Understanding and addressing gender equity for women in neurology

The inequity spectrum

Research on gender disparities demonstrates a spectrum of inequities that range from microinequities to macroinequities,²⁵ with the latter having easily identifiable and quantifiable metrics (e.g., compensation or promotion). While studies of microinequities are frequently quantitative and report data, the metrics used are often unique and sometimes quite creative. For example, one microinequity study demonstrated via video recordings of Grand Rounds speaker introductions that when compared with men, women's professional titles were used less frequently.¹⁷ In a study assessing the representation of men and women physicians (and information about their work) in newsletters published by the American Academy of Physical Medicine and Rehabilitation over a period of more than 5 years, my colleagues and I found that while men were always included, women were completely excluded from more than one-third of the newsletters.²⁶ In another study, we found that women were represented at lower than expected levels among authors of perspective-type articles published in the 4 highest-impact pediatric journals.¹³ These types of studies have added to a growing body of evidence demonstrating how women are often subtly marginalized, silenced, or made invisible. The building of one's professional reputation is both vital and nuanced,²⁷ and the cumulative effect of many subtle slights may have a more pronounced effect on women's careers than previously recognized.

Gender bias and sexual harassment

Gender bias and disparities likely provide fertile ground for sexual harassment, and it is clear that medicine has a serious problem with these issues. The landmark report from the National Academies of Science, Engineering and Medicine (NASEM) titled Sexual Harassment of Women: Climate, Culture, and Consequences in Academic Sciences, Engineering, and Medicine stated that “gender discrimination itself harms women and the broader meritocracy of science. And thus we conclude that together, gender discrimination and male domination are features of the academic science, engineering, and medicine climate that create a permissive environment for sexual harassment.”²⁸ The report describes the normalization of gender-related harassment (including but not limited to sexual harassment) in medicine, and sheds light on the current literature. Relevantly, the true incidence and prevalence is likely underestimated for a variety of reasons (e.g., underreporting by those affected, reluctance to label offending, demeaning, or intrusive behavior as harassment, or failure to follow good research practices). As the report explains, large proportions (and in some studies the majority) of women in academia in general, inclusive of health care training environments such as medical schools and academic medical centers, are targets. For example, surveys of 2 large institutions revealed that 45% to nearly 50% of women medical student respondents had experienced incidents of faculty/staff-on-student sexist hostility.²⁸ Moreover, women medical student respondents were more likely to have experienced faculty/staff-on-student sexist hostility than their same-institutional-system peers in undergraduate, graduate, non–science-engineering-medicine, science, and engineering studies.²⁸ Importantly, it is becoming increasingly clear that in some instances medical schools and other health care organizations have one or more serial harassers who have continued their behavior over the course of many years and affected many targets (generally women, but men and others across the gender spectrum as well). Bystanders who have witnessed or heard about this behavior also may have been negatively affected (figure 1). Although the vast majority of men in medicine are professional and respectful of those with whom they interact and there is no evidence to suggest that most men are guilty of harassment, authors of the NASEM report concluded that “Environments where men outnumber women, leadership is male dominated, and/or jobs or occupations are considered atypical for women have more frequent incidents of sexual harassment for women.“²⁸ Therefore, likely a small group of people, primarily though not exclusively men, who are too often serial harassers or predators are poisoning medicine's learning and working environments.

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Figure 1 Sexual harassment in medicine

This graphic is inclusive of all genders and is intended to show that the proportion of serial harassers or predators (which is unknown) is a much smaller group compared to targets and bystanders.

The key to changing the normalization of sexual harassment then is to recognize that health care leaders' actions aimed at ridding their institutions of toxic behavior exhibited by a proportionally small group of people will determine what happens in the future to a much larger group of people. For example, a few months following the release of the NASEM report, NIH Director Francis Collins acknowledged that sexual harassment is “morally indefensible, it's unacceptable, and it presents a major obstacle that is keeping women from achieving their rightful place in science.”²⁹ He went further to issue a formal apology, stating, “To all those who have endured these experiences, we are sorry that it has taken so long to acknowledge and address the climate and culture that has caused such harm.”²⁹ Finally, he acknowledged, “We are concerned that NIH has been part of the problem [and] we are determined to become part of the solution.”²⁹ In response, the NIH launched a website with new resources and policies aimed at reducing sexual harassment in academic medicine.³⁰ Similarly, Time's Up Healthcare launched in early 2019 as a not-for-profit affiliate of the Time's Up organization formed in response to the #MeToo movement and focused on ensuring an equitable and safe environment for everyone.³¹

Whatever form they take, the evidence demands that both gender discrimination and sexual harassment, which are overwhelmingly directed at women, must be recognized by the medical and scientific community as morally indefensible and unethical:

1. Discrimination is antithetical to the tenets of professionalism in medicine.³²

2. Gender discrimination itself harms women, and supports organizational environments in which sexual harassment has been normalized.²⁸

3. Sexual harassment itself is a form of discrimination.²⁸

4. Academia has a high prevalence of sexual harassment.²⁸

5. “By far, the greatest predictors of the occurrence of sexual harassment are organizational.”²⁸

6. Gender equity is a moral imperative.³³

Therefore, we must conclude that leaders of all health care–related organizations have a moral and ethical imperative to expeditiously address both gender discrimination and sexual harassment of women in medicine.

Gender-related disparities for women physicians in neurology

The evidence base regarding disparities for women in neurology—where women constitute approximately 45% of trainees,³⁴ 30% of neurologists in practice,³⁵ and 40% of faculty in academic medicine¹⁹—is growing and issues identified include compensation,⁶ academic promotion,^7,20 leadership,^36,37 recognition awards given by the American Academy of Neurology (AAN),^10,16 journal editorial board representation,^5,12 and publishing.²⁰

Physician compensation

There is a spectrum of inequities that range from microinequities to macroinequities,²⁵ but there is no doubt that compensation is among the most important. A growing body of published research and national surveys from Doximity, Medscape, and specialty societies collectively and undeniably demonstrate that disparities in compensation for women in medicine often exist even after accounting for variables such as part-time employment and differences in productivity. For example, in a study by Jena et al.⁶ looking at gender-related differences in academic physician salary in 24 US public medical schools across 12 states (n = 10,241 physicians; 3,549 women), researchers found that men in neurology (n = 307) were paid an average of $30,482 (95% confidence interval $9,731 to $51,592) more than women annually (n = 142) even after adjusting for gender, age, years of experience, faculty rank, scientific authorship, NIH funding, clinical trial participation, and Medicare reimbursements. From these data, researchers estimated that women academic neurologists were making approximately 85 cents for every dollar or 85% of the adjusted salaries paid to colleagues who were men.^6,38

While limitations are applicable to any research, including the Jena et al.⁶ study, I found it interesting to consider how compensation in neurology was ranked among the 18 different surgical and nonsurgical specialties included in the report. Among the 36 groups of men or women across 18 specialties, women in neurology were ranked last—earning the least amount annually compared to all of the others (figure 2). My comparison of same-specialty gender-related adjusted salaries revealed that the largest gap for women when compared with men among the 18 specialties was in neurology (15%; range −0.8% to 15%).⁶ Furthermore, women in neurology had the largest gap in salary as a percentage of same-gender specialty-related adjusted salary (figure 3; 17.7%; range −0.8% to 17.7%).

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Figure 2 Rank of academic physicians' salary by specialty and gender

To examine the rank of academic physicians' salary by specialty and gender, the adjusted salaries* of men and women practicing in 18 specialties at 24 US medical schools across 12 states as determined by Jena et al.⁶ were sorted from largest to smallest. Women physicians in neurology were ranked 36 of 36, and 8 steps below men physicians in neurology (+). *Adjustments included those for gender, age, years of experience, faculty rank, scientific authorship, NIH funding, clinical trial participation, and Medicare reimbursements.

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Figure 3 Rank of women academic physicians' specialty-related salary gap as a percentage of income

To examine the rank of women academic physicians' salary gap by specialty, the differences between adjusted salaries* of men and women practicing in 18 specialties at 24 US medical schools across 12 states as determined by Jena et al.⁶ were normalized by dividing the differences by the respective adjusted salaries for women academic physicians in the field. Among 18 specialties, women in neurology were ranked no. 1 and face the largest normalized salary gap as percentage of income. *Salary adjustments included those for gender, age, years of experience, faculty rank, scientific authorship, NIH funding, clinical trial participation, and Medicare reimbursements.

To demonstrate the profound negative consequences this kind of pay disparity can have over the course of a woman neurologist's career, I utilized a set of publicly available online financial modeling tools. I found that if a woman received an additional $30,482 in salary each year, after 40 years of investing and with adjustment for inflation, she would have a net return of $2,507,647 (figure 4).^39,–,41 Arguably, this is a conservative analysis, not taking into account that her return on investment (ROI) may be negatively affected by the possibilities that (1) at the beginning of her career, she could be paying a higher proportion of her salary toward debt and the money she owed may have been associated with an interest rate higher than the historical rate of return; and (2) as her career progressed, her rate of promotion may be slower and to a lower level overall (never reaching the highest levels) than her colleagues who are men. Although readers may take issue with elements of this example, no one should miss the main point: disparities in pay can generate a huge deficit in a person's financial standing over the course of a career.

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Figure 4 Consequences of salary gap on a woman academic physician's personal investment income

Using a set of publicly available online financial modeling tools,^39,40 I examined the consequences of salary disparities on long-term income. I started with the assumption that a woman received an additional $30,482 in salary each year; that is, the dollar amount that would negate the salary gap Jena et al.⁶ identified for women in neurology. Using the 2018 marginal tax rate for a single or separately filing taxpayer with a $200,000 income (32.9%),³⁹ I calculated that this woman would have $20,453 of additional income available after taxes annually. After a 3% adjustment for inflation and in today's dollars, over 40 years she would have earned an additional $479,036 of income.⁴⁰ If she invested that gap-related additional income in a balanced mixed portfolio of 60% bonds and 40% stocks with a historical (1926–2017) average annual compounded investment return of 7.8%,⁴¹ after a 3% adjustment for inflation and in today's dollars, over 40 years she would have accumulated $1,395,060 of pre-tax investment income and booked a net return of $2,507,647.⁴⁰

Men and the collateral consequences of gender disparities in academic medicine

To drive change, one must not only understand the various perspectives of those directly affected, but also the perspectives of those who bear witness to what is happening. For example, a man who is in mid or late career is far more likely than a woman at the same stage to have personally benefited from or at least felt supported by an inequitable recognition, reward, and career advancement system. However, because these metrics do not tell the whole story, we might wonder whether men have truly been as fortunate as the data suggest. Moral people must certainly feel a heavy emotional toll when they are participating in, working in, or witnessing an unjust system in which women are systematically mistreated. As the NASEM report points out, sexual harassment negatively affects not only targets but also bystanders who are witness to the mistreatment.²⁸ Therefore, even men who have enjoyed the benefits of privilege may be paying an emotional price in the form of moral distress or burnout symptoms if their success is due in part to the systematic oppression of women.

Interestingly, men were undercompensated in one of the specialties examined by Jena et al.⁶—radiology—even after accounting for variables that could affect income. Recently, Google began examining its compensation data as well, and found that in some cases men were being underpaid when compared with women.⁵⁴ Thus, men too are at risk of losing millions of dollars over time due to compensation inequities. Moreover, this risk may increase if women who ascend to leadership positions adopt the practices of current leaders that favor same-gender compensation outcomes. Therefore, it is in everyone's best interest—including men—to use an impartial and scientifically driven approach to compensation that ensures that all workers, regardless of gender, are paid fairly.

Gatekeepers and the collateral consequences of gender disparities in academic medicine

Career advancement in academic medicine may involve various types of promotion, and advancement from instructor to professor relies on several factors that a promotions committee must consider. Many of these are reported in the curriculum vitae (CV)—a formulaic document that has sections for grant funding, publications, recognition awards, committee assignments, and leadership positions.¹⁶ Moreover, the number of publications as well as their impact (i.e., bibliometrics such as number of citations and Hirsch index) are part of the analysis.^55,56 Therefore, although the promotions committee resides at the faculty member's home institution, gender bias or disparities occurring at the level of funding agencies, journals, and medical societies may severely limit a woman's ability to be promoted. While many medical institutions are making large financial investments in improving diversity and gender equity, none of these investments will be fully realized if barriers to women's success are imposed by any of 4 gatekeepers who affect an academician's CV: (1) medical schools/academic medical centers themselves, (2) funding agencies, (3) journals, and (4) medical societies. Importantly, if any of the gatekeepers does not treat women fairly, then the success of efforts (and financial investments) that the others make in driving and achieving diversity and gender equity will be reduced, and ROIs remain unrealized (figure 5).

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Figure 5 Consequences of gender bias on return on investment

Even if a gatekeeper—an institution whose environment or actions directly affect the careers of physicians and scientists, particularly in academic medicine—makes investments in diversity by hiring, funding, and supporting women, the gatekeeper's return on investment may be negatively affected if any of the other 3 gatekeepers fail to treat them equitably. The icons used in figure 5 were found via Bing search through Microsoft Word's insert online picture function, designed by unknown authors, and inserted unchanged except for colorways under Creative Commons licensing (creativecommons.org/licenses/by/3.0/).

For example, in a recent study published in JAMA by Oliveira et al.,⁸ among first-time Principal Investigator NIH grant awardees across all grant types and institutions, women received a median award $39,106 less than men ($126,615 vs $165,721, respectively). At Big Ten and Ivy League universities, where some of the most talented scientists are working, disparities for women amounted to a median difference in funding when compared with men of $81,711 and $19,513, respectively. These deeply troubling findings highlight the negative consequences of gender disparities on (1) women researchers' ability to obtain grant funding to advance their careers; (2) institutional ROI—often astronomical and incalculable financial and human resource investments made by the home institutions in the recruitment, retention, and success of a large proportion of their scientific workforce^18,57,–,59; and (3) advancement of the science and medicine women are investigating. In addition, disparities in NIH funding of this nature likely reduce the success of administrative efforts of top-level leaders (i.e., deans and chairs, who are mostly men) to support a diverse scientific workforce at the researchers' home institutions. Because gatekeepers are interdependent, even the careers of men at the highest levels of academic medicine may be negatively affected when one or more of the other gatekeepers treats women inequitably.

Similarly, if journals or medical societies demonstrate bias against women in academic medicine—negatively affecting their ability to publish, present, or be recognized for their work through recognition awards, plenary or other lectures, and newsletter articles—then financial and other negative consequences may extend far beyond the women who are most directly affected, to their home institutions and funding agencies. Medical schools and academic medical centers, too, may be inadvertently undermining the investments that other organizations are making. For instance, the AAN has invested financial and other resources in the Women Leading in Neurology program. If women neurologists who have committed their time have lost clinical compensation or have self-funded their participation are not provided equitable opportunities for advancement in their workplace, the AAN's ROI of financial, administrative, and human resources is reduced as well. Treating women in medicine unfairly hurts everyone—obstructing women who seek career advancement, impeding their leaders (mostly men) who are charged with improving diversity and inclusion, and causing unrealized ROI for many organizations (institutions, funding agencies, journals, and societies) in the health care system.

Driving gender equity in academic medicine

The best way to accelerate gender equity for women in academic medicine is for all of the gatekeepers to hold each other accountable. This means that they must turn away from leaders who are supporting the status quo or the normalization of gender discrimination and sexual harassment and toward ethical leaders who are committed to organizational culture and climate change. In 2018, I developed the Be Ethical Campaign⁶⁰ to encourage leaders in the key gatekeeper groups to use a 6-step process (table 1) and a comprehensive set of unique and customizable metrics with longitudinal data analysis to uncover, address, and accelerate workforce gender equity, including the removal of bias, discrimination, and harassment. Avoiding critical thinking errors during this process is crucial, because they are pervasive in gender equity discussions and tend to slow or derail efforts (table 2).⁶⁰

Importantly, every medical specialty, including neurology, needs to examine its own history, particularly over the last 2 decades, as this is the timeframe most relevant to the majority of women who are in the specialty currently and interventions enacted now will affect their career trajectory for the coming years. What might an ethical path forward in neurology look like for mid-career US women neurologists who have been represented at markedly disproportionate levels as professors, department chairs, medical society presidents, recognition award recipients, and senior editors of neurology journals and who have not received equitable compensation or research funding? If the situation was reversed and over the last 2 decades a large body of evidence showed that men were not fairly compensated, promoted, or recognized, and they were often ignored and silenced, what would today's leaders do now to address this?

Many organizations have been increasing their efforts to address gender equity, inclusion, and safety, and, while a complete list is beyond the scope of this report, some examples include the following: Association of American Medical Colleges' “Promising Practices for Understanding and Addressing Salary Equity at US Medical Schools”⁶¹; American College of Physicians' “Achieving Gender Equity in Physician Compensation and Career Advancement”⁶²; Association of Women Surgeons' “Strategies for Identifying and Closing the Gender Salary Gap in Surgery”⁶³; American Surgical Association's “Ensuring Equity, Diversity, and Inclusion in Academic Surgery”^64,65; and the American Medical Women's Association's “Revolution by Resolution.”⁶⁶ Moreover, professional societies and other organizations are launching initiatives aimed at working together and sharing resources and best practices. For example, the American Academy of Pediatrics, American Academy of Family Physicians, American College of Physicians, American College of Obstetricians and Gynecologists, American Psychiatric Association, and American Hospital Association recently launched “Women's Wellness through Equity and Leadership,”⁶⁷ which will train a cohort of health care professionals in critical leadership skills and develop principles regarding healthy work environments for physicians.

Recently, neurologists have been focusing on their own culture of diversity and inclusion, including but not limited to equity for women neurologists, and both formal and informal initiatives and networks are supporting this work. Table 3 lists some important initiatives by neurology organizations, including the AAN's Women's Leadership Program, which are focused on closing leadership gaps and addressing other disparities for women in neurology. Still, the field has some catching up to do, and “recent data in neurology show that we lag behind the rest of medicine with continued gender disparities.”³⁸ In an editorial I wrote titled “Can neurologists come from behind and lead the way in physician gender equity?”⁶⁸ I commented that this specialty might be the dark horse that surprises us all, in part because neurologists are used to solving challenging problems and embracing scientific methodology. I recommended getting 2 houses in equitable order as quickly as possible—neurology medical societies and journals—because these organizational gatekeepers tend to set the tone for a specialty. Further, if the most influential leaders from the 4 gatekeeper groups in neurology convened and each agreed to use the 6-step process outlined in table 1, neurology would be among the first specialties to use an aligned and scientifically driven strategy to accelerate progress for women in medicine. Neurologists need to unite and commit to treating their talented women fairly. When that happens, everyone wins.