Race and Sex Dictate Publication Rate for Med Students

Publication rates among US medical students vastly differ based on sex, race, and ethnicity, according to new data released online yesterday in JAMA Network Open. Researchers say there may be career consequences for women and racial/ethnic groups underrepresented in medicine (URIM).

Previous studies in the cardiology field have shown similar alarming trends, with men being more likely than women to author invited commentaries and women in general publishing less than men, although there are hints that this could be improving.

“We expected to find some gender disparity and some race/ethnic disparity, based on prior studies at the faculty level,” lead author Mytien Nguyen, MS (Yale School of Medicine, New Haven, CT), told TCTMD. “What was surprising when we looked at intersectionality between the two identities was that we found data that actually mirrors [previous research] among [US National Institutes of Health] faculty where URIM and women face the most inequity, essentially.”

With every one of these individuals, we're impacting not only the professional societies but also all patient populations as clinician scientists. Mytien Nguyen

The study speaks to a broader “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 continue to try and make sure that there's adequate representation in the field,” he told TCTMD. “You can't just have one single approach to this issue.”

Similarly, 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: “Clearly, there are lots of factors that contribute to what we see, which is not surprising. But having it quantified in such a rigorous way is I think very helpful to support what many of us see in reality.”

Also, Armin Zadeh, MD, PhD, MPH (Johns Hopkins University, Baltimore, MD), editor-in-chief of the Journal of Cardiovascular Computed Tomography, told TCTMD in an email that these findings “raise important awareness of persistent bias in our training programs. Clearly, we have more work to do. Our training programs should monitor the research opportunities as well as productivity in relation to sex, race, and ethnicity.”

Significant Gaps

For the study, Nguyen and colleagues included data from the Association of American Medical Colleges on 31,474 medical school graduates (48.2% women; 13.8% URIM) who matriculated between 2014 and 2016.

Students attending top 40 research-ranked schools by the NIH reported more research experiences as well as publications (median 1.60 vs 1.25; P < 0.001) compared with students from non-top 40 schools.

While women reported a higher number of research experiences than men, they published significantly less regardless of whether they attended a top 40 (mean 7.32 vs 8.22) or non-top 40 school (mean 4.81 vs 5.15; P ≤ 0.001 for both). This resulted in a significantly lower adjusted publication rate among women than men, as well, at both top 40 schools (adjusted RR 0.85; 95% CI 0.83-0.86) and non-top 40 schools (adjusted RR 0.91; 95% CI 0.90-0.92).

Compared with white students, those of Asian descent reported higher publication rates at both NIH top 40 schools (adjusted RR 1.10; 95% CI 1.08-1.12) and non-top 40 schools (adjusted RR 1.07; 95% CI 1.05-1.08). However, Black students reported lower publication rates than white regardless of school ranking (top 40: adjusted RR 0.83; 95% CI 0.80-0.86; non-top 40: adjusted RR 0.88; 95% CI 0.85-0.95), and Hispanic students attending non-top 40 schools also reported fewer publications (adjusted RR 0.93; 95% CI 0.90-0.95).

Clearly, there are lots of factors that contribute to what we see, which is not surprising. But having it quantified in such a rigorous way is I think very helpful to support what many of us see in reality. Bruce Ovbiagele

The findings regarding NIH funding specifically indicate that the organization can greatly help to “mitigate and reduce gender and race inequity” by spreading out the wealth more than has been done in the past, Nguyen said. “Right now, what I've seen is that money begets money, so schools that are already well funded well get more NIH funding, and schools that are minority serving—like your historically Black colleges and universities—are not among the top 40.”

By “intentionally match[ing] funding with diversity outcomes,” schools can better generate more diversity in the pool of physician scientists, Nguyen added.

As for some of the gender disparities observed, she said, “we can infer that women are seeking out on research opportunities and are more proactive in finding research opportunities and mentors, but for each of these research opportunities, women students are getting out of it less than men do.” The mechanism for this is unclear, Nguyen added, but she guessed that it could be tied to mentorship trends.

She called for change to start “at the elementary school level” to really have a lasting effect. “We've seen that there is increased diversity in medical school in general, but there's still students who are leaving medicine,” Nguyen said. “It's key to support the continuum for students across their training. . . . With every one of these individuals, we're impacting not only the professional societies but also all patient populations as clinician scientists.”

Mentorship Is ‘Fundamental’

Commenting on the study for TCTMD, Ann Marie Navar MD, PhD (UT Southwestern Medical School, Dallas, TX), who serves as the deputy editor for equity, diversity, and inclusion at JAMA Cardiology, urged caution in overinterpreting the data since they show average publication rates across a large population. “It’s not clear what proportion of each group really wanted to have research experiences that led to publications versus those who had other goals or priorities in medical school including community outreach, service, quality improvement, or education,” she said in an email.

“And while number of publications is important, publication count doesn’t necessarily correlate with the quality of the experience(s) for the trainee. This highlights the importance for residency programs and ultimately academic leadership to look beyond publication count when evaluating potential trainees and faculty,” Navar added.

You can't just have one single approach to this issue. Sunil Rao

Rao agreed that publication counts on their own don’t matter all that much, but funding does if the goal is to have a career in research. Still, the discrepancies highlighted in this paper are “challenging,” he said. And, if the study was done among cardiology trainees, Rao said he expects the gaps would be “worse.”

This may be “rooted in a lot of different things,” Rao observed. “It may be systematic bias. It may be rooted in opportunity. It may be rooted in lack of mentorship.”

Mentorship is “fundamental” to the solution of these issues, he said. “What a good mentor does is they provide opportunities for their mentees that they themselves could benefit from. . . . If you are mentoring someone who is underrepresented, my sense is that they're probably not getting as many opportunities as other mentees. I don't have any data to back that up except to say that there's a reason why we don't have representation in science, and maybe that's one of them.”

Further, Rao said it’s “everybody’s” responsibility to create change, echoing Nguyen’s comment about starting at the elementary school level. “We need to start . . .  getting people interested in science who traditionally have been excluded from science,” Rao said. “All of us benefit when there's diversity. That's what I think people misunderstand. People think of diversity efforts as inclusion of one group at the exclusion of the other group. But that's not what it's about. It's about making sure that we have all the voices of the room heard because that makes all of us better.”

How Should Journals Adjust?

Journals will play a large role in increasing diversity going forward, according to several people interviewed for this article.

Ovbiagele said his experience fostering an editor-in-training program for Stroke has successfully upped diversity for that journal’s editorial board, and he intends to continue a similar program in his new role.

Still, he acknowledged, “at some point, you can only do so much based on who's out there.” In trying to recruit board members for JAHA, Ovbiagele said he has encountered challenges. “Because there are so few underrepresented minorities, everybody wants them,” he said. “When I approach them, they all go: ‘I'm already taken on this board and that board.’”

Similarly, Rao said it’s important to not “overburden specific people who may be asked repeatedly to be on editorial boards or review or write.” Because of this, he also plans to continue his assistant editor program at Circulation: Cardiovascular Interventions.

“I think things are going to change, but let's not be naive about how hard it's going to be,” Rao said. “I think things are changing, but I do think that we have a long way to go.”