The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery

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Preface

The leadership of Women in Neurosurgery (WINS) has been asked by the Board of Directors of the American Association of Neurological Surgeons (AANS) to compose a white paper on the recruitment and retention of female neurosurgical residents and practitioners.

Introduction

Neurosurgery must attract the best and the brightest. Women now constitute a larger percentage of medical school classes than men, representing approximately 60% of each graduating medical school class. Neurosurgery is facing a potential crisis in the US workforce pipeline, with the number of neurosurgeons in the US (per capita) decreasing.

Women in the Neurosurgery Workforce

The number of women entering neurosurgery training programs and the number of board-certified female neurosurgeons is not increasing. Personal anecdotes demonstrating gender inequity abound among female neurosurgeons at every level of training and career development. Gender inequity exists in neurosurgery training programs, in the neurosurgery workplace, and within organized neurosurgery.

Obstacles

The consistently low numbers of women in neurosurgery training programs and in the workplace results in a dearth of female role models for the mentoring of residents and junior faculty/practitioners. This lack of guidance contributes to perpetuation of barriers to women considering careers in neurosurgery, and to the lack of professional advancement experienced by women already in the field. There is ample evidence that mentors and role models play a critical role in the training and retention of women faculty within academic medicine. The absence of a critical mass of female neurosurgeons in academic medicine may serve as a deterrent to female medical students deciding whether or not to pursue careers in neurosurgery. There is limited exposure to neurosurgery during medical school. Medical students have concerns regarding gender inequities (acceptance into residency, salaries, promotion, and achieving leadership positions). Gender inequity in academic medicine is not unique to neurosurgery; nonetheless, promotion to full professor, to neurosurgery department chair, or to a national leadership position is exceedingly rare within neurosurgery. Bright, competent, committed female neurosurgeons exist in the workforce, yet they are not being promoted in numbers comparable to their male counterparts. No female neurosurgeon has ever been president of the AANS, Congress of Neurological Surgeons, or Society of Neurological Surgeons (SNS), or chair of the American Board of Neurological Surgery (ABNS). No female neurosurgeon has even been on the ABNS or the Neurological Surgery Residency Review Committee and, until this year, no more than 2 women have simultaneously been members of the SNS. Gender inequity serves as a barrier to the advancement of women within both academic and community-based neurosurgery.

Strategic Approach to Address Issues Identified.

To overcome the issues identified above, the authors recommend that the AANS join WINS in implementing a strategic plan, as follows: 1) Characterize the barriers. 2) Identify and eliminate discriminatory practices in the recruitment of medical students, in the training of residents, and in the hiring and advancement of neurosurgeons. 3) Promote women into leadership positions within organized neurosurgery. 4) Foster the development of female neurosurgeon role models by the training and promotion of competent, enthusiastic, female trainees and surgeons.

Abbreviations used in this paper: AANS = American Association of Neurological Surgeons; ABNS = American Board of Neurological Surgery; CNS = Congress of Neurological Surgeons; RRC = Neurological Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education; SNS = Society of Neurological Surgeons; WINS = Women in Neurosurgery.

Abstract

Preface

The leadership of Women in Neurosurgery (WINS) has been asked by the Board of Directors of the American Association of Neurological Surgeons (AANS) to compose a white paper on the recruitment and retention of female neurosurgical residents and practitioners.

Introduction

Neurosurgery must attract the best and the brightest. Women now constitute a larger percentage of medical school classes than men, representing approximately 60% of each graduating medical school class. Neurosurgery is facing a potential crisis in the US workforce pipeline, with the number of neurosurgeons in the US (per capita) decreasing.

Women in the Neurosurgery Workforce

The number of women entering neurosurgery training programs and the number of board-certified female neurosurgeons is not increasing. Personal anecdotes demonstrating gender inequity abound among female neurosurgeons at every level of training and career development. Gender inequity exists in neurosurgery training programs, in the neurosurgery workplace, and within organized neurosurgery.

Obstacles

The consistently low numbers of women in neurosurgery training programs and in the workplace results in a dearth of female role models for the mentoring of residents and junior faculty/practitioners. This lack of guidance contributes to perpetuation of barriers to women considering careers in neurosurgery, and to the lack of professional advancement experienced by women already in the field. There is ample evidence that mentors and role models play a critical role in the training and retention of women faculty within academic medicine. The absence of a critical mass of female neurosurgeons in academic medicine may serve as a deterrent to female medical students deciding whether or not to pursue careers in neurosurgery. There is limited exposure to neurosurgery during medical school. Medical students have concerns regarding gender inequities (acceptance into residency, salaries, promotion, and achieving leadership positions). Gender inequity in academic medicine is not unique to neurosurgery; nonetheless, promotion to full professor, to neurosurgery department chair, or to a national leadership position is exceedingly rare within neurosurgery. Bright, competent, committed female neurosurgeons exist in the workforce, yet they are not being promoted in numbers comparable to their male counterparts. No female neurosurgeon has ever been president of the AANS, Congress of Neurological Surgeons, or Society of Neurological Surgeons (SNS), or chair of the American Board of Neurological Surgery (ABNS). No female neurosurgeon has even been on the ABNS or the Neurological Surgery Residency Review Committee and, until this year, no more than 2 women have simultaneously been members of the SNS. Gender inequity serves as a barrier to the advancement of women within both academic and community-based neurosurgery.

Strategic Approach to Address Issues Identified.

To overcome the issues identified above, the authors recommend that the AANS join WINS in implementing a strategic plan, as follows: 1) Characterize the barriers. 2) Identify and eliminate discriminatory practices in the recruitment of medical students, in the training of residents, and in the hiring and advancement of neurosurgeons. 3) Promote women into leadership positions within organized neurosurgery. 4) Foster the development of female neurosurgeon role models by the training and promotion of competent, enthusiastic, female trainees and surgeons.

The AANS Board of Directors requested that the WINS Executive Board prepare a position paper on the recruitment and retention of female neurosurgeons. In the preparation of this white paper, existing data were reviewed to evaluate the many issues relevant to recruitment, retention, and advancement. Additional resources and data-driven studies were used to help analyze the existing neurosurgical data. The following represents a summary of the crucial issues.

Neurosurgery must continue to attract the best and the brightest for the continued growth and viability of our profession. Once recruited, these highly talented individuals must be trained in a learning environment that demands competence, dedication, hard work, inquiry, and a commitment to continual improvement. Activity that merely seeks to maintain the status quo must be recognized as detrimental.

Economic forces are currently threatening academic medicine in general.5 The challenges are increasing for both sexes. Addressing these challenges within medicine and specifically within neurosurgery is paramount for the recruitment, retention, and advancement of women. In the face of a looming crisis in the workforce, the future of American neurosurgery is inextricably linked to the development of female leaders now.

The purpose of this white paper is to identify existing barriers to the recruitment and retention of female neurosurgeons at all levels of training and professional development and to specifically recommend feasible and rational strategies to directly address these barriers.

Women in the Neurosurgery Workforce

Women in Academic Medicine

The percentage of female applicants to medical school began to increase during the 1970s.18,23 Since 1995, female applicants have consistently outnumbered male applicants and have achieved a higher acceptance rate4 in medical school classes. Nonetheless, women continue to lag significantly within academic medicine with respect to faculty appointments, promotion, and tenure. Most striking is the lack of women in positions of leadership (professorships, deanships, and so forth), a finding that has been documented across specialties and institutions.1,2,5,14,18,19,21,23,25,31 Women remain under-represented on professional society and editorial boards universally and are critically lacking in some specialties.8,20,21,23,24 In addition, current studies show that, on average, women in academic medicine continue to earn at least 10% less than their male counterparts.30,31 Encouragingly, once these disparities are recognized, targeted interventions have been shown to eliminate such inequities.30

Looking specifically at surgery and surgical specialties, there has also been a dramatic increase in the total number of female applicants to residencies commensurate with the increased number of women in medical school. Today, women constitute 30% of the general surgery resident population, occupy many chair positions, and hold prominent national and editorial positions.10 It has been suggested that the workforce crisis faced by general surgery training programs during the last decade motivated these programs to implement changes necessary to attract and promote qualified women. Several surgical specialties—including orthopedics, thoracic surgery, and neurosurgery—have progressed at a much slower pace, however. In fact, the percentage of female residents choosing orthopedics is less than 1% and has not changed in 20 years!8

Several task forces have evaluated this issue and made cogent recommendations on the factors identified as barriers to women within academic medicine and means to redress them.3,6,11 These findings are summarized in Appendix 1. These task forces have all emphasized the need for active intervention and continual reanalysis of progress with necessary adjustments. A particularly insightful analysis debunks the existence of a “glass ceiling”—that is, a deliberate and active barrier—and redefines the current challenges in terms of “cumulative disadvantages.”6 The authors also describe a closely related phenomenon of the “glass house,” in which women who do progress in male-predominant arenas represent such a rarity that they are subject to great scrutiny and substantial isolation. It has been determined that any minority with fewer than 15% representation within a group has not reached “critical mass” and therefore should be defined as having “less than minority” status, as their small numbers make them function not as a minority group but rather as isolated individuals.16 In corroboration of this thesis, Dr. Joan Venes, one of the first female neurosurgeons in the US, has remarked on her persistent feelings of isolation from the team.27

Key tactics for remedying this problem include the following: 1) fostering faculty diversity; 2) providing active professional development of all faculty; 3) ensuring critical assessment of institutional practices; 4) enhancing efforts to attract and recruit women to all positions; and 5) supporting programs (financially) that periodically reassess and address these issues.1,6,7,11,17 Mentoring has also been shown to play a crucial role for trainees and, in particular, for women. Effective mentoring can result in translating potential into tangible career strides. Mentoring should thus be included as a core academic responsibility in training programs as well as in professional organizations within neurosurgery.

While many of the issues facing neurosurgery exist within academic medicine, private practice, and society as a whole,1,2,5,9,13,17,19,29 to ignore these issues in the face of an increasingly female medical school class will jeopardize the workforce pipeline that is necessary for the survival of our comparatively small specialty.

Workforce, Women, and Neurosurgery

Two recent articles have addressed the problems facing the neurosurgical workforce: “The Neurosurgical Workforce in North America: A Critical Review of Gender Issues”29 and “Toward Harnessing Forces of Change: Assessing the Neurosurgical Workforce.”4 Both articles point out the growing disparity between the number of women in neurosurgical training and practice versus the number of women in the general workforce and graduating from medical school.

In 2005, > 55% of students accepted to medical school were women, and female applicants to medical school have consistently outnumbered male applicants since 1995.4 In addition, there has been a significant decrease in the overall number of neurosurgeons relative to the general population, “from 1:80,000 in 1990 to 1:91,500 in 2000.”4 This statistic suggests a shrinking supply of neurosurgeons relative to the population, despite a modest increase in the number of residency positions now available.

Woodrow et al.29 cite a graph from JAMA documenting a general increase in female residents in all specialty training programs with a highly disproportionate and slower increase in female neurosurgery residents—especially when compared with general surgery. Currently, approximately 10% of all neurosurgery residents are female4— a figure that has been relatively static since 1998 (Fig. 1). Similarly, the total number of female graduates from neurosurgery residencies grew steadily until 1998 but has largely leveled off since then (Fig. 2). The percentage of female resident applicants choosing neurosurgery between 1990 and 2003 demonstrates no change (0.2% of female resident applicants).

Fig. 1.
Fig. 1.

Line graph showing the percentage of women in the population of neurosurgery residents from 1989 through 2003.

Fig. 2.
Fig. 2.

Line graph showing the number of female graduates from neurosurgery residencies by year.

A critical statistic to consider is the number of women who are ABNS certified. Although this number grew during the decades between 1960 and 1990, this growth was not sustained after 1990 (Fig. 3).

Fig. 3.
Fig. 3.

Bar graph showing the number of ABNS-certified female neurosurgeons by decade.

Currently, only 5.9% of practicing neurosurgeons are women, despite the preponderance of female medical students.4 Furthermore, the number of neurosurgeons in practice in the US has decreased.4 In order to meet the needs of our patient population we need to continue to recruit, train, and retain the next generation of neurosurgeons. Given the realities of the workforce—that is, the preponderance of women graduating from medical school—it is imperative to identify and address the factors that are deterring women from entering or remaining in careers in neurosurgery.

Obstacles

Obstacles to the Recruitment of Women Into Neurosurgery

Authors of several recent studies have sought to identify the most important factors determining career choice within medicine. While it is often assumed that “lifestyle” issues are the driving force behind career selection, studies demonstrate that mentoring and the presence of role models have the strongest influence.9,10,20,28 The gender composition of a given specialty also represents a statistically significant factor in career selection decisions made by women.14,18,22,28

Specifically, 80% of women polled felt that female medical students need role models of successful female faculty members. Currently in the US there are only 189 ABNS-certified female neurosurgeons, 25 full-time female academic neurosurgeons, and 1 female chair of a neurosurgery department (statistics provided by the ABNS and AANS). Globally, exposure of medical students to neurosurgery within most medical schools is limited; however, exposure of medical students to female neurosurgeons is exceedingly rare. While many male neurosurgeons have served and will continue to serve as mentors and role models for women interested in neurosurgery, studies suggest that women frequently prefer female mentors and seek to identify female role models.6 Interest in surgery (neurosurgery) needs to be fostered early in a medical student's education.9 For optimal efficacy, it is necessary to target recruitment efforts at 1stand 2nd-year medical students. Significant efforts directed at medical school curriculum committees are needed. Currently, < 10% of medical students are exposed to a neurosurgery curriculum. There is a compelling need for innovative programs that expose medical students, as well as undergraduates and high school students, to the field of neurosurgery.

Impediments to general recruitment into neurosurgery include long working hours, length of training, and risk of litigation. Women have concerns about, and firsthand knowledge of, gender inequity in regard to salaries, academic promotion, and achieving leadership positions. Another deterrent for women is the perception among medical students that female applicants have difficulty gaining acceptance into neurosurgery residency training programs. The current San Francisco Matching Program (SF Match) database does not allow direct analysis of these data, but indirect statistics support this perception. As late as the 1990s, at least 30% of US neurosurgical residency programs had never graduated a female resident, and in 2007 there are still 4 programs that have had no female residents (see Appendix 2). Three programs (Case Western, Mt. Sinai, and University of Utah), representing just 2% of all residencies, have accepted > 9% of all female residents. These 3, together with an additional 13 programs (representing 12% of the total programs), account for 32% of all female neurosurgeons in training. Interestingly, all but 2 (12.5%) of these 16 programs graduated their first woman prior to 1992. Gender inequity and sexual harassment during medical school rotations and residency application may discourage others.26 Many female medical students further believe that once accepted into a neurosurgery training program they are likely to be subject to harassment and inequity. This view may be supported by medical school faculty members who do not realize that, for the most part, the neurosurgical environment has changed. Believing that they are acting in the students' best interests, medical school advisors and mentors gently guide them away from neurosurgery into other disciplines. It will, in our opinion, take an aggressive, proactive effort in recruiting female resident applicants by all neurosurgical training programs to change these perceptions. There must also be a “zero-tolerance” culture within neurosurgical departments toward harassment, unfairness, and inequity of any kind.

Obstacles to the Retention of Female Neurosurgery Residents

Although anecdotes abound, there are no existing data on the retention of female neurosurgery residents. It has been stated that female residents drop out of training programs more frequently than their male counterparts, but no data exist to support or refute this contention. If it is true, it would be important to know if this rate were any different from the rate at which women change specialty training in general. A thorough analysis of these issues is crucial for the insight it provides into our specialty and its future. Specific recommendations to acquire this information are included in the last paragraph of this section. Ideally, exit interviews with all neurosurgery residents leaving programs—voluntarily or otherwise—should be conducted to identify what factors contribute to attrition. Additionally, confidential questionnaires to female residents currently in training would help identify important remediable problems within the work environment.

Studies demonstrate that residents learn through very different mechanisms.6,10,17 This observation suggests that a variety of learning strategies may be necessary to achieve the intended outcome of a well-trained, competent neurosurgeon. Suitable mentoring is a crucial component for all residents but may be even more important for female residents. For many women, an important component of success, particularly during residency training, is the perception of “team spirit,” with satisfaction derived as much from overall success as from individual accomplishment.15

Obstacles to the Retention of Female Neurosurgeons

The number of women in neurosurgery remains below the 15% threshold required to achieve “minority” status within a field.16 Clearly, the total number of ABNScertified female neurosurgeons has grown since the first woman gained certification in 1960. Overall statistics in the US reveal that only 179 (3.0%) of the 5854 ABNS diplomates are women. Of the 3545 diplomates assumed to be actively practicing, 165 (4.7%) are female. In academic neurosurgery, women account for ~ 6% of the neurosurgeons who are full-time faculty members (25 of 400) and represent 4.6% of those in private practice (145 of 3145). Specifically, review of the data (Fig. 3) demonstrates a tripling of the total number of ABNS-certified female neurosurgeons when comparing the years 1981–1990 with 1991–2000. However, over the last half-decade, this growth curve has leveled off and, in fact, the number of newly certified women has not increased during each of the last 2 decades (Fig. 3). These data do not take into account attrition due to retirement or career change.

As part of a recent internal strategic planning process, WINS conducted a “Member Needs Survey.” The survey was sent to all 352 female residents and graduates of American neurosurgical residency programs via email. Of these 352 surveys sent, 152 (43%) were returned. A number of others, however, were never received due to outdated data or email filters, bringing the true response rate close to 50%. One hundred and seventy (48%) of the 352 surveys were sent to the WINS members for whom email addresses were available. Of the 152 responses, 95 were from WINS members (56% response rate for WINS members).

Of the respondents, many perceived that there was a “glass ceiling” (cumulative disadvantage) in academic neurosurgery (63%) and organized neurosurgery (64%), while 80% of respondents felt that women were not well represented in organized neurosurgery. Above all, 87% of respondents felt that gender inequity was present in neurosurgery. These perceptions are not unfounded, in light of the following facts. In academic medicine, 10.9% of full professorships are held by women,7,18 whereas in neurosurgery only 6% of the faculty are women. It is unclear how many of these women hold tenure-track positions and how many are assistant, associate, or full professors. A female neurosurgeon did not become chair of an American department of neurological surgery until 2005, when Dr. Karin Muraszko was appointed chair of the Department of Neurosurgery at the University of Michigan, and Dr. Muraszko remains the only female chair of a neurosurgical department in the US. The American Academy of Neurological Surgeons voted no woman into membership until 2007 when Dr. Muraszko was voted in. No female neurosurgeon has ever been an officer of the CNS or the AANS. Until 2007, there had never been more than 2 female members of the SNS at any given time (the late 2007 elections for SNS finally broke this barrier). There has never been a female neurosurgeon as an ABNS director or on the RRC.

To date, no study has specifically addressed the issues regarding the obstacles to the retention and advancement of female neurosurgeons. It is likely that many of the issues will be similar to the factors affecting promotion within academic medicine at large (see Women in the Neurosurgery Workforce, above), and thus the potential strategies for improvement are likely to be similar. Unfortunately, it is unlikely that parity exists for compensation or promotion. While hard data is not currently available, rarely are women “groomed” by their chairs to become leaders locally, regionally, or nationally. Several important factors impact the ability of women to overcome this handicap. The following have been identified as the most crucial:

  • • Leadership training for all neurosurgeons is lacking.

  • • Negotiating skills—which are critical for all new faculty and for community-based practitioners—are not a component of neurosurgery residency curricula.

Moreover, it is essential that all institutions and neurosurgery programs have clearly defined and enforced policies on sexual harassment and discrimination. Networking is an important element in job satisfaction and success. As elegantly described by Ellen Daniell in her book Every Other Thursday: Stories and Strategies from Successful Women Scientists,12 it is essential to take the time to develop a cadre of advisors and colleagues who can be supportive throughout the different stages of a career. These must be individuals who are supportive but who will be honest and offer constructive criticism. Female neurosurgeons are often isolated and find it difficult to establish and maintain such a network.

A survey of all female neurosurgeons and a comparable cohort of male neurosurgeons could provide important data about equity issues including salaries and promotions. The results of such a survey would begin to answer the question of whether male and female neurosurgeons receive similar rewards for similar achievements. These data are necessary to help determine why women have not advanced into leadership positions within neurosurgery commensurate with their numbers in the profession over the last decade. In this fashion, potential obstacles to the retention of female neurosurgeons can be most appropriately addressed.

WINS Initiatives Aimed at Recruitment and Retention of Female Residents and Neurosurgeons

Since its inception in 1989, WINS has been a women's advocacy and networking group. The goal of WINS has been to attract women to the profession and to gain recognition for female neurosurgeons who are bright, competent, and highly committed to our profession. In turn, these efforts will help to ensure the continued advancement of neurosurgery. Toward this goal, we have undertaken many independent programs, including:

  • A. Biannual meetings to provide education and networking opportunities.

  • B. “So, You Want To Be a Neurosurgeon?” brochure development and additional contributions to resident recruitment efforts (most recently in conjunction with both the AANS and CNS).

  • C. Resident travel scholarships to the national meetings (AANS and CNS) honoring resident academic contribution. This program has been ongoing for more than 15 years:

    • 1. Louise Eisenhardt Resident Travel Scholarship

    • 2. Sherry Apple Resident Travel Scholarship

  • D. Named lectureships honoring pioneering women in the field of neurosurgery:

    • 1. Louise Eisenhardt, M.D.

    • 2. Ruth Kerr-Jakoby, M.D.

    • 3. Alexa Canady, M.D.

  • E. Recently developed programs, including:

    • 1. Speaker's Bureau—to provide medical student exposure to neurosurgery: WINS is in the early stages of organizing a Speaker's Bureau to offer lectures on neurosurgery careers to medical schools. Endorsement by the AANS and CNS would go a long way in establishing this important program for recruiting the best and the brightest of both genders.

    • 2. Mentoring Program: We have established a specialized Mentoring Program through which we will match students and residents with practicing female neurosurgeons. Dr. Roxanne Todor is the current chair of this program. Ultimately, coordination of this mentoring program with the AANS mentoring program would be optimal, allowing gender-specific mentoring if requested. In addition, the WINS mentoring program will reach out to those not yet eligible for the AANS program. Already, website development has become an integral part of this aspect of the mentoring program. A “Virtual Mentor” bulletin board is now under construction with a projected date of initiation in 2008. The bulletin board will be part of a password-protected site and designed to allow students to ask questions or express concerns and receive responses from WINS members. In addition, medical student membership in WINS is being offered without fee. Interested college students will also be welcome to join. These mentoring efforts are designed to supplement rather than substitute the ongoing national and local mentoring programs.

Strategic Approach to Address Issues Identified

The current situation can be remedied by taking the following broad approach:

  • • Characterize the barriers

  • • Identify discriminatory practices

  • • Eliminate discriminatory practices

  • • Promote competent women into leadership positions

  • • Foster the development of female neurosurgeon role models and mentors

In addition, we strongly recommend that the following specific initiatives be considered as joint projects between WINS and national neurosurgical organizations:

  • A. Establishment of a program to support:

    1. 1. Annual attendance of 1–2 women neurosurgeons at the Hedwig van Ameringen Executive Leadership in Academic Medicine Program for Women (http://www.drexelmed.edu/ELAM/index.html).

    2. 2. Annual attendance of 1–2 women neurosurgeons to the Professional Development Seminar for Early Career Women Faculty (http://aamc.org/members/wim/meetings/start.htm).

    3. 3. Annual attendance of 1–2 women neurosurgeons to the Professional Development Seminar for Mid-Career Women Faculty (http://aamc.org/members/wim/meetings/start.htm).

    4. 4. Home-grown (AANS, CNS) leadership training with particular attention to areas such as negotiating skills.

  • B. Elimination of the registration fee for all sponsored medical students attending the AANS and CNS annual meetings. (Note: Since this paper was written, the AANS waived the registration fee at their 2008 annual meeting.)

  • C. Intensification of early and continuous medical student exposure to neurosurgery, including efforts such as:

    1. 1. Curriculum mandates

    2. 2. Active support of neuroscience/neurosurgery clubs

    3. 3. Innovative programs directed at medical students (as well as high schools and undergraduates):

      • a. Standardized talks about the spectrum of neurosurgery (such as the Gray Matter Program)

      • b. Neuroscience career days, invite-a-student-to-work day

      • c. Neuroscience fairs

      • d. Donation to “White Coat Ceremony” (consider laminated card with neurological exam, reflex hammer, or similar)

    4. 4. Annual “Brain-in-a-Box” programs, which would bring a local, practicing neurosurgeon to each medical school campus with a “packaged program” branded by one or more of the national neurosurgical organizations during an appropriate time, such as Brain Awareness Week.

  • D. Enhancement of efforts for premedical exposure to the positive attributes of neurosurgery and neurosurgeons with a goal of designing “packaged programs” suitable for students from an early age (elementary school) through college; includes neurosurgeons becoming leaders in appropriate public service programs (see above).

  • E. Development of a required program on diversity to be conducted in conjunction with the SNS, to include but not be limited to gender-related issues. Given the current environment of all academic medicine, we believe that such a program will be of enormous benefit to all leaders within neurosurgery.

  • F. Endorsement and promotion of the following attainable goals for women in neurosurgery by the AANS Board of Directors:

    1. 1. 20% of each class entering residency by the year 2012

    2. 2. 20% of all neurosurgery faculty by the year 2020

    3. 3. That progress toward these goals be regularly assessed and efforts toward them be adjusted as required

    4. 4. That the AANS promote adoption of these goals by all national neurosurgical organizations

  • G. Dissemination and analysis of a joint AANS/WINS survey along with utilization of a consultant to examine and provide data on the issues discussed above and progress toward redressing any problems identified.

  • H. Dissemination of this white paper by the AANS to appropriate organizations including the SNS, ABNS, RRC, CNS, and Council of State Neurosurgical Societies (CSNS). Establishment of a formal mechanism with WINS to engage these organizations in implementation of the above recommendations.

Conclusions

We are concerned about the ongoing disparity between the percentage of medical students who are female and the number of women entering neurosurgery training programs and becoming ABNS-certified US neurosurgeons. The leadership of WINS would like the profession of neurosurgery to become attractive to the “best and brightest” medical students regardless of gender and to provide an atmosphere in which qualified women can flourish.

We offer concrete suggestions to characterize the barriers, identify and eliminate discriminatory practices, promote competent women, and foster development of female neurosurgeons in order to address the issues identified in this white paper. We feel strongly that more data are needed to define the problem; surveys should be directed at identifying those factors that deter women from entering neurosurgery training programs, that result in women leaving training programs, and that result in attrition of female neurosurgeons.

There already are bright, competent, and accomplished women within neurosurgery. The promotion of these women into positions of prominence within organized neurosurgery—including leadership positions within the AANS, CNS, and SNS—needs to be accelerated. Placing accomplished and competent female neurosurgeons into positions of prominence within organized neurosurgery demonstrates that female neurosurgeons are valued for their abilities within the profession. These women will then serve as mentors and role models for the recruitment and retention of subsequent female residents and practitioners.

Many of the problems addressed in this paper are not exclusive to neurosurgery or even to medicine. Studies indicate that gender issues arise at a remarkably early age11,31 and escalate over time. It is also apparent that gender issues are magnified in environments that are traditionally male, such as neurosurgery. Furthermore, only direct acknowledgment and active efforts to address these problems will lead to durable success in their remediation. Data clearly support the critical role that leaders play in modeling behavior, and the officers of the national neurosurgical organizations are in an ideal position to help rectify the problems outlined in this paper.

We emphasize that many of the changes recommended are likely to benefit all neurosurgeons, irrespective of gender, and to ensure the viability of our specialty in the future. Given the challenges facing neurosurgery and academic medicine in general, WINS joins with all of organized neurosurgery in the desire to see neurosurgery continue to grow and prosper.

Appendix 1

Recommendations from Women in Academic Medicine, 2007 Report of the British Medical Association*

Appointment and promotion processes
1.1 Both the promotions criteria and process need to be made explicit and transparent to staff.
1.2 Appraisal should be an annual process and timed to fit in with the promotion cycle.
1.3 Appointments committees should reflect the diversity of staff required (e.g., women, ethnic groups).
1.4 Diversity monitoring of equity in appointments and promotions should be in place.
Structures, systems and activities in place regarding career progression
2.1 Career choice, progression, and development
 2.1 Equal opportunity and diversity training should be provided.
2.2 Role models, mentoring, and networking
 2.2 Mentoring for women staff should be mainstreamed and monitored.
2.3 Role models and networking should be recognized and encouraged.
Organizational arrangements and cultures should encompass and ensure the following:
3.1 Workplace and personal factors
 3.1.1 Ensure open, transparent, and fair allocation of teaching and administrative loads.
 3.1.2 Ensure administrative and committee responsibilities have fixed terms of office and are rotated so as to ensure opportunities to all staff and to avoid individuals taking on a disproportionate workload.
 3.1.3 Greater recognition needs to be given to the teaching role in undergraduate and postgraduate education.
 3.1.4 Monitor hours of work and actively discourage long hours culture.
3.2 Gender equality
 3.2.1 Measures of gender equality should be benchmarked against targets and exemplars.
3.3 Measures of esteem
 3.3.1 Journals and bodies awarding grants should take steps to minimize gender bias.
 3.3.2 Encourage leadership programs that develop and maintain skills.
 3.3.3 Recognize the value of different approaches to delivering key goals.
Flexibility in working life: Arrangements to improve working life should include the following:
4.1 Work-life balance
 4.1.1 Leaders of the profession and universities should visibly and vigorously support programs that encourage career progression.
 4.1.2 Promote a positive attitude to those working reduced hours
 4.1.3 Recognize and use the inherent advantages of informal flexible working in academia.
 4.1.4 Forms of academic assessment and accountability should take into account LTFT working and career breaks and measure output against similar post holders.
4.2 Arrangements for flexible (LTFT) working
 4.2 1 Visible support and take-up by vice chancellors and deans.
 4.2.2 Enable a flexible career structure
 4.2.3 Create opportunities for job-share in research and senior positions.
4.3 Importance of lifestyle and personal factors
 4.3.1 Encourage women to recognize the need to invest in quality child care to support their career.
 4.3.2 Seek innovative solutions to suit personal and family circumstances.
4.4 Career breaks
 4.4.1 Ensure provision of contact between staff and departments for staff taking a career break.
 4.4.2 Establish infrastructure for career breaks.

* Adapted with permission from British Medical Association (UK): Women in Academic Medicine Report, July 2007. London, UK: British Medical Association, 2007 (http://www.bma.org.uk/ap.nsf/content/wam2007). Abbreviation: LTFT = less-than-full-time.

Appendix 2

Women in US Neurosurgery Residency Programs*

ProgramNo. of Female ResidentsYrs of Graduation
Albany Medical College21989, 1998
Albert Einstein/Montefiore Medical Center31993, 2000, 2002
Allegheny General Hospital0NA
Baylor College of Medicine31999, 2005, 2008
Brigham & Women's Hospitals81996, 2000, 2002, 2004, 2005, 2006, 2011, 2013
Brown Medical School31994, 1999, 2012
Case Western Reserve University121982, 1986, 1987, 1992, 1992, 1995, 1998, 1999, 2004, 2005, 2013
Cedars–Sinai Medical Center0NA
Cleveland Clinic51980, 1980, 1983, 2011, 2013
Columbia University/New York Neurological Institute61986, 1987, 2002, 2005, 2009, 2013
Cornell University/Weill Medical College21987, 2011
Dartmouth–Hitchcock Medical Center21986, 2007
Duke University Hospital61982, 1984, 1985, 1987, 2002, 2012
Emory University51980, 2001, 2007, 2010, 2010
George Washington University61978, 1985, 1981, 1988, 2005, 2012
Georgetown University12004
Henry Ford Hospital41987, 2002, 2003, 2012
Indiana University School of Medicine41987, 2002, 2003, 2012
Jackson Memorial Hospital/Jackson Health System32004, 2008, 2009
Johns Hopkins University31986, 2005, 2009
Loma Linda University Medical Center21989, 2000
Louisiana State University–New Orleans22010, 2013
Louisiana State University–Shreveport21989, 2010
Loyola University Health Systems21989, 2009
Massachusetts General Hospital41980, 1983, 1986, 2001
Mayo School of Graduate Medical Education41985, 1985, 2009, 2012
Medical College of Georgia51955, 1981, 1982, 2000, 2006
Medical College of Virginia41980, 1989, 2011, 2011
Medical College of Wisconsin51986, 2007, 2009, 2010, 2012
Medical University of South Carolina12010
Mount Sinai School of Medicine101987, 1980, 1981, 1985, 1986, 1987, 2005, 2009, 2012, 2013
National Capital Consortium22000, 2005
National Naval Medical College11985
New Jersey Medical School51986, 2001, 2006, 2010, 2012
New York Medical College31987, 2005, 2009
New York University Medical Center41981, 2006, 2006, 2012
Northwestern University Medical School51984, 1986, 1986, 2001, 2005
Ohio State University71971, 1986, 1980, 1981, 2007, 2010, 2013
Oregon Health & Science University31983, 2006, 2011
Pennsylvania State Medical School32008, 2008, 2011
Rush/Presbyterian/St. Luke's Hospital`1985, 1991, 2001, 2002
St. Joseph's Hospital & Medical Center61992, 2003, 2007, 2009, 2010, 2012
St. Louis University21999, 2001
Stanford University Medical Center51995, 2000, 2003, 2009, 2013
State University of New York– Brooklyn12003
State University of New York Buffalo41997, 2004, 2008, 2011
State University of New York–Syracuse61982, 1992, 1999, 2000, 2008, 2010
Temple University Hospital21989, 2005
Thomas Jefferson University31988, 1997, 2009
Tufts–New England Medical Center32001, 2002, 2012
Tulane University School of Medicine51991, 1996, 2000, 2003, 2005
University of Alabama Birmingham31998, 2004, 2011
University of Arizona12012
University of Arkansas–Little Rock0NA
University of California Davis71988, 1993, 1994, 1999, 2000, 2006, 2008
University of California Los Angeles41985, 1998, 2008, 2010
University of California–San Diego31999, 2012, 2012
University of California San Francisco51994, 1995, 1999, 2004, 2006
University of Chicago31990, 2007, 2013
University of Cincinnati22011, 2011
University of Colorado61991, 1995, 1998, 2002, 2004, 2009
University of Connecticut11992
University of Florida Gainesville41984, 1993, 2009, 2012
University of Illinois at Chicago21983, 2010
University of Illinois at Peoria21997, 1999
University of Iowa Hospitals22003, 2004
University of Kansas Medical Center12005
University of Kentucky Medical Center31989, 1996, 2008
University of Louisville21994, 2011
University of Maryland Medical Center22001, 2004
University of Massachusetts21994, 1998
University of Michigan52001, 2004, 2007, 2010, 2012
University of Minnesota71988, 1990, 1994, 2001, 2004, 2007, 2011
University of Mississippi Medical Center11991
University of Missouri–Columbia31987, 1995, 2000
University of Nebraska Medical Center12006
University of New Mexico12008
University of North Carolina61981, 1990, 2002, 2007, 2010, 2012
University of Oklahoma Health Science Center0NA
University of Pennsylvania61987, 1996, 2001, 2007, 2010, 2011
University of Pittsburgh Medical Center32002, 2004, 2009
University of Puerto Rico Medical School12006
University of Rochester Medical Center11993
University of South Florida22004, 2009
University of Southern California41986, 1997, 2010, 2013
University of Tennessee Memphis51994, 1995, 1997, 2000, 2001
University of Texas Dallas51989, 2004, 2004, 2008, 2010
University of Texas Galveston41989, 1993, 2007, 2013
University of Texas San Antonio41989, 1993, 2007, 2013
University of Utah91984, 1988, 1999, 1999, 2000, 2009, 2010, 2011, 2011
University of Vermont41987, 1999, 2007, 2013
University of Virginia12013
University of Washington51999, 2001, 2010, 2011, 2013
University of Wisconsin Madison31984, 2003, 2007
Vanderbilt University Medical Center41986, 2003, 2009, 2012
Wake Forest University School of Medicine12005
Washington University School of Medicine22006, 2010
Wayne State University31993, 2002, 2006
West Virginia University31993, 2001, 2005
Yale–New Haven Medical Center71999, 2000, 2002, 2005, 2009, 2012, 2013

* NA = not applicable.

Acknowledgments

We gratefully acknowledge the excellent editorial assistance provided by Chris Philips and the statistical assistance provided by Mary Louise Sanderson. We also thank all of the former presidents of WINS, whose dedication and sacrifice on behalf of all women in neurosurgery made this project possible.

References

Article Information

Address correspondence to: Deborah L. Benzil, M.D., 280 North Central Avenue, Suite 235, Hartsdale, New York 10530. email: benzilneurosurg@aol.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Line graph showing the percentage of women in the population of neurosurgery residents from 1989 through 2003.

  • View in gallery

    Line graph showing the number of female graduates from neurosurgery residencies by year.

  • View in gallery

    Bar graph showing the number of ABNS-certified female neurosurgeons by decade.

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