Abstract
Bendels MHK, Wanke E, Schöffel N, Bauer J, Quarcoo D, Groneberg DA. Epilepsia 2017;58:1794–1802.
OBJECTIVE: The study aims to elucidate the state of gender equality in epilepsy research, analyzing the representation of female authorships from 2008 to 2016. METHODS: Gendermetrics aided in analyzing 106,282 authorships from 22,180 epilepsy-related original research articles. The key methodology was the combined analysis of the relative frequency and the odds ratio of female authorships. The Prestige Index measures the distribution of prestigious authorships between the two genders. RESULTS: The following were held by women: 39.6% of all authorships and 44.1% of the first, 41.0% of the co-, and 29.0% of the last authorships. Female authors have an odds ratio of 1.25 (95% CI 1.21–1.29) for first, 1.17 (CI 1.14–1.20) for co-, and 0.57 (CI 0.55–0.59) for last authorships. The female authorship ratios showed substantial growth in recent years, with an annual growth rate of 1.7% overall, with 2.4% for first, 1.4% for co-, and 1.9% for last authorships. Women publish fewer articles compared to men (43.8% female authors hold 39.6% of the authorships). Women are also less likely to secure prestigious authorships in articles with many authors that attract the highest citation rates. Multi-author articles with male key authors are cited slightly more frequently than articles with female key authors. Distinct differences at the country level were revealed. The prognosis for the next decade forecasts significantly increasing female odds for first authorships and only slightly higher female odds for last authorships. A female authorship ratio of 49.2% is predicted for the year 2026. SIGNIFICANCE: The integration of women in the scientific field of epilepsy is advanced. However, a dichotomy is present: Although the current system promotes early career steps, there is an apparent lack of female research leaders. This structural imbalance is expected to grow in the next decade due to the consistently high increase of female early career researchers.
Commentary
We are currently living in an era in which gender equality is gaining greater attention in all areas. The winningest coach in the National Collegiate Athletic Association Division One history is the late Pat Summitt (1). The 2017 to 2018 U.S. medical school applicants and matriculants were 50.7% female (2). My 12-year-old daughter's 7th grade slogan is, “If he can do it, why can't she?” This is an unprecedented time of increasing opportunity and equality for women. However, this perceived equality is often lost in academic medicine.
The recent article by Bendels et al. extensively reviewed over 22,000 articles published on epilepsy over 9 years to determine the proportion of female authorships, female authorship odds ratio, and the chance of prestigious authorships (prestige index) on a global level and by country. While female authorships have grown from 36.6% in 2008 to 41.7% in 2016, there is still an underrepresentation of female authorships. Females were more likely to have first authorships than last authorships. This is of particular importance because the most senior author typically fills the position of last author. Furthermore, articles with male first or last author have higher citation rates than those with females in the same roles.
It was concluded that the findings of this study reflect the field of epilepsy research, in which women are more likely to be early career researchers than principal investigators. It was also suggested that, because the prestigious/last authorship role is important for academic career advancement and a sign of leadership, the underrepresentation of women in this role is likely to hinder further career advancement.
The authors’ concerns about career advancement for women in academic medicine are valid. Besselaar and Sandstrom (3) studied the impact of research performance on academic (nonphysician) research careers over time. In the early phase of research careers, there were essentially no gender-related differences. Approximately 10 years later, men had 17% more publications than women. The median academic position for men was associate professor; assistant professor for women. By 13 years, 61% of male researchers, but only 32% of women were associate or full professors (3). Jena et al. (4) reviewed differences in academic rank in U.S. medical schools between men and women in 2014. Similarly, 11.9% of women versus 28.6% of men were full professors. In the article, women had fewer first and last authorships (mean total, 11.6 vs 24.8). They also were less likely to have National Institutes of Health (NIH) funding (6.8% vs 10.3%) or conduct clinical trials (6.4% vs 8.8%) (4).
We must examine why these gender discrepancies exist. Is there truly a bias against women in academic medicine? There may be other factors to consider that might explain this difference in career trajectories.
There may be more men who have been in practice long enough to have earned the role of senior author, conduct more clinical trials, have NIH funding, or achieve the academic rank of professor. This would reassure us that gender differences will improve over time with medical school classes now having equal numbers of women and men graduates. Jena et al. (4) reviewed academic rank across three different graduation cohorts: 1980, 1990, and 2000. Women who were professors increased from 230 in the 1980 cohort to 969 in the 2000 cohort, and women did complete residency more recently. However, when adjusted for age and years since residency, as well as clinical trials and NIH funding, women were still less likely than men to be full professors, 11.9% versus 28.6%, respectively (4). A study of female physicians practicing at Mayo Clinic for a mean of 26.6 years, matched 2:1 with males, men had significantly more publications (mean 75.8 vs 29.5), higher academic rank (66% men vs 28% women full professors), and held a position of leadership (70% men vs 56% women) (5). One could assume these numbers are affected by gender biases from previous decades that no longer exist. However, in the 2000 graduation cohort, there are significantly fewer women full professors than men and significantly fewer men than women who are still at the level of assistant professor (4). Therefore, these findings do not support the theory that the differences senior authorship is solely due to years in practice.
Perhaps these biases are present due to subspecialties with male overrepresentation? Within Neurology, 31.6% of academic faculty in 2014 was female; 13.1% of women versus 35.7% of men were full professors. By comparison, Pediatrics is a subspecialty consisting of a majority of women (58% of pediatricians in 2013). Therefore, one would expect higher numbers of female authors and leaders. However, in 2015, only 20% of the members of the Association of Medical School Pediatric Department Chairs were women (6). Only 11% of female pediatricians were full professors, versus 27% of males. Furthermore, while approximately half of first authors in three high-impact general pediatrics journals were women, only 34.5% of senior authors were.6 This suggests female underrepresentation within a specialty cannot explain the authorship discrepancies.
One possibility that cannot be ignored is that women are intentionally choosing not to author as many papers as men, often due to work-life balance. In the Mayo Clinic cohort, mean annual publications for women increased from 1.54 to 2.72 after 27 years of employment, whereas men decreased from 3.48 to 1.15 (5). Buddeberg-Fischer et al. (7) prospectively surveyed a cohort of physicians every 2 years following graduation and found females were more inclined to work part time, work less often at research institutions, aspire to a career without a senior position, and choose less prestigious medical specialties.
This begets the question of why women would make this choice. In a survey of residents, both men and women said it was difficult to find time to be residents and parents, but only women commented that they did not think they could cope with having children and working full time in medicine (8). In the Buddeberg-Fischer cohort, they noted that female physicians received significantly less mentoring (7). This may be a key. Mentorship has been reported to be important for career guidance and choice, research productivity, and grant success. Unfortunately, women have more difficulty finding mentors than men (9).
Women are entering the field of medicine at rates equal to men. The Mayo Clinic cohort demonstrates that women clearly are capable of publishing at a productive rate. However, why would women choose less prestigious fields and part time work? It is quite possible that they lack the necessary mentorship for success. They lack the mentor-guided networking that leads to groundbreaking research. Put simply, they lack someone who can teach them what my 12-year-old has already learned: “If he can do it, why can't you?”