Gender Disparity Task Force Report

The Gender Disparity Task Force (GDTF) is pleased to provide the following written report and recommendations to the AAN/AAN Institute Boards of Directors. The charge of the GDTF was to study issues related to the disparities between female and male neurologists including compensation, professional advancement, leadership opportunities, and work/life balance; to make recommendations to the AAN and AAN Institute Boards of Directors for strategies to improve the identified disparities within the neurology and medical communities by February 2017.

Description of the Issue, Goals of the Report
The GDTF met by phone four times between November 2016 and January 2017. Some members were unable to participate in the scheduled calls and participated in one-on-one calls with the task force chair and staff liaison.

The issues of gender disparity are wide-reaching across nearly every profession, though within medicine, neurology exhibits one of the largest differences in salary between men and women. Many entities have worked to combat the problems. The goal of the AAN should be to address specific problems affecting neurologists and identify unique solutions that address gaps in resources and designed to help neurologists.

Background Information
The problem is well defined, though the root causes are harder to pin down. Male neurologists continue to earn more than their female counterparts ($251,000 vs. $214,000), a difference of $37,000.¹ One year after completing their studies, female PhD graduates in the US earn almost one-third less than their male counterparts.² A recent article in JAMA Internal Medicine prompted significant media coverage. It showed that even accounting for variables like age, experience, specialty and faculty rank, female physicians at medical schools earn significantly less than their male counterparts.³ In 2014, only 11% of neurology department chairs at academic medical centers were women.⁴

The identified causes for disparities in compensation, professional advancement, leadership opportunities, and work/life balance were

• Lack of salary transparency - Salaries are often not publicly available, or in some cases, the data shared by academic departments does not paint an accurate picture of full compensation. Female neurologists may not be aware of the salaries of their colleagues
• Absence of negotiating and networking - Women are much less likely than men to negotiate their salary offers, and when they do, they may pay the social cost of being perceived as too pushy.⁵ Women tend to network less than men, and the composition of women's networks tend to more focused on friends and family in contrast to men's networks, which tend to be comprised on non-familial ties.⁶
• Bias - While explicit bias is becoming less common and is easier to identify and target, implicit bias can sneak into many daily interactions and color major decisions without anyone realizing it is happening.
• Penalty for work/life balance and family responsibility - Women more often assume the role of caretaker, whether for children or an ailing parent.⁷

Issue Summaries and Subsequent Task Force Recommendations
Upon extensive research, the GDTF identified a need for the AAN to create or compile resources, selected the stakeholders to work with, and noted additional actions the AAN could take to make a positive impact on gender disparity issues for neurologists. Broadly, the recommendations below address the identified causes noted above and stress the AAN's role in leading the charge, providing education and tools, and working with other organizations to address this important issue.  

For the AAN to implement these recommendations, it will need to:

• Work with other organizations to share content, including the Association of University Professors of Neurology (AUPN) and the American Neurological Association (ANA)
• Target academic departments to ensure residents/trainees are properly trained
• Reach out to experts in the field to further guide the AAN's work on this topic, including providing training courses
  • Joanne Smikle, PhD, at Maryland (offering a mentoring course at Annual Meeting)
  • Karen Johnston, MD, at UVA, neurology chair
  • Linda Babcock at AUPN
  • Katie Donovan

Topic 1: Lead by Example

Problem: It is important that the AAN lead these efforts by assuring it is following these recommendations. According to 2017 AAN Membership data, 30% of physicians serving on Committees at the AAN are female, 34% serving on a subcommittee are female and 42% of AAN Board members are female. In 2016, 31.5% of US neurologist AAN members were female.

In January 2017, 78.3% of AAN staff are female, 42.8% of executive team members are female, and 71.7% of management positions (those who manage other people) are female.
Recommendation 1: The AAN should examine and publish the percentage of women leaders on its own Board and committees and promote equality.
Recommendation 2: The AAN executive administration is encouraged to continue to promote gender friendly work practices, compensation equity, and advancement opportunities.

Topic 2: Education
Problem: There are significant differences in men's and women's approaches to professional careers - negotiating, work hours, work interests. Many of these contribute to the barriers that women face in the work place. Teaching both men and women about these issues will help the disparities.
As the GDTF investigated educational opportunities, it discovered the AAN, and others, are currently offering several educational opportunities which the task force believes can be expanded by additional promotion and coordination. There are opportunities to add to the offerings, better promote them, and better coordinate them. Additionally, content needs to be offered in a variety of venues to allow better access since practicing physicians and early trainees already have many demands on their time and may not be able to attend meetings/courses when offered.
The AAN has a newly formed Leadership for Women Subcommittee of the Leadership Development Committee, focused on developing leadership programs.
Current AAN educational and training offerings:

• 2017 Annual Meeting Courses:
  • Women in Leadership
  • Gender Issues in Leadership
• Women Leading in Neurology Program (begins Fall 2017)

The GDTF investigated external organizations that offer courses or training on relevant topics.

• American Association for Physician Leadership (AAPL)
  • Offers general leadership training with certificate and degree tracks
  • Some courses specifically on negotiating for women
• Association of American Medical Colleges (AAMC)
  • Resources for early and mid-career women
• Association for University Professors in Neurology (AUPN)
  • Meeting for chairs and program directors to discuss issues in academic medicine

Recommendation 1: Develop core educational content and a toolbox of resources for members that can be disseminated through a variety of channels and coordinate with other organizations to spread the content. Content should be available online, to allow access without requiring travel to a conference.

• Incorporate content into existing AAN meetings and programs
  • Annual Meeting, Regional Conferences, Fall Conference 2017, Neurology Chairs Summit, New Weekend Practice Leadership Program, 2018 Breakthroughs, Transforming Leaders Program
  • The AAN should continue to focus on developing family-friendly conferences, where women can bring their families and network with one another
• Develop new AAN educational offerings
  • Webinars, hands on skills workshops for women that can be done at their own institutions, reading materials for AAN magazines and journals that highlight the problems
• Work with other similar organizations to share content

The task force selected specific content and tactics to include in the core educational content and toolbox:

• Explain how salaries are typically determined to aid in negotiating
•  Identify easily accessible information needed to effectively negotiate
• Encourage and facility transparency on implicit bias in all settings
• Train men and women leaders to be proactive mentors by seeking out female candidates for mentoring
• Increase opportunities for training in networking and negotiating skills and opportunities
• Identify effective techniques for discussing salary, benefits, and work-life balance
• Educate on protocols and processes for advancing through the academic ranks
• Identify and promote the business case for nontraditional work hours
• Provide examples of successful women in a variety of practices and settings
• Establish an index of AAN and external resources
• Utilize the resources offered through the AAN Career Center

The task force supports targeting these entities with the core educational content and toolbox:

• Trainees and early career women to change the future work force
• Mid-career women who are working toward chair roles and other leadership opportunities
• Chairs/academic programs to change the culture
• AUPN and ANA to target academics
• AMA and subspecialty societies for coordination and collaboration
• Other organizations and stakeholders to spread the educational core content and toolbox, including but not limited to journalists and the media  

Topic 3: Improve Transparency
Problem: It is hard to negotiate when you don't know what the standard is. While data exists, it can be so proprietary as to be unavailable. The Neurology Compensation and Productivity (NCP) Survey incentivized participants by giving access to the data only to those who filled it out. There may be a better way to incentivize participation without limiting access.
Additionally, in order to be helpful the data needs to be fairly specific by region, by career stage, by practice setting, maybe even by institution. This is currently not available.
Finally, it can be hard to move up in a career path when you don't know the requirements. Academic achievement is based on a variety of factors and it is not always clear what is necessary to move up. Similarly, in private practice it may be hard to move into leadership positions without knowing what is required.
Recommendation 1: Make all information needed to negotiate more broadly available

• Share Neurology Compensation and Productivity - salary data, work force statistics, gender achievement statistics
• Explore options for AAMC and Medical Group Management Association (MGMA) data accessibility for AAN members.
• Develop resources that outline requirements for various career stages (e.g., academic titles, medical staff leadership, chair and chief positions).
• Encourage public institutions to make salary data public.

Topic 4: Address Bias
Problem: Bias is a complicated problem. While explicit bias is easier to identify and is becoming less common, implicit bias is insidious and harder to address. Studies show often women have the same implicit biases against women that men have. To address implicit bias, it is important to first recognize it.
Recommendation 1: The AAN should shine the light on implicit bias in all settings.
The AAN should explore opportunities to offer surveys (like Blind Spot) to reveal biases to individuals, and make these available to departments and practices. Write articles for AAN publications about implicit bias and strategies to combat it.  

Topic 5: Develop Mentors
Problem: “See one, do one, teach one” is how we learn neurology skills. Similar options need to be available for learning career skills. Formal mentoring skills should be taught to current leaders, and then mentoring opportunities need to be available to trainees. People often confuse the role of a mentor, coach, and champion, so the AAN could include training on mentoring in its core educational content.
Recommendation 1: Train men and women leaders to be proactive mentors and encourage them to seek out female candidates for mentoring. The AAN should develop a robust mentor matching program and provide guidance and expectations about a positive mentoring relationship.
Recommendation 2: The AAN should create networking opportunities for women whenever possible.
Recommendation 3: The AAN should highlight female neurologists who have achieved leadership roles or success in a variety of settings, including academic, research, and private practice.

Topic 6: Promote Different Practice Options to Support Work-life Balance
Problem: Women with personal responsibilities or interests may prefer nontraditional work options. They may not want to be tied to 9-5 hours or clinic schedules and responsibilities, or they may need to leave at a certain time to pick up children. At the same time, they may not be aware these opportunities exist or that they may be able to design their own job.
Recommendation 1: The AAN should develop examples of alternative work options. Nontraditional work hours may be attractive to a practice from a business perspective as it will use fixed resources in a broader way (e.g., the building is there and paid for 24/7 so adding morning, evening or Saturday clinics may increase revenue on fixed expenses). Patients often prefer to have appointments during evenings or weekends to avoid missing work.
Recommendation 2: The AAN should develop examples of nonclinical career options, such as industry, research, telemedicine.
Recommendation 3: Encourage use of better support models in practices especially during child-bearing years, such as using scribes and allied health professionals.

Topic 7: Offer a Scholarship/Research Fund
Problem: While the AAN can bring national attention and measures to this issue, grassroots efforts on the local level may help spread change as well. Other organizations have developed scholarship seed money to promote local program development and research to further these issues.
Recommendation 1: The AAN should offer scholarships to members to support research studies or as seed money for small projects to work on the problem.

Topic 8: Legislative Options
Problem: Other countries (England, Canada) have shown significant improvements in gender disparities only by passing legislation that corrects the discriminatory activities of businesses. In August 2016, Massachusetts passed legislation that makes it illegal for an employer to ask an applicant their salary history, which helps to address the compounding problem of women coming in with lower pay. The law also allows employees to discuss their salaries with each other.
Recommendation 1: The AAN should explore legislative options that have been implemented elsewhere that could be pushed in the US either federally or at the state level.
Recommendation 2: As a thought leader in neurology, the AAN should develop a position statement that promotes equality and highlights discrepancies and bias. This can also be used to support legislative and journalistic activities in this area. The AAN should update its Code of Professional Conduct to reflect our position on equal pay for equal work, regardless of gender, and promote it accordingly to the membership

Topic 9: Conduct Further Investigation
Problem: The discrepancies in gender pay and promotions have been present for a long time and have been a focus of many articles and initiatives but they still exist. The causes and solutions are not completely clear so further study should be done specifically in neurology. The recent JAMA article showed smaller pay gaps in certain fields (radiology, emergency medicine, and family medicine), why? Neurology was a particularly bad outlier in discrepancies, why? The Neurology Compensation and Productivity (NCP) Survey does not collect information about marital status, number of children, extended leaves of absences, whether contracts were negotiated, if there is paid/unpaid time off for maternity and family needs, how pay differs for E/M vs. procedural codes. The task force felt this information would be necessary to understand the problems but the NCP work group felt this was out of the scope of their survey. This data may be available through other organizations like AAMC, which has done extensive surveys in these areas. Additionally, the AAN burnout surveys found that women under 40 were less likely to become a physician again, were more fatigued, and were more emotionally exhausted and with less sense of personal accomplishment than men under 40. Qualitative data such as structured interviews with department chairs could be informative. Longitudinal data could help show which factors influence disparity in leadership and salary.
Recommendation 1: The AAN needs to collect further data to better understand the differences in men and women work practices, drivers for differences in pay, and advancement in the field. The AAN should publish articles based on the results.
Recommendation 2: The AAN should pool data from the burnout survey and NCP survey to get more robust results.

Next Steps
This topic spans across the entire AAN portfolio; as a result, the need for ongoing collaboration is essential. The GDTF proposes the Leadership for Women Subcommittee take primary ownership of the recommendations and coordinate with the Women in Neurology section, the Medical Economics and Management Committee, and the Government Relations Committee to implement the recommendations that the board endorses.
The GDTF suggests a report to the board in six months on progress toward implementing the recommendations.

¹ Brooks, Megan. "Neurologist Income Up Slightly But Satisfaction Remains Low." Medscape Medical News. Medscape, 21 Apr. 2015. Web. 25 Jan. 2017. <http://www.medscape.com/viewarticle/843470>.

² Montanez, Amanda. "The Pay Gap, Visualized and Analyzed." Scientific American. N.p., 25 May 2016. Web. 25 Jan. 2017. <https://blogs.scientificamerican.com/sa-visual/the-pay-gap-visualized-and-analyzed/>.

³ Jena, Anupam B., Andrew R. Olenski, and Daniel M. Blumenthal. "Sex differences in physician salary in US public medical schools." JAMA Internal Medicine 176.9 (2016): 1294-1304.

⁴ Lautenberger, Diana, Valerie Dander, Claudia Raezer, and Rae Sloane. "The State of Women in Academic Medicine." Association of American Medical Colleges. N.p., 2014. Web. 25 Jan. 2017. <https://members.aamc.org/eweb/upload/The%20State%20of%20Women%20in%20Academic%20Medicine%202013-2014%20FINAL.pdf>

⁵ Bowles, Hannah. "Why Women Don't Negotiate Their Job Offers." Harvard Business Review. N.p., 19 June 2014. Web. 25 Jan. 2017. <https://hbr.org/2014/06/why-women-dont-negotiate-their-job-offers>.

⁶ Moore, Gwen. "Structural Determinants of Men's and Women's Personal Networks." American Sociological Review 55 (1990): 726-35. JSTOR. Web. 25 Jan. 2017.

⁷ Parks, Susan Hillier, and Marc Pilisuk. "Caregiver burden: gender and the psychological costs of caregiving." American Journal of Orthopsychiatry 61.4 (1991): 501.