) more citations per article compared with those with a man as first author when adjusted for year of publication. In cardiovascular anesthesia, Pagel et al9 found an increase in first, last and corresponding authorship of women over time (9.6%, 7.0%, and 8.7% in 1990, 1991 and 1992, respectively vs. 26.2%, 11.8%, and 16.6% in 2015, 2016, and 2017, respectively). However, when compared with men, women continued to be relatively underrepresented in corresponding and last author roles. Interestingly, when compared with other medical specialties, Karri et al10 reported that women authors were not underrepresented in 7 impactful journals affiliated with the largest pain medicine societies when considering the national prevalence of pain medicine physicians. Although that study reported a trend toward an increased prevalence of first authorship by women over time (from 28.5% in 2014 to 35.5% in 2018), an in-depth analysis of the data revealed a nonsignificant trend towards lower representation of women authors within more impactful and higher cited literature. In critical care research, a slight increase in women authorship has been observed over the last decade, with an average annual increase of 0.4% and 0.5% for woman as first and senior author, respectively.11
With regards to the representation of women in academic neuroscience, Schrouff et al3 reported significantly lower numbers of women as first (49.1%) or last (31.3%) author compared with men, while evaluating the empirical data and feedback received after the release of the Women in Neuroscience Repository (an initiative created to increase the visibility of women in neuroscience). Nonetheless, Dubey et al14 observed a positive trend in the last decade with a nonstatistically significant increase in the proportion of woman as first author (from 27.6% in 2002 to 31.0% in 2012) and senior author (from 16.8% in 2002 to 18.2% in 2012), as well as a significant increase in authors from developing countries (including India) in higher impact factor neuroscience journals. However, there was no increase in women authorship in any of the neuroscience subspecialties, including neurocritical care (man:woman ratio of first author being 75:25).
Although Miller et al4 encouragingly observed a higher proportion of women first authors of neuroanesthesiology articles (30.3%) compared with articles overall (24.8%), but still lower than men, there is limited literature exploring the visibility of women in neuroanesthesiology and neurocritical care academia and professional leadership more generally. Lorello et al5 found that the proportion of women speakers at symposia during the Canadian Anesthesiologists’ Society annual meetings held between 2007 and 2019 varied significantly by subspecialty group. Compared with perioperative medicine (as baseline reference), women were underrepresented relative to men as speakers at neuroanesthesiology symposia (odds ratio [OR]: 0.6; 95% CI: 0.4-1.2), and much less well represented compared with some other subspecialty groups such as obstetric anesthesia (OR: 3.7; 95% CI: 2.3-5.8), pediatric anesthesia (OR: 1.3; 95% CI: 0.8-2.1), and regional anesthesia and pain medicine (OR: 0.8; 95% CI: 0.5-1.2). In a recent editorial, women were reported to have been underrepresented in JNA editorial board over last 2 decades6; on average only 20.0% of its members were women, similar to other anesthesiology journals, and there was a slight decrease in the proportion of women members from ~27.0% in 2006 to 21.0% in 2019. Nonetheless, there was an encouraging increase in the proportion of women peer reviewers over this time, increasing from 17.0% in 2006 to 29.0% in 2019.
The existing literature cites multiple factors for the widely prevalent over-representation of men in academic anesthesiology.2,4,16–18 Although multifactorial, gender discrepancy in medicine is primarily led by stereotypical societal biases against working women.1,2,17,18 Other factors that limit the academic productivity of women include asymmetric childcare and family responsibilities, unsupportive work environments, limited number of women role models in academia, and a perceived lack of the traditional leadership qualities of men.1,2,4,16–18 Not only do these factors affect women’s overall scholarly productivity, they could also affect their choice and desire for specialty and additional training in subspecialties such as neuroanesthesiology and neurocritical care. Although homophily persists among men when appointing to leadership positions, both men and women leaders continue to act as mentors and motivators for women in academic medicine.18
Considering the relation between article type and author gender, previous studies have found that compared with experimental/original research publications and review articles, clinical-based publications such as case reports are more likely to have a higher proportion of women as first author.4,19 Similarly, we found a lower proportion of women first authors of Original Research Articles compared with other article types. One explanation for this finding could be the preferential engagement of women in clinical duties compared with key-role positions in research and publication.
In our study, the United States and India accounted for the majority of the absolute number of contributions by women to neuroanesthesiology and neurocritical care research. This may be partly explained by an increasing representation of women in academic anesthesiology in these countries. Moreover, the 3 journals in this study are affiliated with specialist societies of neuroanesthesiology and neurocritical care, potentially encouraging an increased number of article submissions and subsequent acceptance.14,20–22 Thus, this finding could primarily reflect the higher volume of articles being submitted from the United States and India rather than a higher proportion of contributions from women authors per se. Considering the articles published from each of the 51 countries in this study, China had the highest proportion of women first authors (7.1%), while India had the highest proportion of women corresponding authors (39.3% ). The reasons for the higher proportions of women authors from these 2 countries needs further investigation to consolidate our understanding of the various factors that affect the representation of women in neuroanesthesiology and neurocritical care academia.
Recently, the Society for Neuroscience in Anesthesiology and Critical Care created the Women in Neuroanesthesiology and Neuroscience Education and Research program, to celebrate the success of women in neuroanesthesiology and neurocritical care, and to provide support, mentorship, and sponsorship for early-career and mid-career women in these subspecialties of anesthesiology and critical care.23 The findings of our study could assist in ascertaining the benefits of strategies to promote the role of women in neuroanesthesiology and neurocritical care research by providing reference data against which future studies could be compared.
Our study has several limitations. First, we examined a relatively short period of time (5 y) which may be insufficient to confidentially identify change in the representation of women within this subspecialty. We choose a 5-year time period because one of the journals included in the study (JNACC) was first published in 2014. Second, we included only the 3 journals dedicated to neuroanesthesiology and neurocritical care; there are several other journals which include neuroanesthesiology and neurocritical care-related content either occasionally or in regular subsections which we did not included. As a result, our findings do not reflect the entire neuroanesthesiology and neurocritical care literature published during the study period. In addition, editorials, commentaries and other articles that did not constitute original research or clinical investigations were not included. Third, although the representation of women in neuroanesthesiology might be different from that in neurocritical care, we aggregated these subspecialties considering that neurocritical care is an integral part of neuroanesthesiology training programs. While NCC publishes only neurocritical care focused articles, JNA and JNACC publish articles related to both neurocritical care and neuroanesthesiology. Fourth, we focused our investigation on first and corresponding authorship. Although Tscharntke et al24 noted that author position does not consistently reflect actual author contributions or their role in multidisciplinary scientific collaborations, considering the high volume of multiauthored publications in our study we believe that focusing on the traditionally recognized parameters for academic productivity, that is, first and corresponding authorship, was reasonable. Fifth, we used gender as the construct and gender-related terminology to depict a gendered phenomenon despite having assigned sex based on socialized gendered names and phenotypes. As such, determination of gender was based on authors’ first names and internet searches; no gender identifying programs or software was used. Importantly, gender was not self-identified by the authors in any of the articles included in this study. Moreover, despite an extensive search there were a few publications in which a clear determination of first or corresponding author gender could not be made, and these articles were excluded from the analysis. Similarly, articles with >1 accredited first and/or corresponding authors were excluded from study, resulting in a total loss of 2.6% of data (32/1196). For single authored publications, the same author was counted as both first and corresponding author and this may have over-estimated the total proportion of women and/or men corresponding authors. Furthermore, the proportion of women first and corresponding authors from individual countries was determined by the country of the authors’ organizational affiliation at the time of publication of the article; this may change over time and may not always correspond to the country of origin of manuscript. Finally, we are unable to comment on the potential gender disparity in neuroanesthesiology and neurocritical care article authorship related to national gender representations in these subspecialties. Data regarding the number of practicing neuroanesthesiologists and neurointensivists and their gender in the 51 countries included in the study were not available to us and is difficult to determine.
Men were represented in greater proportions than women as first author of articles published in 3 dedicated journals of neuroanesthesiology and neurocritical care over the last 5 years. Among different article types, women had the lowest representation as authors of Original Research Articles. Although the United States contributed the highest absolute number of articles with women authors, China had the highest proportion of women first authors and India had the highest proportion of women corresponding authors. Our study fills a gap in the literature by providing data on the representation of women as first and corresponding authors according to the type of articles published in 3 neuroanesthesiology and neurocritical care journals over 5 years. When data on gender representation in the subspecialities of neuroanesthesiology and neurocritical care are available, further research is needed to determine whether a gender-gap exists with regards to women authorship in these subspecialties. Studies assessing the possible causes of such disparity and the impact of different strategies to resolve the disparity would then be urgently required.
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