Gender diversity in United States neurosurgery training programs

Katelyn Donaldson University of Vermont College of Medicine;

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Katherine E. Callahan University of Vermont College of Medicine;

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Aaron Gelinne Department of Neurosurgery, University of North Carolina, Chapel Hill, North Carolina

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Wyll Everett University of Vermont College of Medicine;

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S. Elizabeth Ames Department of Orthopaedics and Rehabilitation and

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Ellen L. Air Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan; and

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Susan R. Durham Division of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont;

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OBJECTIVE

Neurosurgery continues to be one of the medical specialties with the lowest representation of females in both the resident and faculty workforce. Currently, there are limited available data on the gender distribution of faculty and residents in Accreditation Council for Graduate Medical Education (ACGME)–accredited neurosurgery training programs. This information is critical to accurately measure the results of any effort to improve both the recruitment and retention of women in neurosurgery. The objective of the current study was to define the current gender distribution of faculty and residents in ACGME-accredited neurosurgery training programs.

METHODS

Data publicly available through institutional and supplemental websites for neurosurgical faculty and residents at ACGME-accredited programs were analyzed for the 2017–2018 academic year. Data collected for faculty included gender, age, year of residency graduation, academic rank, h-index, American Board of Neurological Surgery certification status, and leadership positions. Resident data included gender and postgraduate year of training.

RESULTS

Among the 109 ACGME-accredited neurosurgical residency programs included in this study, there were 1350 residents in training, of whom 18.2% were female and 81.8% were male. There are 1320 faculty, of whom 8.7% were female and 91.3% were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Female faculty were younger, had lower h-indices, and were less likely to be board certified and attain positions of higher academic rank and leadership.

CONCLUSIONS

This study serves to provide a current snapshot of gender diversity in ACGME-accredited neurosurgery training programs. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, the authors’ findings suggest that this is likely due to the small number of women in the neurosurgical field who are the farthest away from residency graduation and serves to highlight the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce.

ABBREVIATIONS

ABNS = American Board of Neurological Surgery ; ACGME = Accreditation Council for Graduate Medical Education .

OBJECTIVE

Neurosurgery continues to be one of the medical specialties with the lowest representation of females in both the resident and faculty workforce. Currently, there are limited available data on the gender distribution of faculty and residents in Accreditation Council for Graduate Medical Education (ACGME)–accredited neurosurgery training programs. This information is critical to accurately measure the results of any effort to improve both the recruitment and retention of women in neurosurgery. The objective of the current study was to define the current gender distribution of faculty and residents in ACGME-accredited neurosurgery training programs.

METHODS

Data publicly available through institutional and supplemental websites for neurosurgical faculty and residents at ACGME-accredited programs were analyzed for the 2017–2018 academic year. Data collected for faculty included gender, age, year of residency graduation, academic rank, h-index, American Board of Neurological Surgery certification status, and leadership positions. Resident data included gender and postgraduate year of training.

RESULTS

Among the 109 ACGME-accredited neurosurgical residency programs included in this study, there were 1350 residents in training, of whom 18.2% were female and 81.8% were male. There are 1320 faculty, of whom 8.7% were female and 91.3% were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Female faculty were younger, had lower h-indices, and were less likely to be board certified and attain positions of higher academic rank and leadership.

CONCLUSIONS

This study serves to provide a current snapshot of gender diversity in ACGME-accredited neurosurgery training programs. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, the authors’ findings suggest that this is likely due to the small number of women in the neurosurgical field who are the farthest away from residency graduation and serves to highlight the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce.

In Brief

The study examined data from institutional and supplemental websites for neurosurgical faculty and residents analyzed for the years 2017–2018 to define the current gender distribution of faculty and residents within US neurosurgery training programs. Great progress has been made toward greater gender diversity in the neurosurgical workforce; however, continued efforts are required to remove barriers to recruitment and career advancement opportunities for females to ensure a diverse physician workforce.

Women accounted for nearly one-half of all medical school graduates in the US in 2018, and female residents currently account for nearly half of the total resident workforce in all specialties in US residency programs. 1,2 Despite this, the number of female residents and attending physicians in neurosurgery remains one of the lowest among all medical specialties. Women account for 17.7% of neurosurgery residents according to the most recent report by the American Association of Medical Colleges, joining orthopedic surgery as the lowest among all medical specialties. 1 The gender gap in neurosurgery widens over the course of a neurosurgery career, as women currently compose only 7.4% of all practicing board-certified neurosurgeons within the US. 3 Female neurosurgeons have been shown to have a higher rate of attrition during residency and a lower rate of board certification than males, both factors that profoundly influence the gender distribution of the neurosurgical workforce. 4,5

Efforts to improve the gender gap in neurosurgery have recently been undertaken, as the benefits of diversity in the workforce are well described in both medicine and other disciplines, particularly business. 6–9 A diverse workforce contributes a broader range of ideas, opinions, and strategies that can lead to superior problem-solving and productivity. 10 Work environments with greater gender diversity typically have more inclusive cultures and, subsequently, reduced employee turnover and improved retention. 10 Moreover, employees working within an inclusive and equitable environment demonstrate greater satisfaction, engagement, and performance. 10 The recruitment and retention of a diverse neurosurgical workforce will serve to benefit the specialty of neurosurgery and the patients that it serves.

There are limited data available on the gender distribution of neurosurgery residents and faculty in Accreditation Council for Graduate Medical Education (ACGME)–accredited neurosurgery residency programs. It is necessary to understand the current gender landscape in neurosurgery residency programs to accurately measure the effect of any effort to improve gender diversity in the neurosurgery workforce. The objective of the current study was to provide baseline data of the gender distribution of faculty and residents in ACGME-accredited neurosurgery residency programs during the 2017–2018 academic year.

Methods

Data Collection

This study was granted IRB exemption approval by the University of Vermont Committee on Human Subjects Research Protection. Data collection began in the fall of 2017. At that time, there were 110 ACGME-accredited neurosurgery residency programs identified via the ACGME website (https://apps.acgme.org/ads/Public/Programs/Search). Data on neurosurgery faculty and residents were collected from publicly available residency program and academic medical institution websites. Data not found on institutional websites were augmented using alternative secondary publicly available websites such as Healthgrades (www.healthgrades.com) and Vitals (www.vitals.com). Data collected for residents included gender, as determined by name, photo, and profile, and postgraduate year. Data collected for faculty members included each physician’s gender, as determined by name, photo, and profile; age; years since residency graduation; academic rank; h-index; and American Board of Neurological Surgery (ABNS) certification status. The genders of the residency program director and of the department chair or division chief were also collected for each program. Faculty were defined as physicians who had completed a neurosurgery residency and held the academic rank of assistant, associate, or full professor. Adjunct faculty were not included in the analysis. Board certification status was obtained from the ABNS website (https://abns.org/find-a-neurosurgeon/). The h-index was determined (https://www.scopus.com/freelookup/form/author.uri) to measure neurosurgery faculty research publication productivity and impact.

Data Analysis

There were 109 ACGME-accredited neurosurgery residency programs training Doctor of Medicine residents identified at the time of data collection. One program training Doctor of Osteopathic Medicine residents was not included. Six programs had incomplete data, and available data were used as appropriate. The following methods were used for the comparisons of male and female faculty. A two-sample t-test was used to compare gender and age. The mean number of years since residency graduation was compared by gender and academic rank using ANOVA. The gender by academic rank interaction term was included to test whether gender differences were dependent on academic rank. Logistic regression models were used to assess the effect of gender on both academic rank and ABNS certification. Since academic rank has three levels, a cumulative logit model was fit with the lowest academic rank as the reference level. The effect of gender and academic rank on h-index was assessed using ANOVA with gender and academic rank and their interaction in the model. Since academic rank, board certification, and h-indices are affected by years since residency graduation, additional analyses were run for these measures, with years since residency graduation included as a covariate in the models. Years since residency graduation were missing for 355 of the faculty. To ensure that the reduced sample data were consistent with the full sample, unadjusted analyses were replicated in the reduced sample of faculty with years since residency graduation, which produced similar results to those of the full sample. All analyses were performed using SAS version 9 statistical software (SAS Institute). Statistical significance was determined based on α = 0.05.

Results

Program Characteristics

A total of 109 ACGME-accredited neurosurgery residency programs were included for analysis (Table 1). There were 1350 neurosurgery residents in training, of whom 246 (18.2%) were female and 1104 (81.8%) were male. Fifty-eight programs (53.2%) had both female faculty and residents, 35 programs (32.1%) had female residents and no female faculty, 4 programs (3.7%) had female faculty and no female residents, and 6 programs (5.5%) lacked both female residents and faculty. Six programs (5.5%) had incomplete data. Seven programs (6.4%) had female residency program directors. Three programs (2.8%) had female department chairs or division chiefs.

TABLE 1.

Distribution of female neurosurgical residents and faculty

TotalNo. of F (%)No. of M (%)
Residents1350246 (18.2)1104 (81.8)
Faculty1320115 (8.7)1205 (91.3)
Program directors1097 (6.4)102 (93.6)
Department chair/division chief1093 (2.8)106 (97.2)

Academic Neurosurgery Faculty Characteristics

There were 1320 neurosurgery faculty, of whom 115 (8.7%) were female and 1205 (91.3%) were male (Table 2). The mean age of female faculty was 44.8 ± 0.8 (mean ± SE) years, which was significantly lower than that of male faculty, who had a mean age of 52.1 ± 0.3 years (t = 5.86, df = 1044; p < 0.001). Female faculty also had a significantly lower mean number of years since residency graduation (12.9 ± 1.1 years) than males (17.0 ± 0.3 years) across all academic ranks (F = 12.96, df = 1, 908; p < 0.001). For both male and female faculty, the mean number of years since residency graduation increased with increasing academic rank (F = 69.8, df = 2, 908; p < 0.001). The gender by academic rank interaction was not significant (F = 0.74, df = 2, 908; p = 0.48). Using the available data, 54% (n = 60) of female faculty were assistant professors, 28% (n = 31) were associate professors, and 18% (n = 20) were full professors. Likewise, 39% (n = 437) of male faculty were assistant professors, 25% (n = 281) were associate professors, and 36% (n = 405) were full professors. Unadjusted analysis of gender differences among the faculty revealed that female faculty were less likely to hold positions of higher academic rank (OR 0.5, 95% CI 0.3–0.7; p < 0.001), were less likely to obtain ABNS certification (OR 0.4, 95% CI 0.3–0.6; p < 0.001), and had a lower mean h-index (14.8 ± 1.3) compared with males (18.6 ± 0.4) across all academic ranks (F = 7.78, df = 1, 1169; p = 0.005). There was no significant gender by academic rank interaction to suggest that the difference between female and male faculty in h-index differed by academic rank (F = 0.69, df = 2, 1169; p = 0.69) (Table 2).

TABLE 2.

Gender differences among faculty: unadjusted analysis

MaleFemalep Value
Total faculty, n (%)1205 (91.3)115 (8.7)
Age in yrs, mean ± SE52.1 ± 0.344.8 ± 0.8<0.001
Yrs since residency graduation, LS means ± SE*
 All academic ranks17.0 ± 0.312.9 ± 1.1<0.001
 Assistant professor9.3 ± 0.54.9 ± 1.5
 Associate professor15.4 ± 0.613.2 ± 1.8
 Full professor26.2 ± 0.520.6 ± 2.3
Academic rank, n (%) <0.001
 Assistant professor437 (38.9)60 (54.1)
 Associate professor281 (25.0)31 (27.9)
 Full professor405 (36.1)20 (18.0)
ABNS certification, n (%)943 (78.3)69 (60.0)<0.001
h-index, LS means ± SE*
 All academic ranks18.6 ± 0.414.8 ± 1.30.005
 Assistant professor9.0 ± 0.66.4 ± 1.7
 Associate professor15.2 ± 0.712.7 ± 2.2
 Full professor31.7 ± 0.625.4 ± 2.8

LS = least-squares.

Least-squares means and standard error from ANOVA and ANCOVA models.

Data were missing for 1123 males and 111 females.

When adjusting for years since residency graduation using ANOVA models, gender differences among the faculty were no longer significant. We did not find that female faculty were less likely to be in a higher academic rank than male faculty (OR 1.0, 95% CI 0.6–1.7; p = 0.90) or less likely to be ABNS certified than male faculty (OR 0.6, 95% CI 0.3–1.1; p = 0.09). In addition, the h-index did not differ significantly between female (16.1 ± 1.6) and male (19.1 ± 0.5) faculty when adjusting for years since residency graduation (F = 3.26, df = 1, 875; p = 0.07). The overall effect of academic rank continued to be significant on h-index (F = 38.91, df = 2, 875; p < 0.001), with the h-index increasing with increasing academic rank for both genders. The gender by academic rank interaction was not significant (F = 0.20, df = 2, 875; p = 0.82) (Table 3).

TABLE 3.

Gender differences among neurosurgery faculty adjusted for years since residency graduation

Male (n = 835)Female (n = 79)OR (95% CI)p Value
Academic rank, n (%)Male: ref Female: 1.0 (0.6–1.7)0.90
 Assistant professor302 (36.2)38 (48.1)
 Associate professor203 (24.3)25 (31.6)
 Full professor330 (39.5)16 (20.3)
ABNS certification, n (%)679 (81.3)50 (63.3)Male: ref Female: 0.6 (0.3–1.1)0.09
h-index, LS mean ± SE*
 All academic ranks19.1 ± 0.516.1 ± 1.60.07
 Assistant professor10.7 ± 0.98.4 ± 2.2
 Associate professor15.6 ± 0.913.5 ± 2.6
 Full professor30.9 ± 0.826.4 ± 3.2

Least-squares means and standard error from ANOVA and ANCOVA models.

Discussion

Gender Diversity in the Academic Neurosurgical Workforce

The current study demonstrates continued progress on eliminating gender disparity in the neurosurgical workforce as female residents now account for 18.2% of the total neurosurgery resident workforce, which is more than triple the number of female neurosurgery residents in training in the early 1980s. 11 In addition, the percentage of female faculty at academic neurosurgical programs is now 8.7%, which also demonstrates an increase, although at a somewhat slower pace since the late 1990s, at a time when females accounted for only 5% of practicing neurosurgeons. 12 While the increasing number of female faculty neurosurgeons and residents over the past several decades is encouraging, the rate of increase lags behind most other specialties, including many surgical subspecialties such as general surgery and otolaryngology, where 40.1% and 36.2% of the resident workforce, respectively, are female. 1 Over the past 3 decades, efforts to increase the number of females applying to neurosurgery programs appear to have been successful, with the number of female applicants to neurosurgical training programs increasing from an average of 13% in the 1990s to an all-time high of nearly 30% in the 2019 match. 13,14

With more women applying to and entering neurosurgery residency programs, strategies should continue to be developed to maintain the number of females in the neurosurgical workforce by reducing attrition of female neurosurgeons both during residency and while in practice. Previous studies have demonstrated an increased rate of attrition among female neurosurgeons compared with their male counterparts. 4,5 Increased attrition of female neurosurgeons would have a detrimental effect on the future of the neurosurgical workforce. Many factors, such as lifestyle, work hours, and emotional burden, have been suggested as contributing to a higher attrition rate among female neurosurgeons in all stages of their careers; however, there are currently very few objective data available on this subject. 12,15 A survey of European neurosurgeons found no significant differences between genders regarding work hours, time in the operating room, or overall administrative burden. Only the time spent on scientific work was greater in men than women. 16 Organized neurosurgery, particularly the Section on Women in Neurosurgery of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, has played a critical role in addressing barriers to recruitment and retention of females in neurosurgery in an effort to improve gender diversity in the neurosurgical workforce.

Academic Rank and Leadership Among Faculty

Gender disparities exist in academic progression across the medical professions, and these differences are more acutely highlighted within surgical fields. While females are increasingly represented in medical school classes and residency programs, this narrative often does not translate to the distribution of female faculty physicians by academic rank. Females currently account for 34% of associate professors and 21% of full professors across all medical specialties. 17 The gender gap in academic rank is even wider in surgical fields, in which females constitute 13.8% of associate professor and 7% of full professor positions among academic surgical faculty. 18 In the current study, we found that females accounted for 12.1% of assistant professors, 9.9% of associate professors, and 4.7% of full professors of neurosurgery, which is similar to the gender profile of many other surgical subspecialties. It is important to note that in the current study, when adjusted for years after residency graduation, there were no differences between genders in the proportions of females to males in each academic rank. A similar finding was also reported in a 2019 study by Dossani et al. in which they assessed gender disparities in academic rank within neurosurgery and found fewer women in higher academic ranks; as with the current study, these differences between genders were eliminated when adjusted for years in practice. 19 Taken together, data from both of these studies suggest that the current gender differences in academic rank among neurosurgical faculty may be explained in part by a “pipeline effect,” which is representative of the few females who entered the neurosurgical workforce decades ago and are now in advanced stages of an academic career, and that gender differences in academic rank among neurosurgeons may disappear as more and more females enter the neurosurgical workforce.

Leadership follows academic promotion, and with fewer women in the higher academic ranks, it follows that there will be fewer women in leadership positions. Having females in visible leadership positions is one strategy that has been proposed to improve female faculty recruitment and retention. Neurosurgery as a specialty has recognized the need for greater female representation among leadership in the field, and, over the past 15 years, there has been a considerable increase in the number of females within leadership positions in both academic programs and organized neurosurgery. 20 There were no female department chairs/division chiefs of neurosurgery residency programs until 2004, when Dr. Karin Muraszko was appointed the first female department chair at the University of Michigan. 12 At the time of data collection for this study in 2017–2018, there were only 3 female department chairs/division chiefs (University of Michigan, University of Vermont, and University of California, Los Angeles), with the latter two being named in 2017. Since the time the data were collected for this study, 2 additional female department chairs have been named (University of Nebraska and University of Indianapolis), now bringing the total to 5. In addition, there are now 8 female residency program directors, a number that also has been steadily climbing over the past decade.

In organized neurosurgery, Dr. Shelly Timmons was named as the first female president of the American Association of Neurological Surgeons in 2018, and in 2019, Dr. Karin Muraszko was named the first female president of the Society of Neurological Surgeons in the nearly 100-year history of the society. More females than ever before now serve on the various executive committees of national neurosurgical organizations, and efforts are being undertaken to promote diversity among the speaking faculty at national neurosurgical meetings. As more and more female neurosurgeons take on leadership roles in both academic and organized neurosurgery, they serve not only as important role models and mentors for female medical students and neurosurgery residents but represent neurosurgery on the national stage as an increasingly gender-balanced specialty of medicine.

Academic Productivity Among Faculty

Both clinical and academic productivity define an academic neurosurgical career. Academic productivity is often defined by the number and quality of one’s academic publications. A 2016 study by Mueller et al. examined gender disparities in scholarly productivity of US academic surgeons and found that female surgeons who were assistant and full professors had significantly lower h-indices than their male counterparts of the same academic rank. 21 Sing et al. found that, although female representation in academic spine research doubled over the past 4 decades, females were half as likely as males to continue publishing after 5 years and published half as many articles as senior authors. 22 In the current study, the unadjusted analysis also found that the h-index for female neurosurgeons was lower than that for male neurosurgeons at all academic ranks; however, after adjusting for years since residency graduation, the difference was no longer statistically significant. This suggests that gender differences in academic productivity among neurosurgeons are likely due to more females being at the earlier stages of their academic careers with correspondingly lower h-indices. As more females enter advanced stages of an academic career in the decades to come, further analysis of gender differences in academic productivity should be undertaken to identify and eliminate any barriers to academic productivity among female neurosurgeons.

ABNS Certification

ABNS certification is the one of the defining professional benchmarks of a neurosurgical career. Previous studies have reported lower ABNS certification rates for female neurosurgeons than for male neurosurgeons, although the reasons for this reported gender difference are not well defined. 5 It is unclear whether this is due to fewer females choosing to become board certified, either by personal choice or having exceeded the time limit to apply for board certification due to taking time off for maternity leave or having a reduced working schedule. It is also unclear whether there are any gender-specific differences in the pass/fail rates of the ABNS certification examination. The ABNS has issued a statement on family and medical leave to address potential delays in ABNS certification due to taking time off for maternity leave or working a reduced schedule permitting extension on a case-by-case basis. 23 In the present study, we also found that female neurosurgery faculty were less likely than male neurosurgery faculty to be ABNS certified; however, when adjusted for years since residency graduation, there was no longer any significant difference in ABNS certification between genders. Again, this suggests that gender differences in ABNS certification rates are likely representative of the increased number of females in early stages of their careers who are not yet eligible for ABNS certification.

Limitations

The current study was limited by the variability and accuracy of data available on institutional websites. The data presented are a single snapshot of the academic neurosurgical workforce during late 2017 and 2018 and are subject to many changes with time. This highlights the need to maintain a more complete database of resident and physician characteristics to better determine the changing gender landscape within the field.

Conclusions

This study serves to provide a snapshot of gender diversity in ACGME-accredited neurosurgery training programs and highlights the significant progress that has been made toward achieving greater gender diversity in the neurosurgical workforce. While there are still fewer female neurosurgeons achieving positions of higher academic rank and serving in leadership positions than male neurosurgeons, this study suggests that these differences are likely due to the small number of women in neurosurgery in the later years of an academic career. Continued study of the barriers to recruitment and retention of females in neurosurgery are warranted to continue the trend toward greater gender diversity in the neurosurgical workforce.

Acknowledgments

We would like to thank Peter Callas and Joan Skelly for statistical support and analysis. We would like to acknowledge Jayne Manigrasso for her contributions to this project.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Donaldson, Gelinne, Everett, Durham. Acquisition of data: Donaldson, Gelinne, Everett, Durham. Analysis and interpretation of data: Donaldson, Gelinne, Everett, Durham. Drafting the article: Callahan, Donaldson, Gelinne, Everett, Durham. Critically revising the article: Callahan, Ames, Air, Durham. Reviewed submitted version of manuscript: Callahan, Ames, Air, Durham. Statistical analysis: Durham. Administrative/technical/material support: Ames, Air, Durham. Study supervision: Durham.

Supplemental Information

Previous Presentations

This paper was presented in poster form at AANS Virtual 2020.

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    Statement on family and medical leave. American Board of Neurological Surgery . Accessed September 25, 2020. https://abns.org/family-and-medical-leave/

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Artist’s illustration of the classic mulberry appearance of a cavernoma. This illustration represents the Seven Cavernomas series by Dr. Michael Lawton, a collection of articles defining the tenets and techniques for the treatment of cavernous malformations, a taxonomy for classifying these lesions, and the nuances of their surgical approaches. Artist: Peter M. Lawrence. Used with permission from Barrow Neurological Institute, Phoenix, Arizona. See the article by Garcia et al. (pp 671–682).

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    ACGME Residents and Fellows by Sex and Specialty, 2017 . American Association of Medical Colleges . Accessed September 2, 2020. https://www.aamc.org/data/workforce/reports/492576/2-2-chart.html

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    Table B-2. 2: Total Graduates by U.S. Medical School and Sex, 2013-2014 through 2017-2018. American Association of Medical Colleges . Accessed September 2, 2020. https://www.aamc.org/download/321532/data/factstableb2-2.pdf

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    Table 1.3 Number and percentage of active physicians by sex and specialty. American Association of Medical Colleges . Accessed September 2, 2020. https://www.aamc.org/data/workforce/reports/492560/1-3-chart.html

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    Lynch G , Nieto K , Puthenveettil S , et al. Attrition rates in neurosurgery residency: analysis of 1361 consecutive residents matched from 1990 to 1999 . J Neurosurg . 2015 ;122 (2 ):240 249 .

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    Butkus R , Serchen J , Moyer DV , et al. Achieving gender equity in physician compensation and career advancement: a position paper of the American College of Physicians . Ann Intern Med . 2018 ;168 (10 ):721 723 .

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    Dezsö CL , Ross DG . Does female representation in top management improve firm performance? A panel data investigation . Strateg Manage J . 2012 ;33 (9 ):1072 1089 .

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    Hossain M , Farooque OA , Momin MA , Almotairy O . Women in the boardroom and their impact on climate change related disclosure . Soc Responsib J . 2017 ;13 (4 ):828 855 .

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    Zhuwao S , Ngirande H , Ndlovu W , Setati ST . Gender diversity, ethnic diversity and employee performance in a South African higher education institution . SA J Hum Resour Manag . 2019 ;17 (4 ):a1061 .

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    Badal S. The business benefits of gender diversity. Gallup. January 20 , 2014 . Accessed September 25, 2020. https://www.gallup.com/workplace/236543/business-benefits-gender-diversity.aspx

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    Abosch A , Rutka JT . Women in neurosurgery: inequality redux . J Neurosurg . 2018 ;129 (2 ):277 281 .

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    Spetzler RF . Progress of women in neurosurgery . Asian J Neurosurg . 2011 ;6 (1 ):6 12 .

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    Table C-2 . Residency Applicants from U.S. MD-Granting Medical Schools to ACGME-Accredited Programs by Specialty and Sex, 2019-2020. American Association of Medical Colleges 2019 Physician Data Book . November 12, 2020. Accessed September 25, 2020. https://www.aamc.org/system/files/2019-12/2019_FACTS_Table_C-2.pdf

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    Durham SR , Donaldson K , Grady MS , Benzil DL . Analysis of the 1990-2007 neurosurgery residency match: does applicant gender affect neurosurgery match outcome? J Neurosurg . 2018 ;129 (2 ):282 289 .

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    Benzil DL , Abosch A , Germano I , et al. The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery . J Neurosurg . 2008 ;109 (3 ):378 386 .

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    Steklacova A , Bradac O , de Lacy P , Benes V . E-WIN Project 2016: evaluating the current gender situation in neurosurgery across Europe—an interactive, multiple-level survey . World Neurosurg . 2017 ;104 :48 60 .

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    Girod S , Fassiotto M , Grewal D , et al. Reducing implicit gender leadership bias in academic medicine with an educational intervention . Acad Med . 2016 ;91 (8 ):1143 1150 .

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    Blumenthal KG , Huebner EM , Banerji A , et al. Sex differences in academic rank in allergy/immunology . J Allergy Clin Immunol . 2019 ;144 (6 ):1697 1702.e1 .

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    Dossani RA , Terrel D , Kosty JA , et al. Gender disparities in academic rank achievement in neurosurgery: a critical assessment . J Neurosurg . 2020 ;133 (6 ):1922 1927 .

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    Lautenberger DM , Raezer CL , Sloane RA . The State of Women in Academic Medicine: The Pipeline and Pathways to Leadership . Association of American Medical Colleges ; 2014 . Accessed September 25, 2020. https://www.hopkinsmedicine.org/women_science_medicine/_pdfs/the%20state%20of%20women%20in%20academic%20medicine%202013-2014%20final.pdf

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  • 21

    Mueller CM , Gaudilliere DK , Kin C , et al. Gender disparities in scholarly productivity of US academic surgeons . J Surg Res . 2016 ;203 (1 ):28 33 .

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    Sing DC , Jain D , Ouyang D . Gender trends in authorship of spine-related academic literature—a 39-year perspective . Spine J . 2017 ;17 (11 ):1749 1754 .

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  • 23

    Statement on family and medical leave. American Board of Neurological Surgery . Accessed September 25, 2020. https://abns.org/family-and-medical-leave/

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