Editor’s note: This is part one of a two-part series on gender disparity in otolaryngology. Part two, which will publish in the June issue of ENTtoday, will focus on gender disparity in clinical trials.
Gender bias in research funding has been persistent and deep seated in many aspects of medicine for a long time; only recently has it started to get the attention it deserves. “It’s simply unfair for women to encounter barriers to their success outside of their control,” said Zainab Farzal, MD, resident and researcher in the department of otolaryngology/head and neck surgery, University of North Carolina at Chapel Hill. “Acknowledging it is important because women’s progress is society’s progress. For these reasons, sex disparities need to be studied and tackled on multiple levels.”
Sujana S. Chandrasekhar, MD, past president of the American Academy of Otolaryngology–Head & Neck Surgery and partner at ENT and Allergy Associates, LLP, in New York City, and her colleagues have documented the existence of gender-based funding disparities in otolaryngology. In a 2013 study, these researchers found that male faculty have higher National Institutes of Health (NIH) funding levels than their female colleagues. This disparity is true both for early and mid-to-late career individuals (Otolaryngol Head Neck Surg. 2013 Jul;149:77–83). Sex bias also occurs in industry funding, research and otherwise, for both otolaryngology and neurosurgery (JAMA Otolaryngol Head Neck Surg. 2017;143:796–802; World Neurosurg. 2017;103:517–525).
Dr. Farzal pointed to a study analyzing NIH research project grant renewal summary statements written by grant reviewers that show substantial implicit biases in the grant peer review process. (J Womens Health. 2017;26:560–570). For instance, male principal investigators were referred to as “leaders” or “pioneers,” and their work was referred to as “highly innovative” or “highly significant research” in summary statements. Conversely, less weighty words were used to describe female principal investigators and their work. They were said to have “expertise” and worked in “excellent” environments.
If we don’t support the growth and professional development of female surgeons who, year after year, become a greater percentage of the specialty, we hold back the whole otolaryngology field.—Zainab Farzal, MD
Another study demonstrated that grant proposals by male and female principal investigators received similar critiques when they were judged primarily on the science in the proposal (Lancet. 2019;393:531–540). However, when the grant review was based on an assessment of the principal investigator’s credentials, grants with female principal investigators received significantly lower scores, Dr. Farzal said.
Why Bias Occurs
© Hyejin Kang / shutterstock.com
Reasons for gender bias are multifactorial. By the time an otolaryngologist has completed his or her training and is ready to establish a career in clinical and/or research practice, he or she is also at the stage of life where it’s common to have children. “Although both men and women have children, in the vast majority of cases, women in all professions bear the bulk of the effort in raising them,” Dr. Chandrasekhar said.
A majority of women, despite dedication to their careers, decrease their academic and research productivity during this time in order to effectively juggle home and work responsibilities. Men, on the other hand, don’t usually make that change at work. “This results in a disparity in scholarly productivity early in women’s careers that benefits men in terms of promotion, research funding, and industry support—while hurting women,” Dr. Chandrasekhar said. “Women actually not only catch up but surpass men [in scholarly productivity] when their children are older but, unfortunately, many chairs and deans choose to be unaware of this, so women consistently lose out” (Otolaryngol Head Neck Surg. 2013;148:215–222; Laryngoscope. 2013;123:1865–1875).
Other reasons for gender bias, according to Kathleen Yaremchuk, MD, MSA, chair of the department of otolaryngology-head and neck surgery at Henry Ford Hospital in Detroit, might be a lack of mentorship for women in research, women being committed to clinical and educational services and therefore lacking dedicated research time, and individuals in leadership positions believing that women are not serious in their academic medicine careers.
Disparity’s Impact
Academic leaders and key opinion leaders are chosen based on metrics such as research funding, scholarly productivity, and industry support. “If there is gender bias in achieving these three metrics, then women who are victims of gender bias in funding, productivity, and support will obviously fall out of the leadership pipeline, leaving fewer and sometimes no women in consideration for leadership roles,” said Dr. Chandrasekhar.
Dr. Farzal believes that a diversity of perspectives and approaches in academic medicine are needed to advance the profession. “We may lose valuable insight into our field if we discredit a female surgeon or scientist,” she said. “On a large scale, if we don’t support the growth and professional development of female surgeons, who year after year become a greater percentage of the specialty, we hold back the whole otolaryngology field.”
Regarding the impact on a female otolaryngologist’s academic career path, adequate research support and funding are stepping stones toward tenure and promotion to higher professorship ranks, particularly for individuals on academic tracks, Dr. Farzal said. Similarly, grant funding and research productivity carry heavy weight in academic job interviews. “Sex bias in research funding or support can be detrimental for women’s career trajectories and has the potential of locking them out of the highest-ranked positions,” she added.
Jennifer A. Villwock, MD, assistant professor of otolaryngology–head and neck surgery at the University of Kansas Medical Center in Kansas City, pointed out that women may be dissuaded from remaining in academics long term if they repeatedly fail to secure research funding. “If it seems that certain groups are excluded from these opportunities, some women may disengage from actively participating in sponsoring organizations,” she said. “A perceived lack of recognition for worthy efforts could also create disillusionment and potentially contribute to burnout.”
Effects on Patient Care
Sex-based disparities affect patient care directly, because instances of underfunding female researchers translate into lost opportunities for the advancement of science and, thus, evidence-based patient care. “They can negatively affect both the short- and long-term evolution of standards of care,” Dr. Farzal said. “For instance, short-term clinical studies, including comparative effectiveness research, often change treatment paradigms, while basic science research has implications for clinical care down the road.”
Gender diversity can also improve outcomes. Within medicine, previous work has shown that female physicians have a more patient-centered communication style, are more encouraging and reassuring, and conduct longer visits with patients than male physicians, Dr. Yaremchuk said. A study of hospitalized Medicare patients demonstrated that 30-day readmission rates were lower for patients treated by female internists across eight medical conditions when compared with male internists (JAMA Intern Med. 2017;177:206–213).
The bottom line is that women have much to contribute to the otolaryngology profession, but, if research funding continues to be distributed unevenly, their hands are often tied when it comes to what they can offer. It would benefit everyone to give promising female researchers the same opportunities to advance the field as men have.
Karen Appold is a freelance medical writer based in New Jersey.
Key Points
- Sex bias in research funding has been persistent and deep-seated in many aspects of medicine for a long time.
- Recent studies show substantial implicit biases in the grant peer review process.
- Reasons for gender bias include a lack of mentorship for women in research and individuals in leadership positions believing that women are not serious in their academic medicine careers.
Seven Ways to Overcome sex Bias in Research Funding
Otolaryngologists and others involved in the field can take steps to deter sex disparity from occurring in research funding. Here are seven ways identified by experts.
- Increase awareness. Otolaryngologists need to actively undertake the mission of addressing sex bias in research funding. “Health system and department leaders can form committees for assessing and counteracting sex biases,” says Zainab Farzal, MD, resident physician and researcher in the department of otolaryngology-head and neck surgery, University of North Carolina at Chapel Hill. Many institutions are involved in programs designed to propel the careers of female researchers in science, technology, engineering, and mathematics (STEM), such as the National Science Foundation’s ADVANCE program, but individual departments may be unaware of them. “Otolaryngology departments need to seek out opportunities like ADVANCE, and make institution-specific expectations for promotions and tenure more transparent so faculty can track their progress toward them.”
- Educate faculty. “If they are perceived as being biased, address their behaviors,” said Sujana S. Chandrasekhar, MD, past president of the American Academy of Otolaryngology–Head & Neck Surgery and partner at ENT and Allergy Associates, LLP, in New York City. “The problem is generally an unconscious bias. Pointing out the lack of diversity in a constructive manner may be all that’s needed. For example, ‘That’s a nice list of potential collaborators. But I noticed that there aren’t any women listed. Shall we brainstorm a more comprehensive list together?’” If the faculty member is deemed to be overtly biased, then remediation falls to the chair or dean, and often will involve human resources and the institution’s ombudsperson. “Although this begins as a confrontational issue, it can actually turn positive quickly and benefit the faculty member and department,” she added.
- Provide attractive opportunities. “Junior faculty should be assigned a research mentor, despite their gender, to help navigate a successful path toward obtaining sustainable funding,” said Lindsay Sobin, MD, assistant professor of otolaryngology, University of Massachusetts Medical School in Worcester. In addition, “Senior faculty should advocate for transparency in starting package offers to ensure equitable offers for candidates,” she said.
- Educate grant review committees. “It may be meaningful to place less weight on what an investigator has done in the past and focus more on the feasibility of their proposed work,” Dr. Chandrasekhar said. “This requires academic leadership to lend their whole-hearted support to the person and project, with a long-distance view.” Chairs and deans need to understand gender differences in academic productivity and be cognizant of the different factors affecting women faculty, she added. “Encouraging healthy personal and professional growth will result in sustained departmental health.”
- Organizations should reflect on award recipients they fund. If a field’s diversity is not adequately represented, they should proactively address the gap. “To clarify, I do not mean that less meritorious applications should receive more favorable reviews,” Dr. Villwock said. “Rather, organizations should encourage more applications and active participation from a more diverse field by providing targeted research mentorship and writing workshops to ensure that future applications are high quality.”
- Organizations need to be aware of the gender bias they present from the podium. Dr. Chandrasekhar recently reviewed years of invited speakers at two major societies. “The results were appalling,” she said. “Not only were female surgeons rarely moderators or panelists, but when they were panelists they were asked to speak on non-surgical topics. (Otol Neurotol. 2019;40:1-5).” Industry leaders need to understand that advancement of women as key opinion leaders is important. “They need to be called out for fielding male-only panels,” Dr. Chandrasekhar added.
- Tap into resources focused on women. View groups such as the AAO-HNS’s Women in Otolaryngology Section, the American Rhinologic Society’s Women in Rhinology Section, and the Women in Neurotology as resources for finding women to serve on panels, Dr. Chandrasekhar said.—KAw often do you have problems learning about your medical condition because of difficulty understanding written material?