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Professionalism-The Gender Gap
More Women in Academic Neurology, but Fewer Published Authors

ARTICLE IN BRIEF

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WOMEN NEUROLOGISTS were underrepresented as first authors in three major neurology journals.

Two studies, which report an underrepresentation of women in academic neurology and as published authors, focus on the question: Are women advancing to top levels in proportion to their numbers? Women leaders in academic neurology and editors of neurology journals weigh in.

Although women account for a growing proportion of practicing neurologists, they are underrepresented in publications and, perhaps by extension, in academic neurology.

Two recent papers — one in JAMA Neurology, the other in Neurology — document the gender gap in publications. The studies were published amid a growing focus on a question being asked in many professions: Are women advancing to top levels in proportion to their numbers?

The neurology manuscripts give rise to both optimism and discouragement, depending on how their findings are interpreted. But those interviewed for this story — neurology editors and women neurology leaders — agreed that attention on this issue is warranted.

“There's a lot of ferment going on because people are thinking about this right now,” said Clifford B. Saper, MD, PhD, FAAN, editor-in-chief of Annals of Neurology and the James Jackson Putnam professor of neurology and neuroscience at Harvard Medical School and head of the neurology department at Beth Israel Deaconess Medical Center. “It's a hot topic in the community,” he said, adding that the journal will publish a paper on the topic this year.

“These are both very important articles and call out an issue that needs to be addressed: the opportunity for advancement of women in neurology,” said Allison Brashear, MD, MBA, FAAN, Walter C. Teagle chair of the neurology department at Wake Forest School of Medicine, who co-directs the neuroscience service line at Wake Forest. “Publications are just one facet of the sex gap in career progression in academic neurology,” Dr. Brashear said. “I think this is the beginning of looking at data to see what we are actually doing and where our gaps are. This issue of why women don't advance to the higher ranks in academics needs more work.”

Frances E. Jensen, MD, FACP, chair of the department of neurology at Perelman School of Medicine of the University of Pennsylvania, thinks focusing only on research-dependent career tracks gives a too-limited perspective on the range of career options in neurology today.

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DR. ALLISON BRASHEAR: “Publications are just one facet of the sex gap in career progression in academic neurology. I think this is the beginning of looking at data to see what we are actually doing and where our gaps are. This issue of why women dont advance to the higher ranks in academics needs more work.”

“Neurology has become a much more vibrant, heterogeneous field, and it needs much more than tenure-track professors doing peer-reviewed research papers,” said Dr. Jensen, who co-directs the Penn Medicine Translational Neuroscience Center. “That is one of many successful career phenotypes, but it does not have to be the ultimate goal for everyone.”

AUTHORSHIP GAP

Because the publication of peer-reviewed manuscripts is an important factor in promotion in academic neurology departments, researchers at Johns Hopkins Medicine sought to learn whether female authors were proportionately represented in three high-impact factor journals: Neurology, JAMA Neurology, and Annals of Neurology.

The number of female first authors and senior authors in the three journals grew steadily during the study period from 1980 through 2015, according to the review by Jina Pakpoor, MD, and colleagues, published February 14 in Neurology. However, a notable sex gap remained as of 2015. In that year, 25 percent of the first authors and 18 percent of the senior authors were female, even though women filled 37 percent of the full-time faculty positions in neurology that year.

Researchers at the University of Michigan took a different approach to examine a related question. They compared the number of men versus women at each academic faculty rank at 29 top-ranked academic neurology programs and how many articles each group — by sex and academic rank — had published.

Among their findings, published in the April 2 online edition of JAMA Neurology, they found that male neurologists in the top programs had more publications than women at every faculty rank above instructor/lecturer, even after adjusting for years since medical school graduation. On average, male assistant professors had twice the number of publications of their female counterparts. However, the sex disparity was reduced at the associate professor level and even lower among professors.

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DR. MOLLIE MCDERMOTT: “We cant just assume this is all going to be fine because there are more women in neurology — our data would not suggest that.”

In addition, the researchers documented that men outnumber women at all levels of faculty rank, including the most junior positions, at top academic neurology departments.

The 29 top-ranked programs had a total of 1,712 academic neurologists in the five-month period of 2015 and 2016, in which Mollie McDermott, MD, MS, assistant professor of neurology at the University of Michigan, and her colleagues were collecting data for their study. Of those, 31 percent were women.

Women accounted for just under 30 percent of the first authors in the Annals of Neurology manuscripts in 2015. Thus, Dr. Saper, the Annals editor, said he believes the male/female publication gap is explained by the sex gap in the faculty.

“That reflects the pipeline,” he said. “With time, as more new young people move into faculty positions, I think the gap is going to disappear.”

Dr. Brashear pointed out, however, that there are a similar number of women chairs of neurology departments today than when she became a chair 12 years ago. In her view, too often women are giving committee work or projects that don't lead to advancement. “We have not advanced, really, despite the fact that more than half the medical students are women,” she said. “This isn't a pipeline issue; it is a sponsorship issue.”

Dr. Pakpoor, a research fellow in the neuroradiology division at Johns Hopkins Medical Institutions, hopes that, by documenting the steady increase in female authorship in the top neurology journals, her research will spur further progress. She believes the upward trend reflects intentional efforts, such as mentorship of women in academic neurology departments, that must continue.

“Hopefully that can serve as an impetus to show that advancements are being made but also that there's room to develop further,” she said. “It's important for these efforts to both continue as they are and to grow.”

Dr. McDermott echoes her concern. Her research found that, at the top programs, men were twice as likely as women to be full professors, even after controlling for years since medical school graduation.

“We can't just assume this is all going to be fine because there are more women in neurology — our data would not suggest that,” she said.

In fact, there are sex disparities of concern at several levels. Women made up 32.6 percent of the physician workforce in 2013, but only 26.9 percent of active neurologists. In 2015, women accounted for 54 percent of instructors, 35 percent of associate professors, and 19 percent of full professors in neurology,

“Medical schools are graduating 50 to 51 percent women at this point, so theoretically we should be seeing the gender breakdown become more equal over time,” Dr. McDermott said. “But in our study, when we controlled for years since medical school graduation, the disparities didn't disappear.”

WHY THE DISPARITY?

Why is that? That's what Robert A. Gross, MD, PhD, FAAN, FANA, editor-in-chief of the Neurology journals published by the AAN, wonders.

“This is something that most of us have been worried about for years — the relative lack of representation of women in higher levels in our departments,” said Dr. Gross, professor of neurology and of pharmacology and physiology at the University of Rochester Medical Center. In his view, the data presented in the Neurology paper is worrisome.

“The pipeline seems to be evening out. At Rochester, over half of our medical students are women — and it remains to be seen in future years whether that will carry through to more equal representation in neurology departments, and therefore, publications, across the country,” he said. “The present data suggest it may not. Are the issues individual, departmental, or institutional? Until we know all the factors related to this disparity, our efforts to mitigate may not be entirely successful.”

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DR. FRANCES E. JENSEN: “Neurology has become a much more vibrant, heterogeneous field, and it needs much more than tenure-track professors doing peer-reviewed research papers. That is one of many successful career phenotypes, but it does not have to be the ultimate goal for everyone.”

Dr. Jensen, however, thinks that the focus on publication rates reflects an outdated perspective that research productivity is the only way to measure progress in a neurology career. Because of research breakthroughs that led to advances in treatment, clinical and medical education career paths are equally important to research careers today.

“Like our institution, many institutions have created additional faculty tracks beyond the traditional clinical investigator and tenure tracks, and these new faculty tracks acknowledge educational excellence and clinical program development,” she wrote in a JAMA Neurology editorial published online April 2, 2018.

Women do not lag in these newer academic career tracks, she said.

WHAT PROGRESS LOOKS LIKE

When Dr. Pakpoor first joined Johns Hopkins, she wanted to present her research at a major conference. She thought the safe bet was to submit it as a poster presentation, increasing the likelihood it would be accepted, and justifying her attendance at the conference. But her mentor insisted that she submit it as an oral presentation, which was accepted.

“The mentorship that I am receiving is having a very, very positive impact on me,” she said. “Now a year later, I have the confidence to be able to evaluate my own work, to see what I feel is worthy of different opportunities.”

In Dr. Brashear's view, the root cause of the sex gap in academic neurology careers is a lack of intentional support for female faculty members through mentorship, sponsorship, and leadership training opportunities.

“Sponsorship is when individuals support someone by having skin in the game,” she said. “They bring them in on a research project. They give them a title and opportunity to lead.”

Such intentional efforts are part of Wake Forest's culture, Dr. Brashear said, and their merits speak for themselves: 60 percent of assistant professors in the neurology department are women, as are 70 percent of the associate professors and 50 percent of the professors.

“All the major grants in our department are held by women,” she said. “And that was purposeful by giving women opportunities and sponsoring them and helping them foster their careers.”

Dr. Gross, who serves ex officio on the AAN Board of Directors, said the Academy is working to try to address the disparities in neurology.

“The Academy is dedicated to fleshing out an understanding of its own membership with regard to demographics, and with regard to publication records, as well as helping departments understand the makeup of their faculties,” he said.

And what about the composition of editorial boards of neurology boards? Other than Lancet Neurology, the editors-in-chief of neurology journals are men. [The editor of Lancet Neurology did not respond to requests for an interview, and the editor-in-chief of JAMA Neurology said that, by policy, he cannot be interviewed about articles published in the journal.]

Drs. Saper and Gross acknowledged that women are underrepresented as editors and peer-reviewers, though the reasons why are not clear. “Members of our editorial board come from the people who are the most prolific reviewers. We send out a list of the people who reviewed the most papers for the journal to the editors, and we ask them to choose people who would be editorial board members,” Dr. Saper said. “And the people who get the largest number of votes end up being on the editorial board. One flaw in our system is that only two of the nine editors are women.”

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DR. JINA PAKPOOR: “The mentorship that I am receiving is having a very, very positive impact on me. Now a year later, I have the confidence to be able to evaluate my own work, to see what I feel is worthy of different opportunities.”

“We get about 10 times as many papers as we can publish,” he added. “We do not encourage or turn people away based on gender, country of origin, or anything else, other than quality of the work.”

Dr. Gross noted that the Neurology journals look for people with a high degree of scientific integrity who can work with the high volume of submissions on a timeline. “We also want to have a good representation of women and international members. And I think we're increasingly better at that,” he said. “When I took over the journal, there were no women associate editors. We now have one at the main journal, and the deputy editor of Neurology: Clinical Practice is a woman. We have more women on our editorial boards. So, I think we're getting there.”

LINK UP FOR MORE INFORMATION:

• Jensen FE. Editorial: Closing the Sex Divide in the Emerging Field of Neurology https://jamanetwork.com/journals/jamaneurology/fullarticle/2676797. JAMA Neurol 2018; Epub 2018 Apr 2.
    • McDermott M, Gelb D, Wilson K, et al. Sex differences in academic rank and publication rate at top-ranked US neurology programs https://jamanetwork.com/journals/jamaneurology/fullarticle/2676799. JAMA Neurol 2018; Epub 2018 Apr 2.
      • Pakpoor J, Liu L, Yousem D. A 35-year analysis of sex differences in neurology authorship http://n.neurology.org/content/90/10/472. Neurology 2018; 90: 472–475.