Diversification of academic medicine improves healthcare standards and patient outcomes. Gender and racial inequalities are major challenges faced by the healthcare system. This article reviews the trends of gender and racial disparity among residents of neurology. This retrospective analysis of the annual Accreditation Council for Graduate Medical Education Data Resource Books encompassed all residents at US neurology residency training programmes from the year 2007 to 2018. The representation of women steadily increased, with an absolute increase of 3% from the year 2007 to 2018. Although the absolute change (%) increased for the White race, Asian/Pacific Islander, Black/African Americans, there was a decrease seen in the Hispanic representation in neurology residents from the year 2011 to 2018. There was no change seen for the Native Americans/Alaskans. Our study concluded that gender and racial disparity persists in the recruitment of residents in neurology. This study highlights the need for targeted interventions to address gender and racial disparity among residents of neurology. Further studies are needed to explore etiological factors to address gender and racial disparity.
- ethics (see medical ethics)
- international health services
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The USA is the third most populous country in the world, with an estimated population of 330 052 960 as of August 2nd, 2020, whereby 49.4% men and 50.6% women constituting the total population.1 Immigration is one of the reasons for the continued increase in the US population, with the foreign-born population doubling from almost 20 million in 1990 to over 45 million in 2015, thus representing a one-third increase in their population.2 In 2017, White/Caucasian comprised 73% of US population, Blacks/African Americans comprised 12.7%, Asians, 5%, American Indians/Native Alaskans, 0.8%, Native Hawaiians/Pacific Islanders, 0.2% and other populations comprised 2% of total US population.3
With the increasing population of minorities in the USA, variegation of health faculty and professionals is crucial to improve health standards and patient outcomes.4 The under-represented minority (URM) physicians are also a valuable resource for mentoring URM students along with the provision of culturally competent care to a culturally diverse patient population.5 Despite ongoing efforts for equity, diversity and inclusion, disparities are prevalent in academic disciplines, professional societies and editorial boards of medical journals.4
Similarly, gender disparity also exists at all academic levels, that is, among medical students, residents, physicians and faculty members.6 Several reports have suggested an under-representation of women in academic medicine.7 8 Female academic physicians are outnumbered by their male counterparts and lag in career progression in academic ranks, accounting for only 13% of department leaders at top US medical schools.9 Between 1979 and 1997, the proportion of female faculty members who were full professors remained approximately 12%.10 Women are also inadequately represented in leadership positions. For example, from 2004 to 2014, there was only a 5% and 6% increase in the percentage of female department chairs and deans, respectively.11
Isolation, hostile work environment, discrimination, communication barriers, greater debt burden, lack of protected research time, lack of mentorship and challenges in making meaningful relationships and difficulties associated with obtaining grants are some of the factors contributing to gender and racial disparities.12 13 Medical organisations like the American Medical Association, the American Association of Medical Colleges (AAMC) and the National Medical Association have made task forces to diversify representation resulting in a more creative, productive, innovative and egalitarian environment. Despite all the efforts, there has been slow progress towards diversification and inclusion in the academic neurology workforce over the past decade.14
In this study, we retrospectively analysed the gender and racial disparity trends in residents of neurology across the USA, by extracting data from the annual data resource book of the Accreditation Council for Graduate Medical Education from 2007 to 2018. Demographic data (ie, race/ethnicity and gender) of residents were extracted. Race/ethnicity was categorised as White/Non-Hispanic, Asian/Pacific Islander, Hispanic, Black/Non-Hispanic, Native American/Alaskan, Others and Unknown. Gender was categorised as Male, Female and Not Reported. Although data for gender distribution were available for all years (ie, 2007–2018), race/ethnicity was reported starting from the year 2011. Gender data were not reported by 7.36% of residents. The representation of women increased steadily with an absolute increase of 3% from 2007 to 2018. However, the rate of growth for our study period was double for men as compared with women. In 2007, men accounted for 55% while women accounted for 40% of all residents in neurology, which represents a ratio of 2:1. Likewise, in 2018, men accounted for 52% while women accounted for 43% of all academic neurologists and it also represents a ratio of 2:1 (figure 1).
For racial distribution, our study period ranged from 2011 to 2018. The absolute change in racial distribution was highest for Whites/Caucasians (+369), followed by Asian/Pacific Islander (+192), Black/African Americans (+54), Hispanics (+38), Native Americans/Alaskans (+1) and others (+5) (table 1). Although the absolute change (%) increased for the White race, Asian/Pacific Islander, Black/African Americans, there was a decrease seen in the Hispanic representation in neurology residents from the year 2011 to 2018. There was no change seen for the Native Americans/Alaskans.
Despite an increase in the total number of residency positions in neurology, significant racial and gender differences persist. When averaged across the 11 years of the study period almost two-thirds of all neurology residents were men; these findings are consistent with previous studies, both for neurology and other medical specialties.5 8 15 In our study, female residents increased in proportion and the absolute number of female residents from 2007 to 2018. Our findings are in line with the study from AAMC according to which, within the most recent decade, the percentage of female physicians practicing neurology in the USA increased by 21.1% between 2007 (n=2923 of 12 612; 23.2%) and 2015 (n=3760 of 13 378; 28.1%).16 The percentage of women working in academic neurology departments increased by 25% between 2009 (n=879; 28%) and 2015 (n=1455; 35%).17 18 Despite these increases, female representation at higher tiers of academic neurology is not adequate.19
Cultural stereotypes, asymmetric home or childcare responsibilities, professional isolation and different career motivation are the few explanations proposed for the gender disparity.20 21 For example, some studies have suggested asymmetric and higher family commitment for female physicians compared with their male counterparts. Similar obstacles coupled with gender-discriminatory behaviour prevent women from entering typically ‘male’ branches. Gender stereotypes lead to the clustering of residents in certain specialties.22 It appears that women often have to make their family decisions during the same years when their dedication to research is expected to be strongest. Access to encouraging resources such as protected time for maternity leave, flexible daycare for children or elderly parents within the hospital settings or telehealth options could minimise some of the burdens placed on women.23 Legislation and incentives for departments that work to actively minimise the gender gap has worked well to resolve this otherwise intractable problem.24 Through offering incentives and financial support for departments that achieve gender equity, offers protected time for family growth, offers support for personal development and these programmes can incentivise gender disparity in the worksite. Our study results corroborated by existing evidence regarding gender disparity in other specialties of healthcare system. A study conducted by Sheikh et al showed the representation of female psychiatrist of only 42% and it was even less for higher academic positions.25 A similar study was conducted to review the gender disparity in editorial board members of journals of psychiatry, which revealed even less representation of 30% for women.26
A similar trend is seen while comparing the representation of different races within the residency training programmes of neurology in the USA. When averaged across an 8-year study period, the WhiteCaucasian/ race was over-represented among all neurology residents followed by Asian/Pacific Islanders. There can be several explanations for our findings. A previous study has attributed the increasing Asian faculty representation to a parallel increase in the total population of Asians in the USA.4 Over the past two decades, the Asian population has been the fastest-growing racial or ethnic group and is projected to be the second fastest-growing group from 2014 to 2060.27 BlackAmericanAfrican /, Hispanic and multiple race physicians have even less representation in healthcare. A study conducted over a period of 12 years to review the racial disparity in academic psychiatry showed that the representation of WhitCaucasians/Caucasian/ was 73% of all academic positions and other races were under-represented.12
Although an increasing percentage of Asian/Pacific Islander faculty has reached the middle tier of academia, they still face challenges to increase their representation in leadership positions. Several barriers are faced by URMs to acquiring a residency position to promotion in faculty, including a greater debt burden, limited negotiation skills, as well as racial prejudice and discrimination at the workplace.12 28 The lack of minority preceptors is another major obstacle in the recruitment and retention of ethnic minorities.29
The advantages of increasing the representation of URM in neurology are multi-faceted. First, it will improve communication with patients and would make healthcare more diverse and accessible.30 Second, cultural competency enables physicians to acknowledge health beliefs and improve compliance and outcomes.12 31 Last, the promotion and retention of URM faculty would provide identifiable preceptors for minority students.31
We recommended several initiatives to minimise these disparities in healthcare system in general and neurology specifically. Setting diversity as priority is the first step. It can be achieved by reflective questioning regarding relevant criteria, data collection to gather qualitative and quantitative indicators of the institution’s diversity and inclusion, synthesis and analysis to identify strengths and opportunities for development and leveraging findings to translate the assessment into outcomes through communications with stakeholders and change agents. An initial, and year-round, inclusive recruitment effort must include seeking out outstanding URM candidates. For this, attending regional and national meetings of student-run organisations that focus on the needs and concerns of URM medical students alongside a holistic review of applicant’s pool should be done. To recruit and match a more diverse residency class, programmes should maximise chances of success by inviting a more diverse group of applicants to interview. The interviews should be conducted using a universal set of criteria. Finally departments, residency faculty and trainees, together with undergraduate medical education (ME) and affiliated medical school students, can partner with local elementary school, high schools and colleges to expose URM students to careers in medicine.32
The findings of this study indicate that further research is needed into the multifactorial reasons contributing to the decreased representation of women and racial disparity in residency training programmes in neurology. Our study has its share of limitations. This study focused on data neurology residents and thus may have limited generalisability to other specialties. Our study used a dataset that describes gender in a binary fashion. Finally, our study did not explore the combined effects of being both a gender and a racial minority, such as female Hispanic or female Black/African American residents. Gender and racial disparity persist within the residency training programmes in neurology. Efforts at all levels are also needed to provide greater support for the careers of URM faculty to ensure their unbiased representation at all levels of academic neurology.
What are the current trends of gender and racial representation among neurology residents in US residency programmes?
What actions do we need to take to increase the representation of women and under-represented minorities in neurology?
Do the findings of our study also hold true for other specialties and subspecialties of medicine?
There is significant gender disparity among residents in academic neurology.
When averaged across 11-year study period, the representation of women increased steadily but the ratio was double for men as compared with women.
Minorities are under-represented among residents in neurology.
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Correction notice This article has been corrected since it first published. The provenance and peer review statement has been included.
Contributors HM contributed to literature search, statistical analysis, writing and composing the manuscript. SN contributed to data collection, modifying research questions and editing manuscript. AMDC contributed to manuscript writing, statistical analysis and data collection. MTK contributed to helping in writing and editing manuscript. FK contributed to data collection and editing manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests FK is the recipient of the AFMC-May Cohen Equity, Diversity and Gender Award (2020).
Provenance and peer review Not commissioned; externally peer reviewed.