These levels are just one measure, but they point to a deeper, probably worse, problem in cardiology, says Sunil Rao.
Posting rates among U.S. medical students differ wildly by gender, race and ethnicity, according to new data published online yesterday in Open JAMA Network. Researchers say there may be career consequences for women and racial/ethnic underrepresented groups in medicine (URIM).
Previous studies in the field of cardiology have shown similar alarming trends, with men being more likely than women to guest author comments and women in general publish less than men, although there are hints it could get better.
“We expected to find some gender disparity and some racial/ethnic disparity, based on previous studies at the faculty level,” said lead author Mytien Nguyen, MS (Yale School of Medicine, New Haven, CT), at TCTMD. “What was surprising when we looked at the intersectionality between the two identities was that we found data that actually reflects [previous research] among [US National Institutes of Health] faculty where URIM and women face most of the inequality, basically.
The study speaks to a larger “pipeline problem,” commented Sunil Rao, MD (NYU Langone Health, New York), editor-in-chief of Circulation: Cardiovascular Interventions. “That’s where I think we need to focus, as well as keep trying to make sure there’s adequate representation on the pitch,” he told TCTMD. “You can’t have one approach to this problem.”
Likewise, Bruce Ovbiagele, MD (University of California, San Francisco), who will take over as editor-in-chief of the Journal of the American Heart Association next year, told TCTMD: “Obviously there are a lot of factors contributing to what we’re seeing, which isn’t surprising. But quantifying it in this way in such a rigorous way is, I think, very helpful in supporting what many of us see in reality.
Additionally, Armin Zadeh, MD, PhD, MPH (Johns Hopkins University, Baltimore, MD), editor of the Journal of Cardiovascular Computed Tomographytold TCTMD in an email that these results “raise an important awareness of the biases that persist in our training programs. Clearly, we still have work to do. Our training programs should monitor opportunities for research and productivity in relation to gender, race and ethnicity.
For the study, Nguyen and her colleagues included data from the Association of American Medical Colleges on 31,474 medical graduates (48.2% female; 13.8% URIM) who enrolled between 2014 and 2016.
Students attending the NIH’s top 40 research-ranked schools reported more research experiences as well as publications (median 1.60 vs. 1.25; P < 0.001) compared to students in the 40 non-top schools.
While women reported more research experiences than men, they published significantly less regardless of whether they attended a top 40 school (mean 7.32 vs. 8.22) or not. 40 best (mean 4.81 versus 5.15; P ≤ 0.001 for both). This resulted in a significantly lower adjusted publication rate for women than for men, both in the top 40 schools (adjusted RR 0.85; 95% CI 0.83-0.86) and in the other 40 schools (adjusted RR 0.91; 95% CI 0.90-0.92).
Compared to white students, those of Asian descent reported higher publication rates in the top 40 NIH schools (adjusted RR 1.10; 95% CI 1.08-1.12) and the other 40 schools (adjusted RR 1.07; 95% CI 1.05-1.08). However, black students reported lower publication rates than white students, regardless of school ranking (top 40: adjusted RR 0.83; 95% CI 0.80-0.86; the other 40: adjusted RR 0.88; 95% CI 0.85-0.95), and Hispanic students attending the other 40 schools also reported fewer publications (adjusted RR 0.93; 95% CI 0 ,90-0.95).
The findings regarding NIH funding specifically indicate that the organization can do much to “mitigate and reduce gender and racial inequities” by distributing wealth more than in the past, Nguyen said. “Right now, what I’ve seen is that money begets money, so schools that are already well-funded get more funding from NIH, and schools that serve minorities – like your historically black colleges and universities – not in the top 40.”
By “intentionally matches[ing] funding with diversity outcomes,” schools can better generate more diversity in the physician-scientist pool, Nguyen added.
Regarding some of the gender disparities observed, she said, “we can infer that women seek research opportunities and are more proactive in seeking research opportunities and mentors, but for each of these research opportunities, female students fare less than male students.The mechanism for this is unclear, Nguyen added, but she guessed it might be related to mentoring trends.
She called for change to start “at primary school level” to really have a lasting effect. “We have seen that there is increased diversity in medical school in general, but there are still students leaving medicine,” Nguyen said. “It is essential to support the continuum of students throughout their training. . . . With each of these individuals, we not only impact professional societies, but all patient populations as clinician-scientists.
Mentoring is “fundamental”
Commenting on the study for TCTMD, Ann Marie Navar MD, PhD (UT Southwestern Medical School, Dallas, TX), who is associate editor for equity, diversity and inclusion at JAMA Cardiology, urged caution in overinterpreting the data as it shows average publication rates across a large population. “It’s unclear what proportion of each group really wanted to have research experiences leading to publications versus those who had other goals or priorities in medical school, including community outreach, services, quality improvement or education,” she said in an email.
“And while the number of posts is important, the number of posts does not necessarily correlate with the quality of the experience(s) for the intern. This highlights the importance for residency programs and ultimately academic leadership to look beyond publication counts when evaluating trainees and potential faculty,” added Navar.
Rao agreed that publication by itself matters little, but funding does matter if the goal is to pursue a career in research. Still, the discrepancies highlighted in this article are “difficult”, he said. And, if the study was done in cardiology trainees, Rao said he expects the discrepancies to be “worse.”
It can be “rooted in a lot of different things,” Rao observed. “It may be a systematic bias. It can be rooted in opportunity. This may be rooted in the lack of mentorship.
Mentorship is “fundamental” to addressing these issues, he said. “What a good mentor does is they provide their mentees with opportunities that they themselves could benefit from. . . . If you mentor someone who is underrepresented, I feel like that he probably doesn’t have as many opportunities as the other mentees I have no data to back that up except to say there’s a reason we don’t have representation in science, and this may be one of them.
Additionally, Rao said it is “everyone’s” responsibility to create change, echoing Nguyen’s comment about starting at the elementary school level. “We have to start. . . engage people in science who have traditionally been excluded from it,” Rao said. “We all benefit from diversity. This is what I think people misunderstand. People think of diversity efforts as the inclusion of one group to the exclusion of the other group. But that’s not what it’s about. It’s about making sure all the voices in the room are heard, because it makes us all better.
How should journals adapt?
Journals will play an important role in increasing diversity in the future, according to several interviewees for this article.
Ovbiagele said his experience promoting an editor program for Stroke succeeded in increasing the diversity of the editorial board of this journal, and he intends to pursue a similar program in his new role.
Still, he acknowledged, “at some point you can’t do much depending on who’s out there.” In trying to recruit board members to YES, Ovbiagele said he encountered difficulties. “Because there are so few underrepresented minorities, everyone wants them,” he said. “When I approach them, they’re all like, ‘I’m already caught on this board and on this board.'”
Likewise, Rao said it was important not to “overload specific people who may be repeatedly asked to serve on editorial boards, to edit, or to write.” For this reason, he also plans to continue his assistant editor program at Circulation: Cardiovascular Interventions.
“I think things will change, but let’s not be naive about the difficulty,” Rao said. “I think things are changing, but I think we still have a long way to go.”
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