Men Continue to Outnumber Women in Academic Neurology

Damian McNamara

April 05, 2018

Men hold approximately 7 in 10 of all academic neurology positions at top-ranked programs overall, and the discrepancy increases with advancing rank, results of a cross-sectional study reveal.

In an analysis of 1712 academic neurologists in the United States, 30.8% were women and 69.2% were men, a statistically significant difference (P < .001). In addition, after adjustment for years since medical school graduation, men published a significantly larger number of publications than women at all academic positions.

"We already know that men outnumber women in medicine, in neurology, and in academic neurology.  In past decades, men outnumbered women in medical schools, so gender disparity is expected among older faculty. Nowadays, medical school graduates are about half women. Thus, if age was the only force driving gender disparity, we would expect the disparities to vanish when adjusting for years since medical school graduation," study coauthor Zachary London, MD, director of the neurology residency program at the University of Michigan in Ann Arbor, told Medscape Medical News.

"Our study was the first to show that this is not the case in top academic neurology programs…gender disparities exist at all levels of experience," he added.

The study was published online April 2 in JAMA Neurology.

Across-the-Board Issue

The current finding is not unique to neurology. Men outnumber women in academic medical positions across specialties. For instance, women represent just 33% of 91,073 faculty positions nationwide (JAMA. 2015;314:1149-1158).

Specific to neurology, 31% of 1073 full-time neurology faculty with medical degrees were women in 2012, according to data compiled by the Association of American Medical Colleges.

Interestingly, the sex distribution is almost equal among all neurologists, with women accounting for nearly 45% of neurology residents in 2013.

To explore the potential sex differences in academic neurology programs, the investigators performed a systematic analysis of 29 top-ranked US academic neurology departments. At 49.1%, Stanford University in California led the list with the highest proportion of female neurologists on faculty.  Mayo Clinic-Jacksonville had the lowest proportion of women in academic neurology positions, at 18.2%.

The researchers used a chi-square test to compare the proportion of men vs women overall and within each academic faculty rank.

The investigators identified the 1712 faculty based on an Internet search of departmental websites between December 2015 and April 2016.

"Our use of department websites as our primary data source was unique. It is possible that this is more accurate than survey-based information," London said.

Assessing the publication number and citation impact for each faculty member based on Scopus and PubMed data was another aim of the study.

Investigators controlled for years since medical school graduation because men had significantly more years in practice than women at the professor (P < .001), associate professor (P = .001), and instructor/lecturer (P = .003) levels.

The only exception was at the assistant professor level, where researchers found no significant difference in years since medical school graduation between women and men.

"It is clear that there are still barriers to women in academic neurology, especially in traditional academic pathways that rely heavily on publication as a measure of success," he said.

Men More Likely to Be Full Professors

After controlling for clustering and years since medical school graduation, the investigators found men were twice as likely as women to be full neurology professors (odds ratio [OR], 2.06). In contrast, male and female neurologists had the same likelihood of holding associate professor positions (OR, 1.04).

The finding of more men among academic neurologists at higher rank "is to be expected because individuals with more senior academic rank are more likely to have graduated when the ratio of male to female medical students was higher," the researchers write. "However, even after controlling for years since medical school graduation, fewer women than men have achieved the rank of full professor."

In an unadjusted analysis, male neurologists published significantly more than women on PubMed at the professor level (144 vs 95 mean articles; P < .001), at the associate professor position (49 vs 33; P = .03), and at the assistant professor level (20 vs 11; P < .001).

Men were still more likely to have more publications than women at the levels of full professor (1.36 exponentiated coefficient), associate professor (1.53), and assistant professor (1.85) of neurology after adjustment for years since medical school graduation.

"While other studies have shown a difference in publication rates between men and women, we also looked for differences in Scopus h-index, measures of clinical activity, educational leadership roles, and book authorship among academic neurologists, and adjusted all for years since medical school graduation," London said.

Male faculty also had a higher log Scopus h-index than women for publishing after researchers adjusted for years since medical school graduation (linear coefficient, 0.44).

When the researchers cast a wider net to capture scholarly activities beyond traditional published material, they found 113 unique books available on the first 10 pages of Amazon results by using the search term "neurology."

This search revealed no significant difference between men and women listed as first or second author. They also did not detect any significant disparity in the educational leadership or clinical productivity between women and men after controlling for years since medical school graduation.

Compared with men, women may be more likely to be recruited for employment positions in neurology that emphasize teaching and mentoring rather than research, or women may be more inclined to choose such positions, the authors note.

Reason for Optimism

Beyond the traditional measures of academic productivity, including publication rate, publication impact, and grant support, "there is a growing recognition of the importance of other factors, such as the quality and quantity of teaching, the development of educational resources, and administrative effectiveness," the authors write.

Mentorship and prominent positions for women within national organizations are potential strategies to address the sex divide in academic neurology, London said.

"While they are still underrepresented, the increased number of female senior faculty members means there are more female mentors for residents and junior faculty.  Female mentors can provide a supportive and collaborative environment, role modeling and advocacy."

Promotions committees often look for evidence of a "national reputation" when considering an individual for a senior promotion, he added. "We need to create opportunities for women in academic neurology to develop a presence outside of their home institutions."

Advocating for more women to speak at national neurology conferences and to hold more leadership roles on national committees may help.

A potential limitation of the study is not evaluating different academic career paths with distinct criteria for promotion. "Women may tend to select appointments in academic career paths that are less focused on promotion to senior faculty rank."

In addition, the study focused on top-ranked neurology programs in the United States, so generalizability to other neurology departments in the United States and elsewhere remains unknown.

The study's cross-sectional design did not allow researchers to draw conclusions regarding any association between the number of publications and promotion.

Strengths of the study include systematic data acquisition and a large sample size.

"One unexpected finding was that the women in the senior academic ranks of associate or full professor were, on average, closer to medical school graduation than men. It is hard to know whether this means women are reaching these ranks sooner than men or just, on average, more recently. Either interpretation suggests a positive trajectory for women in academic neurology," London said.  

"Another reason for optimism is that these conversations are happening," he added. "Studies like ours, which draw attention to gender disparities in medicine, are being published more and more. National organizations are forming women's advocacy groups and hosting career seminars aimed at women. This trend is very encouraging and gives us hope for real change."

When asked if future research could tease out whether women are not being offered the same faculty positions vs whether they are selecting different career paths within academic neurology, London replied, "That's a great point. We need to know the answer to that question in order to take the appropriate steps. Is blatant or unconscious bias hurting women's chances for successful careers? Alternatively, are we missing the boat entirely because we're inappropriately using traditional metrics of academic success as our endpoint?

"Most studies about gender disparities in academic medicine dance around these questions, but they are very hard to answer directly. Our group and others are trying to think about creative ways to address this."

Change Is Too Slow

"As a woman, a tenured professor, and the chair of a neurology department in one of the stated 'top-ranked' neurology programs, I strongly believe that sex differences have no place in the future of the field of neurology," Frances E. Jensen, MD, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, writes in an accompanying editorial.

"Change has been too slow," she adds.

One solution to close the sex divide in academic neurology is to promote the specialty in a way that attracts more female physicians. Jensen cited a recent American Academy of Neurology survey that revealed a 35:65 split of women to men among all neurologists.

"Hence, the subspecialty of neurology needs to be an attractive career option for these newly trained female physicians," she writes. "Should data such as those published by McDermott et al dissuade young women from choosing neurology? My answer is an emphatic no."

Jensen applauded the researchers' recognition that neurology and academic neurology continue to broaden beyond use of publication rate as the sole indicator of career achievement.

"Because of successful translational research in the past 1 to 2 decades, clinical trials are growing at an exponential rate, thus calling for more diverse skill sets. Such clinical expertise is increasingly being used as an indicator for productivity and career promotion."

"There is abundant evidence that diversity enriches all aspects of our medical missions well beyond those of traditional academia," she added.

The Jerry Isler Neuromuscular Fund funded the study. London and Jensen have disclosed no relevant financial relationships.

JAMA Neurol. Published online April 2, 2018.  Abstract, Editorial

Follow Damian McNamara on Twitter: @MedReporter. For more Medscape Neurology news, join us on Facebook and Twitter.

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