CONTEMPORARY ISSUES HORIZONS

Understanding and addressing gender equity forwomen in neurologyJulie K Silver MD

Neurologyreg 2019931-12 doi101212WNL0000000000008022

Correspondence

Dr Silver

julie_silver

hmsharvardedu

AbstractDespite the fact that the percentages of women among physicians and neurologists have beenrising gender-related disparities in numerous metrics persist notably in compensation pro-motion funding recognition leadership publishing and speaking Simultaneously womenworking in academia including medicine face high rates of sexual harassment Leaders of allhealth care-related organizations must accept the moral and ethical imperative to expeditiouslyaddress both gender-related discrimination and harassment (inclusive of but not limited tosexual harassment) of women in medicine At this unique time in history there is an oppor-tunity for leaders in neurology to strategically accelerate efforts to address workforce genderdisparities and ensure harassment-free training and work environments Leaders will have toplan an intentional path forward using a systematic process metrics and strategies unique totheir own organizations to overcome barriers to an equitable and safe work environment forwomen Moreover leaders in 4 gatekeeper organizationsmdashmedical schoolsacademic medicalcenters funding agencies journals and medical societiesmdashmust hold each other accountablefor gender equity as their own success and financial return on investment is dependent on theefforts of those in the other categories In short the path forward is to focus on ethical principlesand behavior when it comes to addressing workforce gender disparities for women in medicine

From the Department of Physical Medicine and Rehabilitation Harvard Medical School Spaulding Rehabilitation Hospital Massachusetts General Hospital and Brigham andWomenrsquos Hospital Boston MA

Go to NeurologyorgN for full disclosures Funding information and disclosures deemed relevant by the author if any are provided at the end of the article

Copyright copy 2019 American Academy of Neurology 1

Copyright copy 2019 American Academy of Neurology Unauthorized reproduction of this article is prohibited

Published Ahead of Print on July 31 2019 as 101212WNL0000000000008022

A landmark moment occurred in 2017 when for the firsttime women accounted for more than half (507) of in-coming US medical students1 One might think then thatmedicine with its large proportion of intelligent and highlytrained women physicians and scientists is leading the wayin gender equity Yet it is not In fact in many cases researchshows slow progress2 no progress3 or even regression45 inworkforce gender equity A robust evidence base primarilyreflecting that most gender equity research occurs in aca-demic medicine demonstrates disparities for women incompensation6 promotion7 research funding8 recognitionawards49ndash11 journal editorial board representation512

publishing1314 speaking15ndash17 workplace environments18

and recruitmentretention offers18 Disparities in promotionstart early in womenrsquos careers and the gaps become morepronounced over time For example women account for474 of assistant professors (1308 of 2760) 385 ofassociate professors (474 of 1231) and 208 of professors(297 of 1429) in neurology19 Although the greatest dis-parities for women in the academic track occur at the pro-fessor level including in neurology20 Schor21 found thatamong senior level leadership only 15 of US medicalschool deans were women Even in surgical specialties thelow number of women at the highest levels is inconsistentwith the available pipeline and Dr Keith Lillemoe stated thefollowing in his 2017 presidential address to the AmericanSurgical Association ldquoThe number of outstanding qualifiedfemale candidates is more than adequate to fill every opensurgical leadership position in America today The problemis not the pipelinemdashit is the processrdquo22

Despite the disparities Carr et al23 found that 40 of the aca-demic institutions they studied had no programs for recruitingpromoting or retaining women (frequently describing suchprogramming as unnecessary) Indeed structural and in-stitutional bias are increasingly recognized as factors in genderdisparities while conventional reasons such as lack of qualifiedwomen (insufficient or leaky pipeline) are being refuted91324

However midcareer and senior women in medicine includingbut not limited to those in neurology have faced years of implicit(unconscious) bias which at times rose to the level of explicit(conscious) biasmdashslowing their career growth causing them tobe overlooked for well-deserved recognition and promotions andmaking them uncomfortable and even unsafe in their workplacesImportantly although this report is focused primarily on womenphysicians and researchers there is no doubt that it is imperativeto address inclusion and safety for every worker student andpatientmdashacross gender ethnic racial sexual orientation abilitylevel and other factors that may make them vulnerable to mis-treatment such as bullying harassment bias or discrimination

The inequity spectrumResearch on gender disparities demonstrates a spectrumof inequities that range from microinequities to macro-inequities25 with the latter having easily identifiable andquantifiable metrics (eg compensation or promotion)While studies of microinequities are frequently quantitativeand report data the metrics used are often unique andsometimes quite creative For example one microinequitystudy demonstrated via video recordings of Grand Roundsspeaker introductions that when compared with men wom-enrsquos professional titles were used less frequently17 In a studyassessing the representation of men and women physicians(and information about their work) in newsletters publishedby the American Academy of Physical Medicine and Re-habilitation over a period of more than 5 years my colleaguesand I found that while men were always included womenwere completely excluded from more than one-third of thenewsletters26 In another study we found that women wererepresented at lower than expected levels among authors ofperspective-type articles published in the 4 highest-impactpediatric journals13 These types of studies have added toa growing body of evidence demonstrating how women areoften subtly marginalized silenced or made invisible Thebuilding of onersquos professional reputation is both vital andnuanced27 and the cumulative effect of many subtle slightsmay have a more pronounced effect on womenrsquos careers thanpreviously recognized

Gender bias and sexual harassmentGender bias and disparities likely provide fertile ground forsexual harassment and it is clear that medicine has a seriousproblem with these issues The landmark report from theNational Academies of Science Engineering and Medicine(NASEM) titled Sexual Harassment of Women Climate Cul-ture and Consequences in Academic Sciences Engineering andMedicine stated that ldquogender discrimination itself harmswomen and the broader meritocracy of science And thus weconclude that together gender discrimination and maledomination are features of the academic science engineeringandmedicine climate that create a permissive environment forsexual harassmentrdquo28 The report describes the normalizationof gender-related harassment (including but not limited tosexual harassment) in medicine and sheds light on the currentliterature Relevantly the true incidence and prevalence islikely underestimated for a variety of reasons (eg under-reporting by those affected reluctance to label offendingdemeaning or intrusive behavior as harassment or failure tofollow good research practices) As the report explains large

GlossaryAAN = American Academy of Neurology CV = curriculum vitae NASEM = National Academies of Science Engineering andMedicine ROI = return on investment

2 Neurology | Volume 93 Number | Month 2019 NeurologyorgN

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proportions (and in some studies the majority) of women inacademia in general inclusive of health care training environ-ments such as medical schools and academic medical centersare targets For example surveys of 2 large institutions revealedthat 45 to nearly 50 of womenmedical student respondentshad experienced incidents of facultystaff-on-student sexisthostility28 Moreover women medical student respondentswere more likely to have experienced facultystaff-on-studentsexist hostility than their same-institutional-system peers inundergraduate graduate nonndashscience-engineering-medicinescience and engineering studies28 Importantly it is becomingincreasingly clear that in some instances medical schools andother health care organizations have one or more serial har-assers who have continued their behavior over the course ofmany years and affected many targets (generally women butmen and others across the gender spectrum as well)Bystanders who have witnessed or heard about this behavioralso may have been negatively affected (figure 1) Althoughthe vast majority of men in medicine are professional andrespectful of those with whom they interact and there is noevidence to suggest that most men are guilty of harassmentauthors of the NASEM report concluded that ldquoEnviron-ments where men outnumber women leadership is maledominated andor jobs or occupations are consideredatypical for women have more frequent incidents of sexualharassment for womenldquo28 Therefore likely a small group ofpeople primarily though not exclusively men who are toooften serial harassers or predators are poisoning medicinersquoslearning and working environments

The key to changing the normalization of sexual harassmentthen is to recognize that health care leadersrsquo actions aimed at

ridding their institutions of toxic behavior exhibited bya proportionally small group of people will determine whathappens in the future to a much larger group of people Forexample a few months following the release of theNASEM report NIH Director Francis Collins acknowl-edged that sexual harassment is ldquomorally indefensible itrsquosunacceptable and it presents a major obstacle that iskeeping women from achieving their rightful place in sci-encerdquo29 He went further to issue a formal apology statingldquoTo all those who have endured these experiences we aresorry that it has taken so long to acknowledge and addressthe climate and culture that has caused such harmrdquo29 Fi-nally he acknowledged ldquoWe are concerned that NIH hasbeen part of the problem [and] we are determined to be-come part of the solutionrdquo29 In response the NIHlaunched a website with new resources and policies aimedat reducing sexual harassment in academic medicine30

Similarly Timersquos Up Healthcare launched in early 2019 asa not-for-profit affiliate of the Timersquos Up organizationformed in response to the MeToo movement and focusedon ensuring an equitable and safe environment foreveryone31

Whatever form they take the evidence demands that bothgender discrimination and sexual harassment which areoverwhelmingly directed at women must be recognized bythe medical and scientific community as morally indefensibleand unethical

1 Discrimination is antithetical to the tenets of pro-fessionalism in medicine32

2 Gender discrimination itself harms women and supportsorganizational environments in which sexual harassmenthas been normalized28

3 Sexual harassment itself is a form of discrimination28

4 Academia has a high prevalence of sexual harassment28

5 ldquoBy far the greatest predictors of the occurrence of sexualharassment are organizationalrdquo28

6 Gender equity is a moral imperative33

Therefore we must conclude that leaders of all health carendashrelated organizations have a moral and ethical imperative toexpeditiously address both gender discrimination and sexualharassment of women in medicine

Gender-related disparities for womenphysicians in neurologyThe evidence base regarding disparities for women inneurologymdashwhere women constitute approximately 45 oftrainees34 30 of neurologists in practice35 and 40 of facultyin academic medicine19mdashis growing and issues identified in-clude compensation6 academic promotion720 leadership3637

recognition awards given by the American Academy of Neu-rology (AAN)1016 journal editorial board representation512

and publishing20

Figure 1 Sexual harassment in medicine

This graphic is inclusive of all genders and is intended to show that theproportion of serial harassers or predators (which is unknown) is a muchsmaller group compared to targets and bystanders

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Physician compensationThere is a spectrum of inequities that range from micro-inequities to macroinequities25 but there is no doubt thatcompensation is among the most important A growingbody of published research and national surveys fromDoximity Medscape and specialty societies collectivelyand undeniably demonstrate that disparities in compensa-tion for women in medicine often exist even after ac-counting for variables such as part-time employment anddifferences in productivity For example in a study by Jenaet al6 looking at gender-related differences in academicphysician salary in 24 US public medical schools across 12states (n = 10241 physicians 3549 women) researchersfound that men in neurology (n = 307) were paid an av-erage of $30482 (95 confidence interval $9731 to$51592) more than women annually (n = 142) even afteradjusting for gender age years of experience faculty rankscientific authorship NIH funding clinical trial participa-tion and Medicare reimbursements From these dataresearchers estimated that women academic neurologistswere making approximately 85 cents for every dollar or85 of the adjusted salaries paid to colleagues who weremen638

While limitations are applicable to any research including theJena et al6 study I found it interesting to consider how com-pensation in neurology was ranked among the 18 differentsurgical and nonsurgical specialties included in the reportAmong the 36 groups of men or women across 18 specialtieswomen in neurology were ranked lastmdashearning the leastamount annually compared to all of the others (figure 2) Mycomparison of same-specialty gender-related adjusted salariesrevealed that the largest gap for women when compared withmen among the 18 specialties was in neurology (15 rangeminus08 to 15)6 Furthermore women in neurology had thelargest gap in salary as a percentage of same-gender specialty-related adjusted salary (figure 3 177 range minus08 to 177)

To demonstrate the profound negative consequences this kind ofpay disparity can have over the course of a woman neurologistrsquoscareer I utilized a set of publicly available online financial mod-eling tools I found that if a woman received an additional $30482in salary each year after 40 years of investing andwith adjustmentfor inflation she would have a net return of $2507647 (figure4)39ndash41 Arguably this is a conservative analysis not taking intoaccount that her return on investment (ROI) may be negativelyaffected by the possibilities that (1) at the beginning of her careershe could be paying a higher proportion of her salary toward debtand the money she owed may have been associated with aninterest rate higher than the historical rate of return and (2) asher career progressed her rate of promotion may be slower andto a lower level overall (never reaching the highest levels) thanher colleagues who are men Although readers may take issuewith elements of this example no one should miss the mainpoint disparities in pay can generate a huge deficit in a personrsquosfinancial standing over the course of a career

Leadership academic promotionand publishingWomen neurologists also have been underrepresented in lead-ership positions and academic promotion particularly to pro-fessor level in neurology5193637 Disparities in representation oneditorial boards especially at the highest levels is also a pervasiveproblem in neurology as well as other specialties5 Lack of equi-table representation on journal editorial boards is itself a gender-related disparity and it may also contribute to other disparitiesincluding those in publications grant funding academic pro-motion leadership positions and compensation134243 Howevereditorial board disparities have been shown to be relatively simpleand inexpensive to fix and a number of journals including somewith high impact factors have done so44 A comment publishedby editors at The Lancet stated the following

We have been involved in and support efforts to expand the adoption ofthe Sex and Gender Equity in Research (SAGER) Guidelines thataddress the inclusion of sex and gender analysis in research contentComplementary guidelines are under development (SAGER II) toprovide a framework for publishers and journals to strive for genderbalance in their workforce The academic publishing community mustrecognise that it is not immune to sexism and gender bias Now is the timeto take decisive action to challenge the status quo44

Importantly the journal Neurologyreg is currently addressingdisparities on its editorial board in an effort to be more diverseand inclusive45

When my colleagues and I studied the largest or most in-fluential professional societies associated with 39 differentspecialties we found that during the most recent decade(2008ndash2017) 10 societies (26) including the AAN had0 years with a woman as president37 Among these 10 socie-ties the AANwas associated with the third highest proportionof women in the specialty (28) The 2 societies associatedwith higher proportions of women in the field than neurologywere dermatology (47) and pathology (37) The 7remaining societies with 0 years with a woman as presidentwere associated with specialties having much lower pro-portions of women in the field (5ndash18) including 5 surgicalspecialties Notably 15 specialty societies associated withlower percentages of women in the field than neurology(lt28 and including 7 surgical specialties) had more yearswith a woman as president (1ndash4 years) than the AAN

In the 71-year history of the AAN there has been only 1 womanpresident Sandra Olson MD (2001ndash2003) and thereafter nowoman led the AAN for 2 decades In the future Orly AvitzurMD MBA is slated to be the second AAN president who isfemale (2021ndash2023) Given the growth of women in neurologyand among members of the AAN if history repeats itself and DrAvitzur is the sole woman president of the society during the nextcouple of decades women would continue not only to be in-equitably represented among presidents but metrics woulddemonstrate a regression in progress toward gender equity inleadership

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This example demonstrates a serious issue in gender equityresearchmdashthere is a difference between celebrating a womanrsquosaccomplishments (Drs Olsonrsquos and Avitzurrsquos elections) andsuggesting that these accomplishments represent organiza-tional progress in gender equity46 Instead to avoid under-mining real progress in gender equity as well as identify andaddress gaps we must use scientific methodology along witha comprehensive set of metrics and longitudinal data analysisto confirm conclusions For example membership data fromthe AANrsquos 2019 Insights Report (personal communicationOrly Avitzur MD MBA) reveals that the percentage ofwomen members has been increasing and in 2018 nearly 40of all members and 50 of junior members (ie physicians inneurology training programs or postdoctoral fellows in re-search training programs) were women Therefore a reason-able target for equitable presidential representation at theAAN over the next 2 decades would be approximately40ndash50mdashor 8ndash10 of 20 years or 4ndash5 of the ten 2-year

terms However to achieve equitable presidential leader-ship at the AAN the societyrsquos leaders and members willneed to analyze and address its culture and processes Asa medical ethicist stated ldquoLeaders establish and maintain anorganizationrsquos moral culture leading to implicit and explicitbehavioral normshellipThe ethical response is to systemati-cally promote women and diverse people into leadershippositionsrdquo33

Knowing that some people might assume women do not wantto run for or hold elected leadership positions Shillcutt et al47

published a follow-up survey study of more than 1200 womenphysicians inquiring about their experience and interest inelected positions We found that 438 (n = 535) ranfor office during high school and medical school comparedwith 167 (n = 204) thereafter47 However the majorityof women surveyed (nearly 60) reported that theywould consider running for office at their workplace and

Figure 2 Rank of academic physiciansrsquo salary by specialty and gender

To examine the rank of academic physiciansrsquo salary by spe-cialty and gender the adjusted salaries of men and womenpracticing in 18 specialties at 24 USmedical schools across 12states as determined by Jena et al6 were sorted from largestto smallest Women physicians in neurology were ranked 36of 36 and 8 steps below men physicians in neurology (+)Adjustments included those for gender age years of ex-perience faculty rank scientific authorship NIH fundingclinical trial participation and Medicare reimbursements

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approximately 50 would run for office in their medical societyin the future In addition to reporting a loss of family time asa barrier respondents noted that lack of encouragement by theirboss or supervisor was a major obstacle They also stated thatmentorship and gaining further experience would be helpful

Recognition awardsIn previous work my colleagues and I also explained thepower of zeromdashciting how an ldquoinexorable zerordquo (a true zeroor near zero level) often has been used by US courts as a primafacie inference of discrimination Using recognition awards as

a metric we showed that inexorable zeroes existed for womenamong recipients of recognition awards in 7 medical spe-cialties including neurology and in 14 different medical so-cieties including the AAN and the American NeurologicalAssociation16 Subsequently we studied recipients from theAAN further concluding the following

Although it has been more than 2 decades since the proportion of womenamong US neurologist members of the AAN was lower than 18 1 in 4AAN award categories demonstrated 0ndash18 representation of womenamong physician recipients during the most recent decade10

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

To examine the rank of women academic physi-ciansrsquo salary gap by specialty the differences be-tween adjusted salaries of men and womenpracticing in 18 specialties at 24 US medicalschools across 12 states as determined by Jenaet al6 were normalized by dividing the differencesby the respective adjusted salaries for women ac-ademic physicians in the field Among 18 special-ties women in neurology were ranked no 1 andface the largest normalized salary gap as per-centage of income Salary adjustments includedthose for gender age years of experience facultyrank scientific authorship NIH funding clinicaltrial participation and Medicare reimbursements

Figure 4 Consequences of salary gap on a woman academic physicianrsquos personal investment income

Using a set of publicly available online financialmodeling tools3940 I examined the consequencesof salary disparities on long-term income I startedwith the assumption that a woman received anadditional $30482 in salary each year that is thedollar amount that would negate the salary gapJena et al6 identified for women in neurologyUsing the 2018 marginal tax rate for a single orseparately filing taxpayer with a $200000 income(329)39 I calculated that this womanwould have$20453 of additional income available after taxesannually After a 3adjustment for inflation and intodayrsquos dollars over 40 years she would haveearned an additional $479036 of income40 If sheinvested that gap-related additional income ina balancedmixed portfolio of 60 bonds and 40stocks with a historical (1926ndash2017) average an-nual compounded investment return of 7841

after a 3 adjustment for inflation and in todayrsquosdollars over 40 years she would have accumu-lated $1395060 of pre-tax investment incomeand booked a net return of $250764740

6 Neurology | Volume 93 Number | Month 2019 NeurologyorgN

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In a letter to the editor published in Neurology regarding ourstudy of AAN recognition awards one reader attributed thedisparities to childbearing48 even though we pointed out thata lack of qualified women neurologists was likely not an issueas there was a sufficiently large and documented pool of highlyaccomplished candidates at the professor and associate pro-fessor levels49 Indeed causality is multifactorial and not well-understood however in one study in which we analyzednomination data we found that women were nominated fortraining and early career awards but were not selected by thecommittee as recipients while no women were nominated forprestigious later career awards46

Physician burnout and gender disparitiesPhysician burnout is a crisis issue among all specialtiesHowever neurology has been ranked among the top spe-cialties at risk for burnout50ndash52 and risk is likely more pro-nounced in women53 Admittedly there is a need for moreresearch on how bias and discrimination affect symptoms ofburnout nevertheless it is logical to conclude that treatingworkers unfairly almost certainly influences how they feelabout their job After all because promotions tend to increaseautonomy and a sense of control slow or stalled career ad-vancement may increase the risk of burnout Similarlymaintaining a sense of personal accomplishment (a risk factorfor burnout) may be more challenging for women if they arenot fairly compensated and valued by others

Men and the collateral consequencesof gender disparities inacademic medicineTo drive change one must not only understand the variousperspectives of those directly affected but also the perspectivesof those who bear witness to what is happening For examplea man who is in mid or late career is far more likely thana woman at the same stage to have personally benefited from orat least felt supported by an inequitable recognition rewardand career advancement system However because thesemetrics do not tell the whole story we might wonder whethermen have truly been as fortunate as the data suggest Moralpeople must certainly feel a heavy emotional toll when they areparticipating in working in or witnessing an unjust system inwhich women are systematically mistreated As the NASEMreport points out sexual harassment negatively affects not onlytargets but also bystanders who are witness to the mis-treatment28 Therefore even men who have enjoyed the ben-efits of privilege may be paying an emotional price in the formof moral distress or burnout symptoms if their success is due inpart to the systematic oppression of women

Interestingly men were undercompensated in one of thespecialties examined by Jena et al6mdashradiologymdasheven afteraccounting for variables that could affect income RecentlyGoogle began examining its compensation data as well and

found that in some cases men were being underpaid whencompared with women54 Thus men too are at risk of losingmillions of dollars over time due to compensation inequitiesMoreover this risk may increase if women who ascend toleadership positions adopt the practices of current leaders thatfavor same-gender compensation outcomes Therefore it is ineveryonersquos best interestmdashincluding menmdashto use an impartialand scientifically driven approach to compensation thatensures that all workers regardless of gender are paid fairly

Gatekeepers and the collateralconsequences of gender disparities inacademic medicineCareer advancement in academic medicine may involve var-ious types of promotion and advancement from instructor toprofessor relies on several factors that a promotions com-mittee must consider Many of these are reported in thecurriculum vitae (CV)mdasha formulaic document that has sec-tions for grant funding publications recognition awardscommittee assignments and leadership positions16 More-over the number of publications as well as their impact(ie bibliometrics such as number of citations and Hirschindex) are part of the analysis5556 Therefore although thepromotions committee resides at the faculty memberrsquos homeinstitution gender bias or disparities occurring at the level offunding agencies journals and medical societies may severelylimit a womanrsquos ability to be promoted While many medicalinstitutions are making large financial investments in im-proving diversity and gender equity none of these invest-ments will be fully realized if barriers to womenrsquos success areimposed by any of 4 gatekeepers who affect an academicianrsquosCV (1) medical schoolsacademic medical centers them-selves (2) funding agencies (3) journals and (4) medicalsocieties Importantly if any of the gatekeepers does not treatwomen fairly then the success of efforts (and financialinvestments) that the others make in driving and achievingdiversity and gender equity will be reduced and ROIs remainunrealized (figure 5)

For example in a recent study published in JAMA by Oliveiraet al8 among first-time Principal Investigator NIH grantawardees across all grant types and institutions women re-ceived a median award $39106 less than men ($126615 vs$165721 respectively) At Big Ten and Ivy League univer-sities where some of the most talented scientists are workingdisparities for women amounted to a median difference infunding when compared with men of $81711 and $19513respectively These deeply troubling findings highlight thenegative consequences of gender disparities on (1) womenresearchersrsquo ability to obtain grant funding to advance theircareers (2) institutional ROImdashoften astronomical and in-calculable financial and human resource investments made bythe home institutions in the recruitment retention and suc-cess of a large proportion of their scientific workforce1857ndash59

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and (3) advancement of the science and medicine women areinvestigating In addition disparities in NIH funding of thisnature likely reduce the success of administrative efforts oftop-level leaders (ie deans and chairs who are mostly men)to support a diverse scientific workforce at the researchersrsquohome institutions Because gatekeepers are interdependenteven the careers of men at the highest levels of academicmedicine may be negatively affected when one or more of theother gatekeepers treats women inequitably

Similarly if journals or medical societies demonstrate biasagainst women in academic medicinemdashnegatively affecting

their ability to publish present or be recognized for theirwork through recognition awards plenary or other lecturesand newsletter articlesmdashthen financial and other negativeconsequences may extend far beyond the women who aremost directly affected to their home institutions and fundingagencies Medical schools and academic medical centers toomay be inadvertently undermining the investments that otherorganizations are making For instance the AAN has investedfinancial and other resources in the Women Leading inNeurology program If women neurologists who have com-mitted their time have lost clinical compensation or haveself-funded their participation are not provided equitable

Figure 5 Consequences of gender bias on return on investment

Even if a gatekeepermdashan institutionwhose environment or actions di-rectly affect the careers of physiciansand scientists particularly in aca-demicmedicinemdashmakes investmentsin diversity by hiring funding andsupporting women the gatekeeperrsquosreturn on investment may be nega-tively affected if any of the other3 gatekeepers fail to treat themequitably The icons used in figure 5were found via Bing search throughMicrosoft Wordrsquos insert online pic-ture function designed by unknownauthors and inserted unchangedexcept for colorways under Crea-tive Commons licensing (crea-tivecommonsorglicensesby30)

8 Neurology | Volume 93 Number | Month 2019 NeurologyorgN

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opportunities for advancement in their workplace the AANrsquosROI of financial administrative and human resources is re-duced as well Treating women in medicine unfairly hurtseveryonemdashobstructing women who seek career advance-ment impeding their leaders (mostly men) who are chargedwith improving diversity and inclusion and causing unrealizedROI for many organizations (institutions funding agenciesjournals and societies) in the health care system

Driving gender equity inacademic medicineThe best way to accelerate gender equity for women in aca-demic medicine is for all of the gatekeepers to hold each otheraccountable This means that they must turn away from leaderswho are supporting the status quo or the normalization ofgender discrimination and sexual harassment and toward eth-ical leaders who are committed to organizational culture andclimate change In 2018 I developed the Be Ethical Cam-paign60 to encourage leaders in the key gatekeeper groups touse a 6-step process (table 1) and a comprehensive set ofunique and customizablemetrics with longitudinal data analysisto uncover address and accelerate workforce gender equityincluding the removal of bias discrimination and harassmentAvoiding critical thinking errors during this process is crucialbecause they are pervasive in gender equity discussions andtend to slow or derail efforts (table 2)60

Importantly every medical specialty including neurology needsto examine its own history particularly over the last 2 decades asthis is the timeframe most relevant to the majority of womenwho are in the specialty currently and interventions enacted nowwill affect their career trajectory for the coming years Whatmight an ethical path forward in neurology look like for mid-career US women neurologists who have been represented atmarkedly disproportionate levels as professors departmentchairs medical society presidents recognition award recipients

and senior editors of neurology journals and who have not re-ceived equitable compensation or research funding If the situ-ation was reversed and over the last 2 decades a large body ofevidence showed that men were not fairly compensated pro-moted or recognized and they were often ignored and silencedwhat would todayrsquos leaders do now to address this

Many organizations have been increasing their efforts to ad-dress gender equity inclusion and safety and while a com-plete list is beyond the scope of this report some examplesinclude the following Association of American MedicalCollegesrsquo ldquoPromising Practices for Understanding andAddressing Salary Equity at USMedical Schoolsrdquo61 AmericanCollege of Physiciansrsquo ldquoAchieving Gender Equity in PhysicianCompensation and Career Advancementrdquo62 Association ofWomen Surgeonsrsquo ldquoStrategies for Identifying and Closing theGender Salary Gap in Surgeryrdquo63 American Surgical Associ-ationrsquos ldquoEnsuring Equity Diversity and Inclusion in AcademicSurgeryrdquo6465 and the American Medical Womenrsquos Associa-tionrsquos ldquoRevolution by Resolutionrdquo66 Moreover professionalsocieties and other organizations are launching initiativesaimed at working together and sharing resources and bestpractices For example the American Academy of PediatricsAmerican Academy of Family Physicians American Collegeof Physicians American College of Obstetricians and Gyne-cologists American Psychiatric Association and AmericanHospital Association recently launched ldquoWomenrsquos Wellnessthrough Equity and Leadershiprdquo67 which will train a cohort ofhealth care professionals in critical leadership skills and de-velop principles regarding healthy work environments forphysicians

Recently neurologists have been focusing on their own cultureof diversity and inclusion including but not limited to equityfor women neurologists and both formal and informal ini-tiatives and networks are supporting this work Table 3 listssome important initiatives by neurology organizations in-cluding the AANrsquos Womenrsquos Leadership Program which arefocused on closing leadership gaps and addressing other dis-parities for women in neurology Still the field has somecatching up to do and ldquorecent data in neurology show that welag behind the rest of medicine with continued gender dis-paritiesrdquo38 In an editorial I wrote titled ldquoCan neurologists comefrom behind and lead the way in physician gender equityrdquo68 Icommented that this specialty might be the dark horse thatsurprises us all in part because neurologists are used to solvingchallenging problems and embracing scientific methodology Irecommended getting 2 houses in equitable order as quickly aspossiblemdashneurology medical societies and journalsmdashbecausethese organizational gatekeepers tend to set the tone fora specialty Further if the most influential leaders from the 4gatekeeper groups in neurology convened and each agreed touse the 6-step process outlined in table 1 neurology would beamong the first specialties to use an aligned and scientificallydriven strategy to accelerate progress for women in medicineNeurologists need to unite and commit to treating their tal-ented women fairly When that happens everyone wins

Table 1 Systematic 6-step process toward achievingorganizational gender equitya

Step Action

1 Examine gender data through the lens of an organizationrsquosmissionvalues and ethical code of conduct

2 Report the results transparently to all stakeholders

3 Investigate causes of disparities

4 Implement strategies to address disparities

5 Track outcomes and adjust strategies as needed

6 Reportpublish results

Health care institutions and affiliated organizations must take a systematicapproach to addressing gender disparities that involves unique and cus-tomized but defined metrics and transparent reporting to allstakeholders60a Table reproduced with permission from the Be Ethical Campaign report

NeurologyorgN Neurology | Volume 93 Number | Month 2019 9

Copyright copy 2019 American Academy of Neurology Unauthorized reproduction of this article is prohibited

DiscussionAt this unique time in history there is an opportunity for leadersin neurology to strategically and expeditiously address itsworkforce gender disparities To do so there will need to bea concerted effort among the 4 gatekeeper organizations (1)medical schoolsacademicmedical centers (2) government andother funding agencies (3) neurology journals and (4) neu-rology professional societies Leaders will have to plan an in-tentional path forward and in their own organizationsovercome barriers to an equitable and safe work environmentfor women Moreover leaders in all 4 types of organizationsmust hold each other accountable for gender equity as their ownsuccess and financial ROI is dependent on the efforts of those inthe other categories In short the path forward is to focus onethical principles and behavior when it comes to addressingworkforce gender disparities for women in medicine

Author contributionsJK Silver draftingrevising the manuscript data acquisitionstudy concept or design analysis or interpretation of dataaccepts responsibility for conduct of research and final ap-proval acquisition of data statistical analysis

AcknowledgmentThe author thanks Orly Avitzur MD MBA FAAN AANPresident-Elect nominee Divya Singhal MD KathrinLaFaver MD FAAN and Amy Nostdahl Senior Managerfor Leadership Development at the AAN for providinginformation about various initiatives that support women inneurology and Julie Poorman PhD for her assistance withmanuscript preparation The icons used in figure 5 were foundvia Bing search through Microsoft Wordrsquos insert onlinepicture function designed by unknown authors and insertedunchanged except for colorways under Creative Commonslicensing (creativecommonsorglicensesby30)

Study fundingNo targeted funding reported

DisclosureJK Silver has personally funded the Be Ethical Campaignand proceeds from the campaign support disparities re-search As an academic physician J K Silver has publishedbooks and receives royalties from book publishers and shegives professional talks such as grand rounds and medicalconference plenary lectures and receives honoraria fromconference organizers JK Silver has grant funding from

Table 2 Critical thinking errors related to gender equity25

Critical thinking error Example

Perpetuating myths Leaders and colleagues thinking that there are not enough qualified women to fill positionsparticularly leadership positions

Holding the affected group responsible for theproblem

Leaders and colleagues blaming women for gender-related disparities in compensationpromotion and publishing and expecting women to fix the disparities themselves

Preserving willful ignorance about the problem Failure of institutional and organizational leaders and colleagues to read understand andrespond in a timely manner to the growing evidence-based gender disparity literature

Presuming that the affected group should conformto the establishment culture

Leaders and colleagues failing to understand that outdated organizational processes criteria andrulesmdashsuch as but not limited to hiring and admission practices and evaluation and promotionstandardsmdashmay not support equitable inclusion of a diverse workforce

Table 3 Organizational initiatives for women in neurologya

Sponsor Initiative Description and purpose

AAN Leadership for WomenSubcommittee

Subcommittee of the Leadership Development Committee responsible for the followingbull Development and implementation of the Women Leading in Neurology Programbull Implementation of additional annual meeting and regional programming focusing on women in leadership

Women Leading inNeurology Program

A 1-year midcareer leadership training program for up to 12 women neurologists requiring the followingbull Participants to attend leadership retreats coaching calls and small group callsbull The AAN to cover all program-related expenses for the selected participants

Womenrsquos Issues inNeurology Section

Section of the AAN with nearly 800 members focused on the followingbull Integrating sex and gender into neurology researchbull Supporting women neurologistsrsquo careers through activities such as mentorship network speakernominations committee membership and FAAN applications

Independent Womenrsquos Neurology Group Facebook group of more than 2500 members that provides an online community through which womenneurologists can share professional information and expand their professional network

Abbreviations AAN = American Academy of Neurology FAAN = Fellow of the American Academy of Neurologya This is not intended to be a complete list

10 Neurology | Volume 93 Number | Month 2019 NeurologyorgN

Copyright copy 2019 American Academy of Neurology Unauthorized reproduction of this article is prohibited

The Arnold P Gold Foundation (physician and patient caredisparities research) and Binational Scientific Foundation(culinary telemedicine research) Go to NeurologyorgNfor full disclosures

Publication historyReceived by Neurology March 27 2019 Accepted in final formJune 12 2019

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2 Helitzer DL Newbill SL Cardinali G Morahan PS Chang S Magrane D Changingthe culture of academic medicine critical mass or critical actors J Womens Health201726540ndash548

3 Bickel J Women in medicine evidence that more evidence is insufficient in effectingimprovements Acad Med 201792274

4 Silver JK Blauwet CA Bhatnagar S et al Women physicians are underrepresented inrecognition awards from the Association of Academic Physiatrists Am J Phys MedRehabil 20189734ndash40

5 Amrein K Langmann A Fahrleitner-Pammer A Pieber TR Zollner-Schwetz IWomen underrepresented on editorial boards of 60 major medical journals GendMed 20118378ndash387

6 Jena AB Olenski AR Blumenthal DM Sex differences in physician salary in US publicmedical schools JAMA Intern Med 20161761294ndash1304

7 Jena AB Khullar D Ho O Olenski AR Blumenthal DM Sex differences in academicrank in US medical schools in 2014 JAMA 20153141149ndash1158

8 Oliveira DFM Ma Y Woodruff TK Uzzi B Comparison of National Institutes ofHealth grant amounts to first-time male and female principal investigators JAMA2019321898ndash900

9 Silver JK Bhatnagar S Blauwet CA et al Female physicians are underrepresented inrecognition awards from the American Academy of Physical Medicine and Re-habilitation PM R 20179976ndash984

10 Silver JK Bank AM Slocum CS et al Women physicians underrepresented inAmerican Academy of Neurology recognition awards Neurology 201891e603ndashe614

11 Ellinas EH Rebello E Chandrabose RK Shillcutt SK Hernandez M Silver JK Dis-tinguished service awards in anesthesiology specialty societies analysis of genderdifferences Anesth Analg Epub 2019 Mar 17

12 Kennedy BL Lin Y Dickstein LJ Women on the editorial boards of major journalsAcad Med 200176849ndash851

13 Silver JK Poorman JA Reilly JM Spector ND Goldstein R Zafonte RD Assessmentof women physicians among authors of perspective-type articles published in high-impact pediatric journals JAMA Netw Open 20181e180802

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15 Boiko JR Anderson AJM Gordon RA Representation of women among academicGrand Rounds speakers JAMA Intern Med 2017177722ndash724

16 Silver JK Slocum CS Bank AM et al Where are the women The un-derrepresentation of women physicians among recognition award recipients frommedical specialty societies PM R 20179804ndash815

17 Files JA Mayer AP Ko MG et al Speaker introductions at internal medicine GrandRounds forms of address reveal gender bias J Womens Health 201726413ndash419

18 Martinez LR OrsquoBrien KR HeblMR Fleeing the ivory tower gender differences in theturnover experiences of women faculty J Womens Health 201726580ndash586

19 Association of American Medical Colleges Table 13 US medical school faculty bysex rank and department 2018 Available at aamcorgdownload495048data18table13pdf Published 2019 Accessed March 13 2019

20 McDermott M Gelb DJ Wilson K Pawloski JF Shelgikar AV London ZN Sexdifferences in academic rank and publication rate at top-ranked US neurology pro-grams JAMA Neurol 201875956ndash961

21 Schor NF The decanal divide women in decanal roles at US medical schools AcadMed 201893237ndash240

22 Lillemoe KD Surgical mentorship a great tradition but can we do better for the nextgeneration Ann Surg 2017266401ndash410

23 Carr PL Gunn C Raj A Kaplan S Freund KM Recruitment promotion and re-tention of women in academic medicine how institutions are addressing genderdisparities Womens Health Issues 201727374ndash381

24 Carnes M Morrissey C Geller SE Womenrsquos health and womenrsquos leadership in aca-demic medicine hitting the same glass ceiling JWomensHealth 2008171453ndash1462

25 Silver JK Rowe M Sinha MS Molinares DM Spector ND Mukherjee D Micro-inequities in medicine PM R 2018101106ndash1114

26 Silver JK Reilly JM Gallegos-Kearin V Poorman JA Bhatnagar S Zafonte R Womenphysicians are often not visible in newsletters published by the American Academy ofPhysical Medicine and Rehabilitation Paper presented at the Annual Assembly ofAmerican Academy of Physical Medicine and Rehabilitation October 25ndash28 2018Orlando FL

27 Woolston C Recognition build a reputation Nature 2015521113ndash11528 National Academies of Sciences Engineering and Medicine Sexual Harass-

ment of Women Climate Culture and Consequences in Academic SciencesEngineering and Medicine Washington DC The National Academies Press2018

29 Collins FS Tabak LA Wolinetz CD et al Update on NIHrsquos efforts to address sexualharassment in science National Institutes of Health Available at nihgovabout-nihwho-we-arenih-directorstatementsupdate-nihs-efforts-address-sexual-harassment-science Published 2019 Accessed March 14 2019

30 National Institutes of Health Anti-sexual harassment Available at nihgovanti-sexual-harassment Published 2018 Accessed March 12 2019

31 Thielking M Timersquos Up sets its sights on gender bias and harassment in health careSTAT Available at statnewscom20190228times-up-health-care-bias-harass-ment Published 2019 Accessed March 13 2019

32 American College of Physicians ACP Ethics Manual 6th ed 2012 Available atacponlineorgclinical-informationethics-and-professionalismacp-ethics-manual-sixth-editionacp-ethics-manual-sixth-edition Accessed February 22 2019

33 Burgart AM Physician sexual assault the moral imperative for gender equity inmedicine Am J Bioeth 2019194ndash6

34 Association of American Medical Colleges Table 22 Number and percentage ofACGME residents and fellows by sex and specialty 2017 Available at aamcorgdataworkforcereports4925762-2-charthtml Published 2018 Accessed March25 2019

35 Association of American Medical Colleges Table 13 Number and percentage ofactive physicians by sex and specialty 2017 Available at aamcorgdataworkforcereports4925601-3-charthtml Published 2017 Accessed March 13 2019

36 Cordonnier C Coutts SB Johnston KC Rost NS Crucial role of womenrsquos leadershipin academic stroke medicine Stroke 201950e149ndashe152

37 Silver JK Ghalib R Poorman JA Al-Assi S Bhargava H Shillcutt SK Analysis ofgender equity in leadership of physician-focused medical specialty societies 2008-2017 JAMA Intern Med Epub 2019 Jan 7

38 Graves JS Brashear A Gender bias in American Academy of Neurology recognitionawards Neurology 201891291ndash292

39 KJE Computer Solutions Inc Marginal tax rate calculator for 2018 Available atdinkytownnetjavamarginal-tax-rate-calculatorhtml Accessed March 20 2019

40 KJE Computer Solutions Inc Investment returns Available at dinkytownnetjavainvestment-returnshtml Accessed March 20 2019

41 The Vanguard Group Vanguard portfolio allocation models Available at personalvanguardcomusinsightssaving-investingmodel-portfolio-allocationslang=enAccessed March 19 2019

42 Silver JK Gender equity on journal editorial boards Lancet 20193932037ndash203843 Hengel E Publishing while female are women held to higher standards Evidence

from peer review Cambridge UK University of Cambridge 201744 Lundine J Bourgeault IL Clark J Heidari S Balabanova D The gendered system of

academic publishing Lancet 20183911754ndash175645 Gross RA American Academy of Neurology Editorial changes at Neurology Avail-

able at aancomAAN-ResourcesDetailscontact-aan Published 2019 AccessedMay 24 2019

46 Silver JK Cuccurullo SJ Ambrose AF et al Association of academic physiatristswomenrsquos task force report Am J Phys Med Rehabil 201897680ndash690

47 Shillcutt S Parangi S Diekman S et al Survey of women physiciansrsquo experience withelected leadership positions Health Equity 20193162ndash168

48 Ortega M Reader response women physicians underrepresented in AmericanAcademy of Neurology recognition awards Neurology 201992923

49 Bank AM Slocum CS Blauwet CA et al Author response women physicians un-derrepresented in American Academy of Neurology recognition awards Neurology201992924

50 Peckham C Medscape national physician burnout amp depression report Available atmedscapecomslideshow2018-lifestyle-burnout-depression-60092351 Published2018 Accessed March 14 2019

51 Dyrbye LN Burke SE Hardeman RR et al Association of clinical specialty withsymptoms of burnout and career choice regret among US resident physicians JAMA20183201114ndash1130

52 Shanafelt TD Boone S Tan L et al Burnout and satisfaction with work-life balanceamong US physicians relative to the general US population Arch Intern Med 20121721377ndash1385

53 Moore LR Ziegler C Hessler A Singhal D LaFaver K Burnout and careersatisfaction in women neurologists in the US J Womens Health201928515ndash525

54 Wakabayashi D Google finds itrsquos underpaying many men as it addresses wage equityThe New York Times Available at nytimescom20190304technologygoogle-gender-pay-gaphtmlfbclid=IwAR1ijM1IstbM-El_L1_ZVO-t7RolMKcXOlOYI3G2pwfO1GM1R_7uzYNLLn_c Published 2019 AccessedMarch 14 2019

55 Yang HY Rhee G Xuan L Silver JK Jalal S Khosa F Analysis of H-index in assessinggender differences in academic rank and leadership in physical medicine and re-habilitation in the United States and Canada Am J Phys Med Rehabil 201998479ndash483

56 Knowlton SE Paganoni S Niehaus W et al Measuring the impact of research usingconventional and alternative metrics Am J Phys Med Rehabil 201998331ndash338

57 Hamidi MS Bohman B Sandborg C et al Estimating institutional physician turnoverattributable to self-reported burnout and associated financial burden a case studyBMC Health Serv Res 201818851

NeurologyorgN Neurology | Volume 93 Number | Month 2019 11

Copyright copy 2019 American Academy of Neurology Unauthorized reproduction of this article is prohibited

58 Grigsby K Association of American Medical Colleges Faculty turnover costs inacademic medicine and science Available at aamcorgmembersgwimsresources397190costofturnovergrigsbyhtml Accessed March 18 2019

59 Schloss EP Flanagan DM Culler CL Wright AL Some hidden costs of faculty turn-over in clinical departments in one academicmedical center AcadMed 20098432ndash36

60 Silver JK BeEthical a call to healthcare leaders ending gender workforce disparitiesis an ethical imperative Available at sheleadshealthcarecomwp-contentuploads201810Be_Ethical_Campaign_101418pdf Published September 17 2018Accessed March 13 2019

61 Dandar VM Lautenberger DM Garrison GE Promising Practices for Understandingand Addressing Salary Equity at USMedical Schools Washington DC Association ofAmerican Medical Colleges 2019

62 Butkus R Serchen J Moyer DV Bornstein ST Achieving gender equity in physiciancompensation and career advancement a position paper of the American College ofPhysicians Ann Intern Med 2018168721ndash723

63 Sanfey H Crandall M Shaughnessy E Stein A Parangi S Laronga C Strategies foridentifying and closing the gender salary gap in surgery J Am Coll Surg 2017225333ndash338

64 Task Force on Equity Diversity and Inclusion Ensuring Equity Diversity and In-clusion in Academic Surgery Beverly MA American Surgical Association 2018

65 West MA Hwang S Maier RV et al Ensuring equity diversity and inclusion inacademic surgery an American Surgical Association white paper Ann Surg 2018268403ndash407

66 American Medical Womenrsquos Association Revolution by resolution advancing genderequity in medical societies state by state Available at amwa-docorgrevolution-by-resolution Published 2019 Accessed March 13 2019

67 Korioth T American Academy of Pediatrics Project aims to support female physi-cians in wellness equity leadership Available at aappublicationsorgnews20190226wel022619 Published 2019 Accessed May 24 2019

68 Silver JK Can neurologists come from behind and lead the way in physician genderequity J Womens Health 201928421ndash422

12 Neurology | Volume 93 Number | Month 2019 NeurologyorgN

Copyright copy 2019 American Academy of Neurology Unauthorized reproduction of this article is prohibited

DOI 101212WNL0000000000008022 published online July 31 2019Neurology

Julie K SilverUnderstanding and addressing gender equity for women in neurology

This information is current as of July 31 2019

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2019 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

ServicesUpdated Information amp

022fullhttpnneurologyorgcontentearly20190719WNL0000000000008including high resolution figures can be found at

Citations

022fullotherarticleshttpnneurologyorgcontentearly20190719WNL0000000000008This article has been cited by 13 HighWire-hosted articles

Subspecialty Collections

httpnneurologyorgcgicollectionprofessional_conduct_and_ethicsProfessional conduct and ethics

httpnneurologyorgcgicollectionmethods_of_educationMethods of education

nhttpnneurologyorgcgicollectionall_equity_diversity_and_inclusio(IDEAS)Inclusion Diversity Equity Anti-racism and Social Justice

httpnneurologyorgcgicollectioncmeCME

httpnneurologyorgcgicollectionall_rehabilitationAll Rehabilitation

ueshttpnneurologyorgcgicollectionall_ethics_in_neurology_legal_issAll Ethics in NeurologyLegal issuesfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in

Reprints

httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2019 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology

ServicesUpdated Information amp

022fullhttpnneurologyorgcontentearly20190719WNL0000000000008including high resolution figures can be found at

Citations

022fullotherarticleshttpnneurologyorgcontentearly20190719WNL0000000000008This article has been cited by 13 HighWire-hosted articles

Subspecialty Collections

httpnneurologyorgcgicollectionprofessional_conduct_and_ethicsProfessional conduct and ethics

httpnneurologyorgcgicollectionmethods_of_educationMethods of education

nhttpnneurologyorgcgicollectionall_equity_diversity_and_inclusio(IDEAS)Inclusion Diversity Equity Anti-racism and Social Justice

httpnneurologyorgcgicollectioncmeCME

httpnneurologyorgcgicollectionall_rehabilitationAll Rehabilitation

ueshttpnneurologyorgcgicollectionall_ethics_in_neurology_legal_issAll Ethics in NeurologyLegal issuesfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwneurologyorgaboutabout_the_journalpermissionsits entirety can be found online atInformation about reproducing this article in parts (figurestables) or in

Reprints

httpnneurologyorgsubscribersadvertiseInformation about ordering reprints can be found online

rights reserved Print ISSN 0028-3878 Online ISSN 1526-632X1951 it is now a weekly with 48 issues per year Copyright copy 2019 American Academy of Neurology All

reg is the official journal of the American Academy of Neurology Published continuously sinceNeurology