Gender Inequality in Leadership Positions in Neurology and Neurosurgery Journals and Societies

OBJECTIVE

Gender inequalities persist in several areas of medicine, despite the growing number of female doctors and medical students. In this study, we aimed to reveal the gender inequality in the top journals' editorial boards and national societies' leadership positions in the field of neurology and neurosurgery.

METHOD

This is a cross-sectional study that uses public information accessed through the internet via journals' and academic societies' public websites. The medical journals are selected and included according to their h5-index in the field of neurology and neurosurgery. We evaluated the gender composition of the editorial boards and academic societies' leadership positions.

RESULTS

The female editorial board member ratio was 44.0% in the top 10 neurology journals. However, this ratio was significantly decreased to 29.7% in the other journals(P < 0.001). The top 10 neurosurgery journals had a female editorial board member ratio of 13.7%. This ratio was significantly decreased to 5.3% in the other 10 journals with lower h5-index(P < 0.001). A significantly lower number of female individuals are present in the editorial boards of the neurosurgery journals than in neurology(P < 0.001). The female president or delegate ratio was 19.3% in the World Federation of Neurology-affiliated countries, and it was 4% in the World Federation of Neurosurgical Societies-affiliated countries.

CONCLUSIONS

In conclusion, there is a significant gender inequality among editorial board members. The position of neurosurgical societies and journals is far different than the field of neurology. Furthermore, these findings should be evaluated as a continuum of the gender inequality in the professional societies' executive boards and delegates representing the national academical community.

Differential Time-To-Promotion Trajectories Among Female and Male Neurosurgeons Contribute to Gender Disparities in Academic Rank Achievement

OBJECTIVE

Despite the increasing representation of females in neurosurgical training, the fraction of female to male neurosurgeons decreases dramatically as faculty rank (Assistant, Associate, or Full Professor) increases. To assess this discrepancy, we quantified self-reported time-to-promotion trajectories for female and male neurosurgeons holding academic appointments.

METHODS

In this cross-sectional institutional review board (IRB)-approved study, 147 female and 84 male neurosurgeons currently holding faculty positions in the US were contacted via email and invited to complete an anonymous, standardized survey. Respondents provided the calendar year of postgraduate training completion, promotion to different faculty ranks, geographic region of current practice (Western, Midwest, Southern, Northeast), and practice subspecialty.

RESULTS

The response rate was 44.2% for females and 59.5% for males, with 114 participants included (65 female, 49 male). On average, female neurosurgeons required 25% longer to become an Associate Professor (P = 0.017), 34% longer to become a Full Professor (P = 0.004), 37% longer for promotion from Assistant to Associate Professor (P < 0.001), and 32% longer from Assistant to Full Professor (P = 0.012). Promotion timelines did not vary by region or specialty among male and female cohorts. Linear regressions revealed that female neurosurgeons with more recent training completion experienced shorter time-to-promotion to Associate and Full Professor compared to females of earlier generations (P = 0.005 and 0.001, respectively), while male timelines remained stable.

CONCLUSIONS

This study identifies a significant delay in time-to-promotion for female neurosurgeons compared to their male counterparts. Investigation and standardization of promotion timelines are necessary to ensure meaningful representation gains from the increased number of women entering neurosurgical training.

A Decade of Global Skull Base Researchers: Gender Data from over 2,700 Abstract Authors in the Journal of Neurological Surgery Part B: Skull Base

Objective  The North American Skull Base Society (NASBS) annual conference brings together skull base researchers from surgical and nonsurgical fields. Our objective was to quantify the contributions of the authors by gender, who presented their work at NASBS and were subsequently published in the Journal of Neurological Surgery Part B: Skull Base . Methods  Oral and poster abstracts presented at the NASBS annual meeting from January 1, 2011 to December 31, 2020 were extracted from the Journal of Neurological Surgery Part B: Skull Base. The genderize.io Web application programming interface was utilized to determine authorship gender. A minority of first and last authors had departmental affiliations listed; a subgroup analysis was performed of these authors. Results  Female gender was assigned to 498 (17.8%) of the 2,798 first authors and 269 (9.7%) of the 2,762 last authors. Female authorship has consistently increased over the last decade. Representation was higher in otolaryngology (23.3% of first authors, 12.1% of last authors; p  = 0.018) than neurosurgery (13.5% of first authors, 4.3% of last authors; p  = 0.004). Female researchers were not less likely than their male counterparts to receive prestigious oral presentations. Of the 52 total countries represented, 20 (38.5%) had at least one female first author. Representation varied dramatically between countries. Conclusion  The NASBS' efforts have undoubtedly contributed to these impressive strides toward gender parity. More work is needed to ensure that the best and the brightest, regardless of background, continue to contribute to skull base surgery research.

Women in neurosurgery in Peru: current situation and representation

The participation of women in neurosurgery in Peru began in 1974 with the first Peruvian female neurosurgeon, who was accepted into a residency program with the condition of not getting married during her training. Nowadays, the conditions are more just, and there is greater equality of opportunities between men and women, but the numbers show that the differences have not yet been fully equalized. As evidence of this, it has been observed that only 17% of the residency positions offered in 2022 were filled by women, and there has been reduced participation of female neurosurgeons in the Peruvian Society of Neurosurgery. This article discusses the importance of tracking and promoting stories of Peruvian female neurosurgeons and calls for research in the area of women in neurosurgery in latin countries, like Peru.

Gender Differences in Medicare Practice and Payments to Neurosurgeons

Importance

Despite efforts to promote diversity within the neurosurgical workforce, individuals from underrepresented groups face significant challenges.

Objective

To compare practice metrics and earning potential between female and male neurosurgeons and investigate factors associated with gender disparity in Medicare reimbursement.

Design, Setting, and Participants

This retrospective cross-sectional study used publicly accessible Medicare data on reimbursements to female and male neurosurgeons for procedural and evaluation and management services delivered in both inpatient and outpatient settings between January 1, 2013, and December 31, 2020. Data were analyzed from December 9, 2021, to December 5, 2022.

Main Outcomes and Measures

The primary outcome was the mean annual payments received and charges submitted by female and male neurosurgeons for services rendered between 2013 and 2020. Secondary outcomes included the total number and types of services rendered each year and the number of beneficiaries treated. Univariate and multivariable analyses quantified differences in payment, practice volume, and composition.

Results

A total of 6052 neurosurgeons (5540 men [91.54%]; 512 women [8.46%]) served the Medicare fee-for-service patient population. Female neurosurgeons billed for lesser Medicare charges (mean [SE], $395 851.62 [$19 449.39] vs $766 006.80 [$11 751.66]; P < .001) and were reimbursed substantially less (mean [SE], $69 520.89 [$2701.30] vs $124 324.64 [$1467.93]; P < .001). Multivariable regression controlling for practice volume metrics revealed a persistent reimbursement gap (-$24 885.29 [95% CI, -$27 964.72 to -$21 805.85]; P < .001). Females were reimbursed $24.61 less per service than males even after matching services by code (P = .02).

Conclusions and Relevance

This study found significant gender-based variation in practice patterns and reimbursement among neurosurgeons serving the Medicare fee-for-service population. Female surgeons were reimbursed less than male surgeons when both performed the same primary procedure. Lower mean reimbursement per service may represent divergence in billing and coding practices among females and males that could be the focus of future research or educational initiatives.

Characterization of neurosurgery fellowship directors: strengths and room for improvement

BACKGROUND

While many current and aspiring neurosurgeons are looking to supplement their clinical practices with leadership positions, there has not been research characterizing current leadership positions such as fellowship directors (FDs) in neurosurgery to provide insight into objective qualities that distinguish these individuals from the rest of the workforce. This study aims to outline the current characterization of spine, endovascular, pediatric, and stereotactic and functional neurosurgery fellowship directors.

METHODS

A list of accredited neurosurgical fellowship programs located within the US and their respective directors was acquired through the AANS Neurosurgical Fellowship Training Program Directory. This study obtained educational, demographic, institutional, research, and professional background variables through curriculum vitae, institutional profiles, personal websites, emails, and the Scopus database.

RESULTS

Of the 152 FDs analyzed, 143 (94%) were male, 9 (6%) were female, and the mean age was 52.2±8.5 years. The mean Scopus H-index and mean total citations for all FDs was 27±15.7 and 3782.1±4526.7, respectively. Furthermore, the majority of FDs were Caucasian (69.1%), followed by Asian (20.4%), Black or African American (5.3%), and Hispanic or Latino (5.3%). The mean number of years as FD was 8.9±7.2.

CONCLUSIONS

This analysis showed neurosurgery fellowship directors are primarily Caucasian males. Neurosurgery training pedigree seems to play a role in FD attainment. In addition, these directors are largely distinguished by their research productivity. This analysis serves as an insight into the current climate for students aspiring to serve as academic leaders in the field of neurosurgery.

Women in Neurosurgery: Turkey's Yıldız Yalçınlar

BACKGROUND

Severalreports have been published on the history of pioneering women pursuing neurosurgery. Women in Turkey started receiving neurosurgery specialty training later than men, as was the case in other parts of the world. However, compared to other countries, Turkey saw the admission of women in neurosurgery sooner, with Aysima Altınok who obtained her specialization in 1959. Nevertheless, Yıldız Yalçınlar, one of the pioneers, remains relatively unknown.

METHODS & RESULTS

In this paper, we witness Yıldız Yalçınlar's journey, from her graduation from Ankara Medical Faculty in 1954 and her subsequent specialization in general surgery to her arrival in Iğdır as a young surgeon in the early 1960s, where she faced cultural challenges. We explored her transition into neurosurgery, becoming the second neurosurgeon in Turkey in 1965. We examine her complex career progression from receiving her specialization in neurosurgery to her academic journey toward becoming a department chief and her role as one of the founding members of the Turkish Neurosurgery Association.

CONCLUSIONS

In Turkey, the number of women practicing as neurosurgeons has increased consistently. Despite this upward trend, the representation of women in the field of neurosurgery remains disproportionately low. We hope that Yıldız Yalçınlar's achievements, which began in the early 60s, will encourage women today and contribute to the continuing growth of neurosurgery.

Gender-Based Disparities in Academic Productivity Arise During Neurosurgery Residency: A Systematic Review

BACKGROUND

Although female neurosurgery residents are increasing, women remain underrepresented in academic leadership.

OBJECTIVES

To assess academic productivity differences between male and female neurosurgery residents.

METHODS

We used the Accreditation Council for Graduate Medical Education records to obtain 2021-2022 recognized neurosurgery residency programs. Gender was dichotomized into male/female by male-presenting/female-presenting status. Extracted variables included degrees/fellowships from institutional websites, number of preresidency and total publications from PubMed, and h -indices from Scopus. Extraction occurred from March to July 2022. Residency publication number and h- indices were normalized by postgraduate year. Linear regression analyses were conducted to assess factors associated with numbers of in-residency publications. P < .05 was considered statistically significant.

RESULTS

Of 117 accredited programs, 99 had extractable data. Information from 1406 residents (21.6% female) was successfully collected. 19 687 and 3261 publications were evaluated for male residents and female residents, respectively. Male and female residents' median preresidency publication numbers did not significantly differ (M:3.00 [IQR 1.00-8.50] vs F:3.00 [IQR 1.00-7.00], P = .09), nor did their h -indices. However, male residents had significantly higher median residency publications than female residents (M:1.40 [IQR 0.57-3.00] vs F:1.00 [IQR 0.50-2.00], P < .001). On multivariable linear regression, male residents (odds ratio [OR] 2.05, 95% CI 1.68-2.50, P < .001) and residents with more preresidency publications (OR 1.17, 95% CI 1.16-1.18, P < .001) had higher likelihood of publishing more during residency, controlling for other covariates.

CONCLUSION

Without publicly available, self-identified gender designation for each resident, we were limited to review/designate gender based on male-presenting/female-presenting status from gender conventions of names/appearance. Although not an ideal measurement, this helped show that during neurosurgical residency, male residents publish significantly more than female counterparts. Given similar preresidency h- indices and publication records, this is unlikely explained by differences in academic aptitude. In-residency gender barriers to academic productivity must be acknowledged and addressed to improve female representation within academic neurosurgery.

Composition and Gender Distribution of Editorial Boards for Top Neurosurgical Journals

BACKGROUND

Though women now comprise approximately 21.5% of all neurosurgery residents in the United States, women only represent 10% of practicing neurosurgeons nationally. Serving as a journal editor is 1 measure of academic success. We investigated characteristics of editorial boards for top neurosurgical journals to identify factors influencing membership on editorial boards. We sought to identify gender differences to explain the paucity of women on editorial boards.

METHODS

This is a cross-sectional study of editorial boards for the top 10 English-language neurosurgical journals. Data were obtained from journal websites, program faculty lists, or physician online profiles. Gender differences were compared using Student t test and χ2 analysis.

RESULTS

Seven hundred twenty-two editorial board members were examined (female n = 65; male n = 650; unidentified n = 7). Overall, women had fewer years in practice (P = 0.002) and more often had additional advanced degrees (P = 0.009) while men had higher h-indices (P < 0.0001). Within the boards of Neurosurgery and Acta Neurochirurgica, men had been in practice longer (P = 0.014; P = 0.023) and had higher h-indices (P = 0.003; P = 0.025). Male editors for Journal of Neurosurgery: Spine and World Neurosurgery had higher h-indices (P = 0.007; P = 0.018).

CONCLUSIONS

Women constitute ∼9% of editorial boards for top neurosurgical journals, a percentage comparable to the amount of practicing female academic neurosurgeons. This finding is encouraging as in that there appears to be no readily identifiable bias in the selection of editorial board members. The differences in years in practice and h-index suggest that gender distribution may equalize with time as more women enter practice and produce scientific literature. Efforts to recruit and retain women in neurosurgery should be pursued to rectify this discrepancy.

Women in leadership positions in European neurosurgery - Have we broken the glass ceiling?

Introduction

The proportion of male neurosurgeons has historically been higher than of women, although at least equal numbers of women have been entering European medical schools. The Diversity Committee (DC) of the European Association of Neurosurgical Societies (EANS) was founded recently to address this phenomenon.

Research question

In this cross-sectional study, we aimed to characterize the status quo of female leadership by assessing the proportion of women heading European neurosurgical departments.

Material and methods

European neurosurgical departments were retrieved from the EANS repository. The gender of all department chairs was determined via departmental websites or by personal contact. The proportion of females was stratified by region and by type of hospital (university versus non-university).

Results

A total of 41 (4.3%) female department chairs were identified in 961 neurosurgery departments in 41 European countries. Two thirds (68.3%) of European countries do not have a female neurosurgery chair. The highest proportion of female chairs was found in Northern Europe (11.1%), owing to four female chairs in a relatively small number of departments (n = 36). The proportions were considerably smaller in Western Europe (n = 17/312 (5.5%)), Southern Europe (n = 14/353 (4.0%)) and Central and Eastern Europe (n = 6/260 (2.3%)) (p = 0.06). The distribution of female chairs in university (n = 19 (46.3%)) versus non-university departments (n = 22 (53.7%)) was even.

Discussion and Conclusion

There is a significant gender imbalance with 4% of all European neurosurgery departments headed by women. The DC intends to develop strategies to support equal chances and normalize the presence of female leaders in European neurosurgery.

Parenting and Childbearing in Neurosurgical Residency: Perspectives from the United States and Canada

BACKGROUND

Despite growing interest in family planning alongside surgical training, significant barriers exist including time constraints, stigma, and lack of paid leave and formal policies. We currently lack a deep understanding of the challenges residents face and how practice cultures may prohibit successful policy enactment.

OBJECTIVE

To investigate residents' perspectives surrounding parenting and childbearing during neurosurgical residency in the United States and Canada.

METHODS

A cross-sectional, qualitative study methodology was used, including focus groups with neurosurgical residents. Purposive sampling was employed to capture a broad range of perspectives including stage of training, geographical location, and gender. Data collection and analysis occurred in parallel, using a thematic analysis approach. Data collection continued until no new themes relating to the research questions were identified.

RESULTS

Notable challenges included lack of formal family leave policies, time constraints, insufficient clinical human resources, physical health concerns, lack of lactation accommodations, and lack of mentorship. A subset of barriers were uncovered that stem specifically from workplace cultures, including gender norms, difficulty in asking for help, concerns for inconveniencing others, and pressures to time parental leave during research blocks. Several positive changes were identified including growing awareness and female representation, and benefits of the dual surgeon-parent identity.

CONCLUSION

While parenting during neurosurgery residency is becoming increasingly common, significant practical and cultural barriers persist including a marked absence of formal policies. Culture shifts are essential in ensuring opportunities for life outside of medicine for all residents, irrespective of family status.

Has the Increase of Women in Surgical Training Programs Led to a Concomitant Increase in Female Leadership Positions? A 10-Year Analysis

INTRODUCTION

Women represent greater than 50% of medical students in America and are becoming increasingly well represented in surgical fields. However, parity at the trainee level has yet to be accomplished, and surgical leadership positions have remained disproportionately biased toward men. To date, there have been no comparisons on the progress within plastic surgery and other surgical specialties. This investigates the gender disparity in resident and leadership representation over the past 10 years within surgical specialties and how these disparities compare to plastic surgery.

METHODS

Counts of female and male residents and surgical society leaders were collected from 2008 to 2018. Surgical fields included plastic, vascular, urologic, neurologic, orthopedic, cardiothoracic, and general surgery. Leadership positions were defined as board seats on executive committees of major surgical societies or board associations. Data were acquired from publicly available sources or provided directly from the organizations. Resident data were obtained from the Accreditation Council of Graduate Medical Education residents' reports. Individuals holding more than 1 leadership position within a year were counted only once.

RESULTS

In our aggregated analysis, the proportion of women in surgical leadership lags behind women in surgical residency training across all specialties (13.2% vs 27.3%, P < 0.01). General surgery had the highest proportion of female residents and leaders (35% and 18.8%, P < 0.01), followed by plastic (32.2% and 17.3%, P < 0.01), vascular (28.2% and 11.3%, P < 0.01), urologic (24.3% and 5.1%), and cardiothoracic surgery (20.5% and 7.8%, P < 0.01). Women in surgical leadership, however, increased at a faster rate than women in surgical training (11% vs 7%, P < 0.05). Plastic surgery showed the greatest rate of increase in both residents and leaders (17% and 19%, P < 0.05) followed by cardiothoracic surgery (16% and 9%, P < 0.05) and general surgery (8% and 14%, P < 0.05). For neurologic and orthopedic surgery, neither the difference in proportions between residents and leaders nor the yearly growth of these groups were significant.

CONCLUSIONS

Between 2008 and 2018, women in plastic surgery training and leadership positions have shown the most significant growth compared with other surgical subspecialties, demonstrating a strong concerted effort toward gender equality among surgical professions.

Current Trends in Subspecialty Fellowship Training for 1691 Academic Neurological Surgeons

OBJECTIVE

Neurosurgical subspecialty fellowship training has become increasingly popular in recent decades. However, few studies have evaluated recent trends in postgraduate subspecialty education. This study aims to provide a detailed cross-sectional analysis of subspecialty fellowship training completion trends and demographics among U.S. academic neurosurgeons.

METHODS

Academic clinical faculty (M.D. or D.O.) teaching at accredited neurosurgery programs were included. Demographic, career, and fellowship data were collected from departmental physician profiles and the American Association of Neurological Surgeons (AANS) membership database. Relative citation ratio scores were retrieved using the National Institutes of Health iCite tool.

RESULTS

This study included 1691 surgeons (1756 fellowships) from 125 institutions. The majority (79.13%) reported fellowship training. Fellowship completion was more common among recent graduates (residency year >2000), as was training in multiple subspecialties (P < 0.0001). Spine was the most popular subspecialty (16.04%), followed by pediatrics (11.18%), and cerebrovascular (9.46%). The least common were trauma/critical care (2.52%) and peripheral nerve (1.26%). Spine, neuroradiology, and endovascular subspecialties grew in popularity over time. Pediatrics and spine were the most popular for females and males, respectively. Epilepsy and cerebrovascular had the most full professors, while endovascular and spine had the most assistant professors. Stereotactic/functional and epilepsy had the most Ph.Ds. Fellowship training correlated with higher weighted, but not mean, relative citation ratio scores among associate (P = 0.002) and full professors (P = 0.005).

CONCLUSIONS

There is an emerging proclivity for additional fellowship training among young neurosurgeons, often in multiple subspecialties. These findings are intended to help guide professional decision-making and optimize the delivery of postgraduate education.

Seventy-five years of neurosurgery residency training at The Mount Sinai Hospital

The Department of Neurosurgery's residency program at The Mount Sinai Hospital was founded in 1946. The department has its origins in 1914 as a division of general surgery, with Charles Elsberg at the helm. Neurosurgery then became a separate department in 1932 under the leadership of Ira Cohen. Dr. Cohen oversaw the creation of the neurosurgery residency training program 75 years ago. Since its inception, the residency program has graduated 120 residents. For more than 100 years, The Mount Sinai Hospital has been a site of clinical excellence, groundbreaking research, and technological innovation in neurosurgery. Currently, the Department of Neurosurgery has 39 clinical faculty members, performs more than 5300 surgeries and endovascular procedures annually, and is in the top 25 neurosurgical departments for NIH funding.

Neuro-oncology authorship trends in gender since 1944: a systematic review of 14,020 articles from five top-tier academic journals

OBJECTIVE

This study was performed to compare authorship trends, by gender, in the neurosurgical oncology literature.

METHODS

Complete author listings for neurosurgical oncology articles published between 1944 and 2021 in five top neuro-oncology journals were extracted from the PubMed database and journal websites on December 2, 2021. Author gender was characterized with the web application programming interface (API) genderize.io. The statistical significance (p < 0.05) of time-, journal-, and gender-based differences was determined by independent-samples t-test, chi-square test, and/or Fisher’s exact test.

RESULTS

A total of 14,020 articles were written by 67,115 unique authors occupying 97,418 authorship spots. The gender for 80,030 authorship positions (82.2%) was successfully characterized. Male authors were significantly more likely than the female authors to have a first-author publication, have a last-author publication, and have authored multiple articles within the data set. Among authors who published in multiple different years (n = 11,532), women had a shorter time window of publishing (5.46 vs 6.75 years between first and last publication: mean difference [MD] 1.28 [95% CI 1.06–1.50] years, p < 0.001). During this window, however, they were slightly more productive than the men, based on the mean number of publications per year (1.06 vs 1.01 articles: MD 0.05 [95% CI 0.02–0.09] articles, p = 0.002). The percentage of female authors on each neuro-oncology research team has increased by 3.3% (95% CI 2.6%–3.9%) per decade to a mean of 26.5% in the 2020s. Having a female last author was positively associated with having a female first author (OR 2.57 [95% CI 2.29–2.89]) and a higher proportion of women on the research team overall. The percentages of female first and last authors increased at significantly higher rates in medically oriented journals than in surgically oriented journals (first authors: 0.72% [95% CI 0.58%–0.87%] vs 0.36% [95% CI 0.30%–0.42%] per year, p < 0.001; and last authors: 0.50% [95% CI 0.38%–0.62%] vs −0.03% [95% CI −0.10% to 0.05%] per year, p < 0.001).

CONCLUSIONS

Female authorship in top neuro-oncology journals has increased since the 1940s, with female-led teams showing greater gender diversity. However, female researchers lag behind their male counterparts in quantity of published research and are less likely to hold first or last authorship positions. This difference is more pronounced in the three neurosurgical oncology journals than in the two medical neuro-oncology journals, which may reflect the relatively low female representation in neurosurgery relative to medical oncology. Collectively, these trends have meaningful implications for career advancement, which is often dependent on academic productivity.

Status of Women in Neurosurgery: Results from a National Survey in Italy

Background

Gender inequity in surgery has increasingly been a matter of debate. Contributions of female neurosurgeons to academic medicine and societies are poorly highlighted. The aim of this study was to evaluate several aspects of the professional and work-life balance of female neurosurgeons in Italy.

Methods

Data of the female neurosurgical population were extracted from a general 83-item questionnaire administered to a total of 3242 respondents. The survey was composed of multiple-choice questions investigating demographics, surgical training and practice, satisfaction, mentorship, discrimination, and harassment.

Results

A total of 98 female neurosurgeons were included. Most responders were married or cohabiting (49%). Thirty-nine (43%) were planning to have children, and 15 of them (44%) stated the reason they still didn't have any was because of professional constraints. Seventy (71%) women were neurosurgeons with an academic position (residents or academics) and 28 (29%) were full-time attendings. Most of the female neurosurgeons are satisfied with their work: sometimes (35%), often (20%), and always or almost always (20%). Most of them (45%) stated they are rarely victims of harassment, but 66% think that they are treated differently because they are women. A similar rate for a poor and fulfilling work-life balance (34% and 35%, respectively) was detected. The majority of participants (89%) had encountered a role model during their career, but in only 11% of cases was that person female.

Conclusions

Even though the rate of satisfaction among female neurosurgeons in Italy is high, some of them experienced gender discrimination, including incidents of sexual harassment and microaggressions. Policies including job sharing paradigms, consistent and meaningful options for parental leave, mentorship programs, equal and fair remuneration for equal work, and zero tolerance for harassment should be encouraged.

Consequences of inequity in the neurosurgical workforce: Lessons from traumatic brain injury

Women and minorities leave or fail to advance in the neurosurgical workforce more frequently than white men at all levels from residency to academia. The consequences of this inequity are most profound in fields such as traumatic brain injury (TBI), which lacks objective measures. We evaluated published articles on TBI clinical research and found that TBI primary investigators or corresponding authors were 86·5% White and 59·5% male. First authors from the resulting publications were 92.6% white. Most study participants were male (68%). 64·4% of NIH-funded TBI clinical trials did not report or recruit any black subjects and this number was even higher for other races and the Hispanic ethnicity. We propose several measures for mitigation of the consequences of the inequitable workforce in traumatic brain injury that could potentially contribute to more equitable outcomes. The most immediately feasible of these is validation and establishment of objective measures for triage and prognostication that are less susceptible to bias than current protocols. We call for incorporation of gender and race neutral metrics for TBI evaluation to standardize classification of injury. We offer insights into how socioeconomic factors contribute to increased death rates from women and minority groups. We propose the need to study how these disparities are caused by unfair health insurance reimbursement practices. Surgical and clinical research inequities have dire consequences, and until those inequities can be corrected, mitigation of those consequences requires system wide change.

Evaluating diversity in neurosurgery through the use of a multidimensional statistical model: a pilot study

OBJECTIVE

There is a growing body of evidence demonstrating the benefits of diversity across many domains. However, neurosurgery consistently lags most of medicine in many aspects of diversity. Any inability to make progress in this arena is likely due to the multifactorial and complex nature of the issue, which makes it difficult to meaningfully measure and track diversity within the workforce. The goal of this pilot study was to assess the utilization of a multidimensional statistical model to quantify and assess diversity within neurosurgery. The authors sought to 1) assess the diversity of neurosurgery residents using Simpson's Diversity Index and Sullivan's Composite Diversity Index (CDI) and 2) determine if a medical school's intrinsic academic opportunities and resources, indicated by US News & World Report's (USNWR's) best research medical schools ranking, are related to the number of neurosurgery residents produced per medical school.

METHODS

A cross-sectional study of all neurosurgery residents (projected graduation years 2020-2026) and 1st-year medical students (matriculating years 2016-2019) was undertaken. Biographical diversity data (gender and matriculation data) were collected from institutional websites between December 2019 and June 2020. The CDI expresses the diversity of a given population by representing the effective proportion of categories present across all diversity attributes and was calculated for neurosurgery residents and medical students. Statistical results are reported as the median and interquartile range.

RESULTS

Neurosurgery residency program CDI (0.21, IQR 0.16-0.25) was significantly less (p < 0.001) than medical school CDI (0.42, 0.37-0.48). There was no significant difference in CDI between top-40 and non-top 40 Doximity ranked research output neurosurgery residency programs (p = 0.35) or between top-40 and non-top 40 USNWR ranked research medical schools (p = 0.11). Over a 7-year period, top-40 ranked research medical schools produced significantly more (p < 0.001) neurosurgery residents (11.9, IQR 7.1-18.9) than the non-top 40 ranked research medical schools (5.6, IQR 2.6-8.5).

CONCLUSIONS

The authors demonstrated the feasibility of using a multidimensional statistical model as a measure to understand the complex issues of diversity. Their preliminary data suggested that neurosurgery's challenge in achieving the desired diversity relates to uneven attraction and/or recruitment across an increasingly diverse medical student body. In recent years, neurosurgery has made great progress in the arena of diversity and has shown a strong desire to do more. Utilization of these diversity measures will help the neurosurgery field to monitor progress along this valuable journey.

Projected timeline to achieve gender balance within the United States neurosurgical workforce exceeds 150 years: a National Plan and Provider Enumeration System analysis

OBJECTIVE

Despite incremental progress in the representation and proportion of women in the field of neurosurgery, female neurosurgeons still represent an overwhelming minority of the current US physician workforce. Prior research has predicted the timeline by which the proportion of female neurosurgery residents may reach that of males, but none have used the contemporary data involving the entire US neurosurgical workforce.

METHODS

The authors performed a retrospective analysis of the National Plan and Provider Enumeration System (NPPES) registry of all US neurosurgeons to determine changes in the proportions of women in neurosurgery across states, census divisions, and census regions between 2010 and 2020. A univariate linear regression was performed to assess historical growth, and then Holt-Winter forecasting was used to predict in what future year gender parity may be reached in this field.

RESULTS

A majority of states, divisions, and regions have increased the proportion of female neurosurgeons from 2010. Given current growth rates, the authors found that female neurosurgeons will not reach the proportion of women in the overall medical workforce until 2177 (95% CI 2169-2186). Furthermore, they found that women in neurosurgery will not match their current proportion of the overall US population until 2267 (95% CI 2256-2279).

CONCLUSIONS

Whereas many studies have focused on the overall increase of women in neurosurgery in the last decade, this one is the first to compare this growth in the context of the overall female physician workforce and the female US population. The results suggest a longer timeline for gender parity in neurosurgery than previous studies have suggested and should further catalyze the targeted recruitment of women into the field, an overhaul of current policies in place to support and develop the careers of women in neurosurgery, and increased self-reflection and behavioral change from the entire neurosurgery community.

Women in Neurosurgery: Historical Path to Self-Segregation and Proposal for an Integrated Future

Despite the rising percentage of women accessing the medical profession over the last few decades, surgical specialties are still largely male-dominated; in particular, a remarkable gender disparity is evident in neurosurgery, where only 19% of practitioners are females. Although women may be reluctant to choose a challenging specialty like neurosurgery due to concerns around how to balance family and career, it must be admitted that prejudices against female neurosurgeons have been deeply rooted for long, prompting many to give up and switch track to less demanding subspecialties. Among those who have persisted, many, if not most, have experienced difficulties in career progression and received unequal treatment in comparison with their male counterparts. In 1989, a group of 8 female neurosurgeons founded Women in Neurosurgery (WINS), an organization that aimed to guarantee inclusivity in neurosurgery, encouraging a better and more egalitarian working environment. Thereafter, WINS sessions were regularly promoted at international conferences, offering female neurosurgeons a platform to report issues related to gender discrimination. Over recent years, the mission of WINS sessions in national and international conferences has taken an unexpected deviation; they have progressively become supplementary scientific sessions with only women neurosurgeons as speakers, thus paving the road to a form of self-segregation. This tendency has also resulted in the establishment of sections of only female neurosurgeons within some national societies. Although there remains a faction that fiercely supports the WINS mindset of reserved spaces for women, such segregation is an upsetting prospect for those who believe that science and professionalism have no gender; a growing part of the global neurosurgical community believes that the conception of a “female neurosurgery” and a “male neurosurgery” is misguided and counterproductive and consider the existence of the WINS as anachronistic and no longer necessary.

Assessment of female authorship in Journal of NeuroInterventional Surgery (JNIS) publications in 2016-2020

BACKGROUND

Since female neurointerventionalists make up a minority of the work force, the contributions this group has made to academic scholarship should be highlighted.

OBJECTIVE

The main objective of this project was to identify all of the recent papers published in the Journal of NeuroInterventional Surgery (JNIS) by female first authors or last authors over 5 years.

METHODS

The online issues of JNIS from January 2016 through December 2020 were reviewed. Data were collected on the number and types of articles published monthly. For each article, the gender of the first author and the senior author was evaluated. Bivariate analyses were performed to compare female authorship trends between 2016 and 2020.

RESULTS

In 2016, 38 (14.8%) of the 257 articles published had female involvement compared with 60 (22.8%) of 263 articles in 2020 (p=0.019). In 2016, 9.7% of all articles had a female first author only, 3.9% had a female last author only, and 1.2% had both a female first and last author. In 2020, the percentages increased to 14.5%, 6.5%, and 1.9% respectively. Over 80% of the articles published in 2016 and 2020 by female authors were original research articles. One editorial commentary and two special topic articles were published by female authors in 2020 compared with none in 2016.

CONCLUSION

More papers were published by female authors in JNIS in 2020 relative to 2016. Most of these papers had a female first author, and were original research articles.

Gender Equality in Neurosurgery and Strategic Goals Toward a More Balanced Workforce

The Women in Neurosurgery (WINS) and the American Association of Neurological Surgeons published a white paper in 2008 setting an ambitious goal for women to comprise 20% of neurosurgery residents by 2012 and 20% of practicing neurosurgeons by 2020. Although there has been steady progress, we have fallen short of these benchmarks. We take this opportunity to look back at the accomplishments made over the past decade and provide an update on our present status. We evaluate current barriers toward progress and propose new goals, highlighting the systemic changes necessary to accomplish them. We propose the following updated recommendations to recruit and retain diverse talent into the neurosurgical workforce. (1) Neurosurgical departments and societies should provide diverse, early formal mentorship opportunities for medical students, residents, and junior faculty members. (2) Parental leave policies must be delineated, promoted, and enforced for all neurosurgeons, with greater awareness of internal discrimination and normalization of the discussion surrounding this topic. (3) We need to strive for compensation equity, with transparency in compensation mechanisms and regular assessment of compensation metrics. (4) Departments and institutions must have a zero-tolerance policy for sexual harassment and discrimination and establish a safe reporting structure. Finally, we propose attainable benchmarks toward achieving gender balance in the neurosurgical workforce, with a goal for women to comprise 30% of the entering residency class by 2030 and to comprise 30% of practicing neurosurgeons by 2038. We hope that this will guide further progress toward our future of building a balanced workforce.

What Are Patients Saying About Minimally Invasive Spine Surgeons Online: A Sentiment Analysis of 2,235 Physician Review Website Reviews

Objective

Physician review websites are becoming increasingly popular for patients to find and review healthcare providers. The goal of this study was to utilize quantitative analyses to understand trends in ratings and written comments on physician review websites for Society of Minimally Invasive Spine Surgery (SMISS) members.

Methods

This is a cross-sectional study. The reviews of SMISS surgeons were obtained from healthgrades.com, and sentiment analysis was used to obtain compound scores of each physicians' reviews. SMISS surgeons who were international or had fewer than three written reviews, often consisting of residents and fellows, were excluded. Inferential statistics were utilized, and word frequency analysis reported the phrases used to characterize reviews.

Results

One hundred sixty-nine surgeons met the inclusion criteria. 98.6% were males and the mean age was 51.7 years old. A total of 2,235 written reviews were analyzed. Younger surgeons were significantly more likely to receive higher star ratings (p<0.01). Positive behavioral characteristics, such as “kind” and “bedside manner,” conferred significantly improved odds of receiving positive reviews (p<0.01). Ancillary “staff” conferred a 2x greater odds of receiving a positive review whereas a comment on “wait” times halved a surgeon’s odds (p<0.01). Sentences describing pain drove down the odds of positive reviews whereas those describing pain relief produced greater odds of positive reviews (p<0.01).

Conclusion

Physicians who were younger, personable, provided sufficient pain relief, and who worked in favorable offices received the most positive reviews. This study informs SMISS members on the traits deemed important by patients who ultimately review surgeons online.

Women in Neuromodulation: Innovative Contributions to Stereotactic and Functional Neurosurgery

Stereotactic neurosurgery emerged in the mid-20th century following the development of a stereotactic frame by Spiegel and Wycis. Historically women were underrepresented in clinical and academic neurosurgery. There is still a significant deficit of female scientists in this field. This article aims to demonstrate the career and scientific work of some of the most important women who contributed to the development of stereotactic and functional neurosurgery. Exceptional women from all over the world, represented in this review, assisted the evolution of modern stereotactic and functional neurosurgery as neurosurgeons, neuropathologists, neurologists, neurophysiologists and occupational therapists. Fortunately, we could conclude that in the last two decades the number of female researchers has increased significantly.

Discrimination of residents during neurosurgical training in Mexico: Results of a survey prior to SARS-CoV-2

Background:

Recent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic represents an important negative impact on global training of neurosurgery residents. Even before the pandemic, discrimination is a challenge that neurosurgical residents have consistently faced. In the present study, we evaluated discriminatory conditions experienced by residents during their neurosurgical training in Mexico before the SARS-CoV-2 pandemic.

Methods:

An electronic survey of 18 questions was sent among residents registered in the Mexican Society of Neurological Surgery (MSNS), between October 2019 and July 2020. Statistical analysis was made in IBM SPSS Statistics 25. The survey focused on demographic characteristics, discrimination, personal satisfaction, and expectations of residents.

Results:

A response rate of 50% (132 of 264 residents’ members of MSNS) was obtained and considered for analysis. Median age was 30.06 ± 2.48 years, 5.3% (n = 7) were female and 16.7% (n = 22) were foreigners undergoing neurosurgical training in Mexico. Approximately 27% of respondents suffered any form of discrimination, mainly by place of origin (9.1%), by gender (8.3%) or by physical appearance (6.1%). About 42.9% (n = 3) of female residents were discriminated by gender versus 6.4% (n = 8) of male residents (P = 0.001); while foreign residents mentioned having suffered 10 times more an event of discrimination by place of origin compared to native Mexican residents (36.4% vs. 3.6%, P < 0.001).

Conclusion:

This manuscript represents the first approximation to determine the impact of discrimination suffered by residents undergoing neurosurgical training in Mexico before the SARS-CoV-2 pandemic.

International Women in Neurosurgery

The history of women in neurosurgery worldwide has been characterized by adversity and hardships in a male-dominated field, where resilient, tenacious, and ingenious women have nevertheless left their mark. The first women in neurosurgery appeared in Europe at the end of the 1920s, and since then have emerged in all continents in the world. Women neurosurgeons all over the globe have advanced the field in numerous directions, introducing neurosurgical subspecialties to their countries, making scientific and technical advances, and dedicating themselves to humanitarian causes, to name a few. The past 30 years, in particular, have been a period of increasing involvement and responsibility for women in neurosurgery. We must now focus on continual system improvements that will promote a diverse and talented workforce, building a welcoming environment for all aspiring neurosurgeons, in order to advance the specialty in the service of neurosurgical patients.

Gender Equity of Promoting Practices in Academic Neurosurgery in the United States

BACKGROUND

Women have historically been underrepresented in academic medicine, particularly in surgical subspecialties. This study investigated potential associations between gender and promoting practices in academic neurosurgery.

METHODS

Faculty data, including time from residency, professorship, specialty, and h-index, were obtained from websites of the institutions listed in the American Association of Neurological Surgeons Neurosurgical Residency Training Program Directory. Demographics, training, and appointments were compared between male and female neurosurgeons. Predictors of professorship, chair, directorship, and division leadership were identified using multivariable models.

RESULTS

The study examined 1629 faculty members. Women were more likely to be assistant professors (P < 0.0001), while men were more likely to be full professors (P < 0.0001), hold chair positions (P = 0.007), lead subspecialty divisions (P = 0.008), and have a higher Scopus h-index (P < 0.0001). In a multivariable analysis, years from training (P < 0.001), fellowship (P = 0.009), h-index (P < 0.001), and chair/program director/division leadership position (P < 0.001) were significant positive predictors of full professorship. Holding additional advanced degrees (P = 0.010), leading a subspecialty division (P = 0.005), and having a higher h-index (P = 0.002) positively predicted chair position. However, when accounting for all other factors, gender was not a significant predictor of full professorship, division leadership, chair, or program directorship.

CONCLUSIONS

While significantly more men hold leadership positions in U.S. academic institutions, after controlling for contributing variables, there did not appear to be an association between gender and full professorship, division leadership, chair, or program directorship in academic neurosurgery. While the field still has significant work to do to achieve gender equity, these results may serve as encouragement to women who are looking to advance their careers in academic neurosurgery.

Women in neurointervention, a gender gap? Results of a prospective online survey

BACKGROUND AND PURPOSE

Women's representation in medicine has increased over time yet the proportion of women practicing neurointervention remains low. We conducted an anonymous online survey through which we could explore the gender gap in neurointervention, identify potential issues, difficulties, or obstacles women might face, and evaluate if men encounter similar issues.

METHODS

An online questionnaire was designed in SurveyMonkey®. Invitation to participate was emailed through national and international neurointerventional societies as well as directly through private mailing lists to men and women working in neurointervention. Responses were collected from 10 May 2019 to 10 September 2019.

RESULTS

There were 295 complete responses, 173 (59%) male and 122 (41%) female. Most respondents (83%) fell within age categories 35-60 years, with representation from 40 countries across five continents. In all 95% were working full time, 73% had worked as a neurointerventionalist for >6 years, 77% worked in University-affiliated teaching institutions. Almost half of the respondents indicated no female neurointerventionalist worked in their center. Female respondents were younger and age-adjusted analysis was undertaken. Significantly fewer females than males were married and had children. Significantly fewer females held supervisory roles, held academic titles, and significantly less had a mentor. Females were less satisfied in their careers. More females felt they receive less recognition than colleagues of the opposite sex. Males had a greater proportion of work time dedicated to neurointervention. Similar proportions of both genders experienced bullying in work (40%-47%); however, sexual harassment was more common for females. There were no differences between genders in how they dealt with complications or their effects on mental well-being.

CONCLUSION

There are many potential reasons why women are underrepresented in neurointervention, however, the literature suggests this is not unique to our specialty. Multiple long-term strategies will be necessary to address these issues, some of which are discussed in the article.

Gender disparity in German neurosurgery

OBJECTIVE

Despite the rising number of women in higher education and leadership positions, the proportional rise of female neurosurgeons still lags behind these fields. This study evaluates the gender distribution in German neurosurgical departments across all career levels, and is aimed at heightening the awareness of gender disparity and the need for improving gender equality and its related opportunities.

METHODS

Data on gender distribution across all professional levels in German neurosurgical departments were obtained from departmental websites as well as by email and telephone request. Results were additionally analyzed in reference to hospital ownership type of the neurosurgical departments.

RESULTS

A total of 140 German neurosurgical departments employing 2324 neurosurgeons were evaluated. The analysis revealed a clear preponderance of men in leadership positions. Only 9 (6.3%) of 143 department heads were women, and there were only 1 (2.4%), 17 (14.5%), and 4 (12.5%) women among 42 vice-directors, 117 chief senior physicians, and 32 managing senior physicians, respectively. Senior physicians not holding a leadership position were female in 23.1%, whereas board-certified neurosurgeons not holding a senior physician position and residents were female in 33.6% and 35.0%, respectively. Of note, the highest proportion of female department heads (15.6%) was found in private hospitals.

CONCLUSIONS

The number of women in leadership positions in German neurosurgical departments is dramatically low, and with increasing leadership status gender disparity increases. Mentorship, recruitment, the perception of benefits offered by diversity and programs facilitating gender equality, job sharing, parental leave policies, and onsite childcare programs are needed to turn German neurosurgical departments into modern medical departments reflecting the gender profile of the general patient population.

Socioeconomic Implications of Professional Relationships within Modern Care Delivery Systems

No physician can successfully deliver high-value patient care in the modern-day health care system in isolation. Delivery of effective patient care requires integrated and collaborative systems that depend on dynamic professional relationships among members of the health care team. An overview of the socioeconomic implications of professional relationships within modern care delivery systems and potential employment models is presented.

Neurosurgery in Ethiopia: A New Chapter and Future Prospects

BACKGROUND

Inequitable access to surgical care is most conspicuous in low-income countries (LICs), such as Ethiopia, where infectious diseases, malnutrition, and other maladies consume the lion's share of the available health resources. The aim of this article was to provide an update on the current state of neurosurgery in Ethiopia and identify targets for future development of surgical capacity as a universal health coverage component in this East African nation.

METHODS

Publicly available data included in this report were gathered from resources published by international organizations. A PubMed search was used for a preliminary bibliometric analysis of scholarly output of neurosurgeons in Ethiopia and other low-income countries. Statistical analysis was used to determine the correlation between the number of neurosurgeons and academic productivity.

RESULTS

Neurosurgeon density has increased >20-fold from 0.0022 to 0.045 neurosurgeons per 100,000 population between 2006 and 2020. The increase in neurosurgeons was strongly correlated with an increase in total publications (P < 0.001) and the number of new publications per year (P = 0.003). Despite recent progress, the availability of neuroimaging equipment remains inadequate, with 38 computed tomography scanners and 11 magnetic resonance imaging machines for a population of 112.07 million. The geographic distribution of neurosurgical facilities is limited to 12 urban centers.

CONCLUSIONS

Ethiopian neurosurgery exemplifies the profound effect of international partnerships for training local surgeons on progress in low-income countries toward improved neurosurgical capacity. Collaborations that focus on increasing the neurosurgical workforce should synchronize with efforts to enhance the availability of diagnostic and surgical equipment necessary for basic neurosurgical care.

Factors Associated With Pregnancy and Perinatal Outcomes in Female Neurosurgeons: A Cross-Sectional Study

Neurosurgery is male dominated with women representing only 12% of residents and 5% of practicing neurosurgeons. The conflicting demands of training versus pregnancy and motherhood are significant deterrents to women entering the field. We examined pregnancy incidence and timing, perinatal complications, and the perceived career impact of motherhood on female neurosurgeons using an anonymous survey of 643 training, practicing, and retired female neurosurgeons from the United States. Among 260 respondents, 50.8% (132/260) reported pregnancies, with an average age at first pregnancy that was significantly higher than the national average (32.1 vs 26.3 yr). In all, 40.1% (53/132) of respondents reported perinatal complications in at least one of their pregnancies. Only 25% (33/132) of respondents noted designated program maternity allowances. The most significant challenges associated with being a mother and neurosurgeon reported were issues relating to work/life balance, "mommy guilt," and sleep deprivation. A majority of respondents, 70.1% (82/116), reported fear of backlash from co-residents, partners, and staff, as well as hindered career advancement related to childbearing. Female neurosurgeons face challenges surrounding family planning different from those faced by male practitioners. Higher perinatal and fetal complications, backlash from colleagues, and demanding workload are significant issues. Progress requires institutional support and mentorship for women to create a more diverse field of practitioners.

Social Perception and Academic Trends on Women in the Field of Neurosurgery: A Bibliometric Analysis

BACKGROUND

The ongoing trend of societal evolution in contemporary civilization has allowed increased inclusion of heterogenous identity groups into fields, such as neurosurgery, where certain groups have traditionally been underrepresented. In regard to the field of neurosurgery, the increasing recognition of the disparities faced by women is illustrated by a growing body of academic literature.

METHODS

We conducted a bibliometric analysis querying the PubMed, Web of Science, Scopus, and Embase databases for articles on women in neurosurgery using the MeSH terms "woman," "women," "gender," neurosurgery," neurological surgery," and "neurosurgeon." Articles were excluded if they did not concern societal impact of nonmale population in the context of neurosurgery. Total citations, mean citations per year, publishing journal information, and author demographics were abstracted from included reports. Associations between abstracted continuous variables were evaluated using the Pearson correlation coefficient. Derived P values < 0.05 were taken as significant.

RESULTS

A total of 49 articles were included. Total numbers of citations per report were positively associated with mean citations per year (r = 0.7289, P = 0.0253), the latter of which was slightly negatively associated with the age of the report (r = -0.0413, P = 0.0009). Age of publication year was found to be negatively correlated with the number of reports published per year (r = -0.648, P = 0.0066). Total citations per reports were significantly correlated with increased numbers of citations during the last completed calendar year (2019: r = 0.8956, P = 0.0397).

CONCLUSIONS

Recognition in societal evolutionary trends as evidenced by academic activity has shown increased focus on the explicit and intrinsic biases faced by women in neurosurgery. Recent years have seen significant increases in published reports concerning the subject, as well as rising academic impact per a given report. This phenomenon is speculated to continue, and understanding to broaden as societal perception continues to develop.

Academic Accomplishments of Female Neurosurgeons Currently in Practice in the United States

BACKGROUND

Women have now surpassed men in the number of medical students currently enrolled in the United States. However, in surgical subspecialties including neurosurgery, women continue to be significantly underrepresented. The objective of this study was to investigate the academic accomplishments of women in academic neurosurgery as measured by academic title, publications, and grant funding.

METHODS

A list of ACGME (Accreditation Council for Graduate Medical Education) accredited neurosurgery departments was utilized and department websites were reviewed to collect data regarding female and male faculty. Scopus and National Institutes of Health (NIH) RePORTER websites were used to collect other variables.

RESULTS

Women comprise 11.0% of all academic neurosurgeons. Of the 116 neurosurgery residency programs in the United States, 77% have at least 1 female faculty member. There are 172 academic female neurosurgeons in practice in the United States currently. Of academic female neurosurgeons, 61% are assistant professors, 21% are associate professors, and 18% are professors. Only 20 women hold leadership positions in their departments. Women have an average of 39.7 49.6 publications. The average h-index of academic female neurosurgeons is 12.0 11.1. Twenty-two women have or have had NIH funding with an average cumulative total grant value of $3,409,919. Having NIH funding and more publications is associated with higher academic rank and holding a leadership position. Women have significantly less funding and publications than men.

CONCLUSIONS

Women represent younger faculty with expected publication and grant funding productivity. As women continue to advance into more senior positions, the trends for number of publications and grant funding is expected to increase.

Trends in United States neurosurgery residency education and training over the last decade (2009-2019)

OBJECTIVE

Postgraduate training in medicine has been under scrutiny in the last 10 years, with a focus on improving residents' education. The aim of this study was to quantify trends in neurosurgery residency (NSR) training and education over the last 10 years.

METHODS

The authors assessed Accreditation Council for Graduate Medical Education (ACGME), National Resident Matching Program, and American Board of Neurological Surgeons records and searched PubMed to collate 2009-2019 data. Analyzed trends included residents' demographic data, programs' characteristics, graduation and attrition rates, match data, resident case logs, and qualitative educational curriculum changes.

RESULTS

Significant increases in residents' demographic data (p < 0.05) included the number of female residents (from 12.7% to 17.6%) and the absolute number of residents (from 1112 to 1462). Age (mean 28.8 years), ethnicity, and number of residents per program (mean 13 residents per program) were unchanged. There were 16 new ACGME NSR programs, with currently 115 programs nationwide. The number of applicants per year (324 applicants per year) and the matching rate (mean 64%) remained stable. The mean attrition rate of 2.6% (range 2%-4%) was higher than the mean 2.1% ACGME attrition rate, a rate that decreased from 3% in 2009 to 1.6% in 2019. Education curriculum changes aimed at the standardization of training across the US included residents' boot camp (2009), the Milestones project (2012), and mandatory 7-year training initiated in 2013. An increase in endovascular, functional, trauma, and spine resident caseload was noted. The number of yearly publications about US NSR education has significantly increased (p < 0.05).

CONCLUSIONS

NSR education has received greater attention over the last decade in the US. Standardization of training has been implemented. A steady number of students remain interested in neurosurgery, with an increased number of women entering the field. Attention to wellness, in addition to high-quality education, should be further assessed as a factor to improve the overall NSR training and retention rate.

Female insertion in neurosurgery: Evolution of a stigma break

BACKGROUND

Utilizing the Brazilian Medical Demography analysis and a literature review, we evaluated how women choose to become neurosurgeons in Brazil and around the world, specifically citing the Europe, the USA, India, and Japan.

METHODS

We utilized the Brazilian Medical Demography prepared by the Federal Council of Medicine and the Regional Council of Medicine of the State of São Paulo (2011, 2013, 2015, and 2018). We also included an evaluation of 20 articles from PubMed, the Scientific Electronic Library Online, and National Health Library databases (e.g., using descriptors "Women in neurosurgery" and "Career").

RESULTS

In Brazil in 2017, women comprised 45.6% of active doctors, but only 8.6% of all neurosurgeons. Of 20 articles identified in the literature, 50% analyzed the factors that influenced how women choose neurosurgery, 40% dealt with gender differences, while just 10% included an analysis of what it is like to be a female neurosurgeon in different countries/continents.

CONCLUSION

The participation of women in neurosurgery has increased in recent years despite the persistence of gender inequality and prejudice. More women need to be enabled to become neurosurgeons as their capabilities, manual dexterity, and judgment should be valued to improve the quality of neurosurgical health-care delivery.

Cross-sectional analysis of women in neurosurgery: a Canadian perspective

OBJECTIVE

Although the past decades have seen a steady increase of women in medicine in general, women continue to represent a minority of the physician-training staff and workforce in neurosurgery in Canada and worldwide. As such, the aim of this study was to analyze the experiences of women faculty practicing neurosurgery across Canada to better understand and address the factors contributing to this disparity.

METHODS

A historical, cross-sectional, and mixed-method analysis of survey responses was performed using survey results obtained from women attending neurosurgeons across Canada. A web-based survey platform was utilized to collect responses. Quantitative analyses were performed on the responses from the study questionnaire, including summary and comparative statistics. Qualitative analyses of free-text responses were performed using axial and open coding.

RESULTS

A total of 19 of 31 respondents (61.3%) completed the survey. Positive enabling factors for career success included supportive colleagues and work environment (52.6%); academic accomplishments, including publications and advanced degrees (36.8%); and advanced fellowship training (47.4%). Perceived barriers reported included inequalities with regard to career advancement opportunities (57.8%), conflicting professional and personal interests (57.8%), and lack of mentorship (36.8%). Quantitative analyses demonstrated emerging themes of an increased need for women mentors as well as support and recognition of the contributions to career advancement of personal and family-related factors.

CONCLUSIONS

This study represents, to the authors' knowledge, the first analysis of factors influencing career success and satisfaction in women neurosurgeons across Canada. This study highlights several key factors contributing to the low representation of women in neurosurgery and identifies specific actionable items that can be addressed by training programs and institutions. In particular, female mentorship, opportunities for career advancement, and increased recognition and integration of personal and professional roles were highlighted as areas for future intervention. These findings will provide a framework for addressing these factors and improving the recruitment and retention of females in this specialty.

Neurosurgeons in 2020: the impact of gender on neurosurgical training, family planning, and workplace culture

OBJECTIVE

In 2008, a Women in Neurosurgery Committee white paper called for increased women applicants and decreased women's attrition in neurosurgery. However, contributing factors (work-life balance, lack of female leadership, workplace gender inequality) have not been well characterized; therefore, specific actions cannot be implemented to improve these professional hurdles. This study provides an update on the experiences of neurosurgeons in 2020 with these historical challenges.

METHODS

An anonymous online survey was sent to all Accreditation Council for Graduate Medical Education (ACGME)-accredited US neurosurgical programs, examining demographics and experiences with mentorship, family life, fertility, and workplace conduct.

RESULTS

A total of 115 respondents (64 men, 51 women; age range 25-67 years) had trained at 49 different US residencies. Mentorship rates were very high among men and women in medical school and residency. However, women were significantly more likely than men to have a female mentor in residency. During residency, 33% of women versus 44% of men had children, and significantly fewer women interested in having a child were able to do so in residency, compared to men. Significantly more women than men had a child only during a nonclinical year (56.3% vs 19.0%, respectively). Thirty-nine percent of women and 25% of men reported difficulty conceiving. The major difficulty for men was stress, whereas women reported the physical challenges of pregnancy itself (workplace teratogens, morning sickness, etc.). Failed birth rates peaked during residency (0.33) versus those before (0.00) and after residency (0.25).Women (80%) experience microaggressions in the workplace significantly more than men (36%; p < 0.001). Ninety-five percent of macro-/microaggressions toward female neurosurgeons were about their gender, compared to 9% of those toward men (p < 0.001). The most common overall perpetrators were senior male residents and attendings, followed by male patients (against women) and female nurses or midlevel providers (against men).

CONCLUSIONS

Accurate depictions of neurosurgery experiences and open discussions of the potential impacts of gender may allow for 1) decreased attrition due to more accurate expectations and 2) improved characterization of gender differences in neurosurgery so the profession can work to address gender inequality.

History of Women in Neurosurgery (WINS)

In 2020, the Women in Neurosurgery (WINS) organization, a joint section of the AANS and Congress of Neurological Surgeons, celebrated 30 years since its inception. In this paper, the authors explore the history of WINS from its beginnings through its evolution over the past three decades. The achievements of the group are highlighted, as well as the broader achievements of the women in the neurosurgical community over this time period.

Slow progress in the visibility of women in neurosurgery in the United States: opportunity for improvement

OBJECTIVE

The goal of this study was to analyze the visibility of women within organized neurosurgery, including leadership positions, lectureships, and honored guest/award recipients at neurosurgical conferences.

METHODS

A cross-sectional study was used to analyze the gender demographics within the five major national neurosurgical societies (Congress of Neurological Surgeons [CNS], American Association of Neurological Surgeons [AANS], Society of Neurological Surgeons [SNS], American Board of Neurological Surgery [ABNS], and Council of State Neurosurgical Societies [CSNS]) from 2000 to 2020. Data for top leadership positions, keynote speakers, honored guests, and invited lectureships at these neurosurgical societies were reviewed. Additionally, national neurosurgical residency match data from 2018 to 2020 were collected. For each aforementioned data point, gender was determined and confirmed via publicly available data. Data from the US News and World Report best hospitals publication for 2020 were applied for analyzing gender trends within neurosurgical residencies specifically.

RESULTS

In the past 2 decades (2000-2020), top leadership positions across the neurosurgical organizations were held by 45 individuals, of whom 5 (11.1%) were women. Spanning from 2000 to 2018, just 8.1% (50 of 618) of guests/honored speakers on the national neurosurgical stage of the CNS, AANS, SNS, and CSNS meetings have been female. Excluding the Louise Eisenhardt Lecture (honoring women), the percentage of female guests/honored speakers at the AANS meeting was just 5% (17 of 367). For the CNS annual meetings, 13.4% (20 of 149) of the speakers were women from 2000 to 2018, whereas the CSNS annual meeting data from 2001 to 2018 found that 11.9% (7 of 59) of speakers were women. From 1952 to the present, there have been no female honored guests at the CNS annual meeting. Across the residency match cycles from 2018 to 2020, the percentages of matched applicants identifying as female have been 22.7%, 28.1%, and, most recently, 25.3%. The percentage of female residents is 28.5% (top 20 program) versus 24.3% (non-top 20 program) (p = 0.267).

CONCLUSIONS

This study found that for all the data points surveyed, including leadership positions, invited lectureships at national neurosurgical meetings, and successful neurosurgical residency applicants, disproportionate female underrepresentation was evident. Consistent lack of visibility leads to a negative impact on progress in the recruitment and retention of women in neurosurgery. Visibility, mentorship, role models, and sponsorship are highly interrelated processes and are essential for meaningful progress.

Women neurosurgeons around the world: a systematic review

OBJECTIVE

Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field.

METHODS

The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows.

RESULTS

The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden.

CONCLUSIONS

The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.

Women's role in neurosurgical research: is the gender gap improving?

OBJECTIVE

The percentage of women publishing high-impact neurosurgical research might be perceived as a representation of our specialty and may influence the perpetuation of the existing gender gap. This study investigated whether the trend in women taking lead roles in neurosurgical research has mirrored the increase in female neurosurgeons during the past decade and whether our most prestigious publications portray enough female role models to stimulate gender diversity among the new generation of neurosurgeons.

METHODS

Two of the most prominent neurosurgical journals-Journal of Neurosurgery and Neurosurgery-were selected for this study, and every original article that was published in 2009 and 2019 in each of those journals was investigated according to the gender of the first and senior authors, their academic titles, their affiliations, and their institutions' region.

RESULTS

A total of 1328 articles were analyzed. The percentage of female authors was significantly higher in Europe and Russia compared with the US and Canada (first authors: 60/302 [19.9%] vs 109/829 [13.1%], p = 0.005; and senior authors: 32/302 [10.6%] vs 57/829 [6.9%], p = 0.040). Significantly increased female authorship was observed from 2009 to 2019, and overall numbers of both first and senior female authors almost doubled. However, when analyzing by regions, female authorship increased significantly only in the US and Canada. Female authors of neurosurgical research articles were significantly less likely to hold an MD degree compared with men. Female neurosurgeons serving as senior authors were represented in only 3.6% (48/1328) of articles. Women serving as senior authors were more likely to have a female colleague listed as the first author of their research (29/97 [29.9%] vs 155/1231 [12.6%]; χ2 = 22.561, p = 0.001).

CONCLUSIONS

Although this work showed an encouraging increase in the number of women publishing high-impact neurosurgical research, the stagnant trend in Europe may suggest that a glass ceiling has been reached and further advances in equity would require more aggressive measures. The differences in the researchers' profiles (academic title and affiliation) suggest an even wider gender gap. Cultural unconscious bias may explain why female senior authors have more than double the number of women serving as their junior authors compared with men. While changes in the workforce happen, strategies such as publishing specific issues on women, encouraging female editorials, and working toward more gender-balanced editorial boards may help our journals to portray a more equitable specialty that would not discourage bright female candidates.