Cristina Iannuccelli

Elisa Gremese

Francesca Romana Spinelli

M. Vadacca

Maria Sole Chimenti

Paola Conigliaro

S L Bosello

Undetermined

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Reumatismo 4/2019 173EDITORIALReumatismo, 2019; 71 (4): 173-176Fighting against inequality is one of the key focus areas chosen by the French presidency of G7 which launched the Gen-der Equality Advisory Council to Make Gender Inequality History (https://www.elysee.fr/en/g7/2019/08/20/publication-of-the-report-of-the-g7-gender-equality-advi-sory-council). Gender equality is also a central topic in the plan of the European Program Horizon 2020 which includes three main objectives:1) fostering gender balance in research teams;2) ensuring gender balance in decision-making;3) integrating the gender dimension in re-search and innovation contents.The purpose of this editorial is to point out the issue of gender equality in medicine and to assess the Italian situation in aca-demic rheumatology.Gender parity is a purely numerical con-cept; it is a statistical measure that provides a numerical value of female-to-male ratio for indicators such as income or education. For example, if there are equal numbers of girls and boys who completed primary education in a specific country, the gender parity ratio for that indicator is one. The greater the difference between girls and boys, the lower is the gender parity value. Gender parity is a useful tool for assess-ing gender inequality in specific areas, in setting goals, and in assessing change and progress under specific indicators of gen-der equality (1, 2).Improvements in gender parity among medical school graduates have not trans-lated to gender parity among practicing physicians or medical schools (3). In 2015, more than one third (34%) of the active physician workforce in the United States was female (4); an estimated 46% of all physicians-in-training and more than half of all medical students are women (5, 6). The year 2017 marked the first time in his-tory when the number of women enrolling in US medical schools exceeded the num-ber of men (7, 8).Gender parity does not correspond to gen-der equality, so much so that gender-based disparities in salaries and advancement per-sist. A clear demonstration of the inequali-ty in medicine is the difference in women’s versus men’s salaries. (3, 6, 9, 10). In the United States and some other de-veloped countries, in cases of equal work and position (same rank, training, and ex-perience), unequal pay continues to disad-vantage women (10-13), despite evidence that the quality of care women provide is equivalent, and in some cases superior, to that of their male colleagues (14).Lower salaries for women compared with men in academic medicine have been at-tributed to women’s lesser productivity, defined by the number of grants and au-thorship roles (3, 15). The gender dispar-ity in research funding is particularly com-plex to address but clearly evident. A study in JAMA found that the start-up package funding for junior investigators was low-er for women performing basic research (p<0.001) and for women with a PhD de-gree (p<0.001) with respect to men (11, 12). These are critical differences that can affect an investigator’s success in estab-lishing a research program and competing for national research grants. What is clear from this research is that early disparities Corresponding author:Maria Sole ChimentiRheumatology, Allergology  and Clinical ImmunologyUniversity of Rome Tor Vergata, Rome, ItalyE-mail: msolechimenti@hotmail.comGender equality in RheumatologyS.L. Bosello1*, M.S. Chimenti2*, P. Conigliaro2*, C. Iannuccelli3*, E. Gremese1*, F.R. Spinelli3*, M. Vadacca4*1UOC di Reumatologia, Fondazione Policlinico Universitario A. Gemelli - IRCCS; 2Rheumatology, Allergology and Clinical Immunology, University of Rome Tor Vergata, Rome, Italy; 3Reumatologia, Dipartimento di Medicina Interna e Specialità Mediche, Sapienza Università di Roma, Rome, Italy; 4Rheumatology, Allergology and Clinical Immunology, Campus Bio Medico University of Rome, Rome, Italy; *ReDO-Reumatologhe Donne- Executive CommitteeNon-ommercil us onlyEDITORIAL174 Reumatismo 4/2019S.L. Bosello, M.S. Chimenti, P. Conigliaro, et al.in funding between women and men have major career implications that may ex-plain why women do not seem to advance through the scientific career ranks as quick-ly as men (11, 12).Although equal numbers of men and wom-en now graduate from medical school, only a small fraction of female physicians be-come medical leaders.Although women have held faculty posi-tions in academic medicine for decades, women still account for only 21% of full professors and 15% of department chairs (12, 16). Moreover, the share of females in the faculty declines at each subsequent rank, such that the share of female profes-sors is 56% lower than the share of male assistant professors (3, 4, 16). Females holding faculty positions are less likely than male equivalents to be invited to speak at major events, less likely to be introduced with their title when they speak, and less likely to receive awards from their profes-sional societies (3, 17). Female employment is constrained by two kinds of barriers: those at the entry in the labour market and those when progress-ing through it. These barriers to advance-ment are also known as the glass ceiling: an invisible mix of cultural attitudes, gen-der-linked stereotypes, ways of working, lack of policies on the workplace that help balance family care and professional life, which all contribute to the fact that women are retained and promoted less than equally skilled men. There is widespread consen-sus that putting women at the top of organi-zations is the most effective way of break-ing the glass ceiling: women in decision-making positions can change the cultural attitudes, unspoken norms and the ways of working in order for an organization to be more open to promoting women (1, 2).Even if international organizations have done a tremendous job in leading by exam-ple in terms of gender parity, the fact that women are still seriously underrepresented at their senior management level is a mat-ter of concern. Disparities in compensation persist, and inequities have contributed to the disproportionately low number of fe-male physicians achieving academic ad-vancement and serving in leadership posi-tions. It is at this level that the presence of more women can radically change cultural attitudes, internal practices and ways of working that otherwise make achieving gender parity more difficult (2, 6).The medical profession and our patients benefit greatly from a diversified physi-cian workforce. A concerted effort must be made to address the systemic inequi-ties that pose as barriers to gender equity in academic medicine careers, to eliminate the imbalance in remuneration and career advancement opportunities and to incorpo-rate women as full participants in our pro-fessions (1, 6, 12).As explained by the Executive Editor Dr. Jocalyn Clark in a special issue of The Lan-cet, gender equity is not only a matter of justice and rights, it is crucial for produc-ing the best research and providing the best care to patients (18).In the rheumatology field, in recent years the proportion of women has been increas-ing worldwide; in the US the overall num-ber of females currently exceeds the num-ber of male rheumatologists (19). How-ever, women are still underrepresented in academic rheumatology (20, 21). In 2019, EULAR established a task-force on gender equity in rheumatology which will address the potential unmet needs and differences across European countries and delineate opportunities for EULAR to develop a comprehensive intervention on gender eq-uity (22).As for academic rheumatology in Italy, currently the number of female and male assistant professors is quite similar (49 vs 64), reflecting the increasing number of fe-males choosing an academic career (Figure 1). The still evident different distribution across the highest academic positions may be related to the greater number of male students attending the medical schools dur-ing the last 30 years. In conclusion, even if in recent years parity between the genders has certainly improved, the path to gender equity still has a long way to go, a path to be taken together, driven by the motivation of the medical and non-medical European programs.Non-commrcial us onlyReumatismo 4/2019 175Gender equality in Rheumatology EDITORIALNote: The authors are members of the As-sociation Reumatologhe Donne (ReDo), a group of doctors whose mission is to pro-mote networking among rheumatologists for women in medicine and science.n	 REFERENCES1. Anne-Marie Sluaghter, Why Women Still Can’t Have It All, in «The Atlantic», July/Au-gust 2012.2. European Commission, Strategy on equal op-portunities for women and men within the Eu-ropean Commission (2010-2014), 2010, SEC (2010)1554/3. 3. Raj A, Kumra T, Darmstadt GL, Freund KM. Achieving Gender and Social Equality: More Than Gender Parity is Needed. Acad Med. 2019 [Epub ahead of print]. 4. Association of American Medical Colleges. 2016 Physician Specialty Data Report: Execu-tive Summary. Washington, DC: Association of American Medical Colleges; 2016. Avail-able from: www.aamc.org/download/471786/data/2016physicianspecialtydatareportexecutivesummary.pdf Accessed: 22 December 2017.5. Association of American Medical Colleges. Matriculating Student Questionnaire: 2017 All Schools Summary Report. Washington, DC: Association of American Medical Colleg-es; 18 December 2017. Available from: www.aamc.org/download/485324/data/msq2017re-port.pdf Accessed: 29 January 2018.6. Butkus R, Serchen J, Moyer DV, et al. Achiev-ing Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians. Ann In-tern Med. 2018; 168: 721-3.7. Kang SK, Kaplan S. Working toward gender diversity and inclusion in medicine: myths and solutions. Lancet. 2019; 393: 579-86.8. Association of American Medical Colleges. More women than men enrolled in U.S. medi-cal schools in 2017. Available from: https://news.aamc.org/press-releases/article/applicant-enrollment-2017/ Accessed: Sept 14, 2018.9. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016; 176: 1294-304.10. Parks AL, Redberg RF. Women in medicine and patients outcomes: equal rights for better work? JAMA Intern Med. 2017; 177: 161.11. Sege R, Nykiel-Bub L, Selk S. Sex differences in institutional support for junior biomedical researchers. JAMA. 2015; 314: 1175-7.12. Bates C, Gordon L, Travis E, et al. Striving for Gender Equity in Academic Medicine Ca-reers: A Call to Action. Acad Med. 2016; 91: 1050-2.13. Jena AB, Olenski AR, Blumenthal DM. Sex differences in physician salary in US public medical schools. JAMA Intern Med. 2016; 176: 1294-304.14. Wallis CJ, Ravi B, Coburn N, et al. Com-parison of postoperative outcomes among pa-tients treated by male and female surgeons: A population based matched cohort study. BMJ. 2017; 359: j4366.15. Filardo G, da Graca B, Sass DM, et al. Trends and comparison of female first authorship in high impact medical journals: Observational study (1994-2014). BMJ. 2016; 352: i847.Figure 1 - The increasing number of females choosing an academic career. *TemporaryStates: effect of gender and generation. Arthritis Rheumatol. 2016; 68. 20. Elston MA. Women and medicine: the future. London: Royal College of Physician; 2009. 21. Edmunds LD, Ovseiko PV, Shepperd S, et al. Why do women choose or reject careers in academic medicine? A narrative review of empirical evidence. Lancet. 2016; 388: 2948–58. 22. Andreoli L, Ovseiko PV, Hassan N, et al. Gender equity in clinical practice, research and training: Where do we stand in rheumatology? Joint Bone Spine. 2019 [Epub ahead of print].      Figure 1 - The increasing number of females choosing an academic career. 34.4%39.1%15.6%10.9%4.1%Full Professor Associate ProfessorMen (64) Women (49)Assistant Professor Assistant Professor*30.6%28.6%36.7%454035302520151050Non-commrcial use onlyEDITORIAL176 Reumatismo 4/2019S.L. Bosello, M.S. Chimenti, P. Conigliaro, et al.16. Lautenberger DM, Dandar VM, Raezer CL, Sloane RA. The State of Women in Academic Medicine: The Pipeline and Pathways to Lead-ership 2013-2014. Washington, DC: Associa-tion of American Medical Colleges. 2014.17. Boiko JR, Anderson AJ, Gordon RA. Represen-tation of women among academic grand rounds speakers. JAMA Intern Med. 2017; 177: 722-4.18. The Lancet. Feminism is for everybody. Lan-cet. 2019; 393: 493.19. Deal C, Bolster MB, Hausmann JS, et al. Adult rheumatology specialists in the United States: effect of gender and generation. Arthri-tis Rheumatol. 2016; 68.20. Elston MA. Women and medicine: the future. London: Royal College of Physician. 2009.21. Edmunds LD, Ovseiko PV, Shepperd S, et al. Why do women choose or reject careers in academic medicine? A narrative review of em-pirical evidence. Lancet 2016; 388: 2948-58.22. Andreoli L, Ovseiko PV, Hassan N, et al. Gen-der equity in clinical practice, research and training: Where do we stand in rheumatology? Joint Bone Spine. 2019 [Epub ahead of print].Non-commercial use only

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