Current Status and Future Strategies for Mentoring Women in Neurology

The American Academy of Neurology's (AAN) 2017 Gender Disparity Report identified improving mentorship as a key intervention to fill the leadership and pay gaps for women in neurology. Here we summarize the literature on mentoring women, provide an outline of ideal components of programs geared toward closing gender gaps, and present a mentoring program for AAN members. The strategies discussed share similarities with those for closing gaps related to race, ethnicity, and religion. Developing effective mentorship and sponsorship programs is essential to ensure a sufficiently diverse pool of academic faculty and private practitioners and to establish equal representation in leadership roles in this field.


Introduction
Mentorship is beneficial for career and life development and encompasses interactions and partnership between a mentor, who provides multifaceted support and guidance, and a mentee, who seeks knowledge, advice, and expertise. 1,2 An ideal mentor can help, guide, direct, and influence a mentee while also identifying his or her own areas of improvement. Together with institutional support, both mentor and mentee strive to achieve a shared vision of the mentorship relationship. 3 Dedicated time for mentoring is challenged by clinical, research, and administrative demands, and women more often report difficulty in finding mentors. 4 Despite mounting evidence for the benefits of mentorship at all career stages, the lack of an effective framework that effectively supports mentees with diverse backgrounds, while providing protected time for mentors, persists. Moreover, sex and gender minority individuals (e.g., nonbinary, LGBTQ+) (SGM) and physicians belonging to groups that are underrepresented in medicine (URM) likely face a similar lack of support.
The American Academy of Neurology (AAN) Gender Disparity Task Force's report and recommendations highlighted mentorship as a critical component of rectifying gender gaps in neurology. 5 These recommendations included formal mentor training for current leaders and offering mentorship training as part of AAN's educational programming. 5 This narrative review highlights the benefits of mentoring, addresses the current gender gap in mentorship in neurology, reviews current national women-specific mentorship and sponsorship initiatives, and makes recommendations to establish mentorship programs for women and other underrepresented groups.

Benefits of Mentoring in Academic Medicine
The benefits of mentorship are highlighted in table 1. Mentoring has a strong influence on academic performance, research interests, and interest in academia. 3 As neurology has one of the highest rates of burnout among medical specialties, 5 mentoring in neurology can help build mechanisms to avoid or overcome burnout. Residents who participated in a mentorship program had decreased stress, emotional exhaustion scores, and levels of depersonalization, as well as higher personal achievement scores and improved quality of life. 6,7 Similar findings were reported in a review showing that mentorship positively affects health and well-being. 8 Successful mentorship also contributes to higher faculty retention. 9 Furthermore, successful mentorship programs establish pipelines of mentors by increasing the odds of a mentee becoming a mentor. 10 Models of mentorship vary according to the number of participants, the structure (formal, informal), the roles of mentor and mentee (dyadic, multiple), the approach (apprenticeship, team, peer, or senior-to-junior mentoring), and method of delivery (distance, virtual, or face-to-face) (table 2). 1,11 There are few evidence-based conclusions on the effect of mentorship or guidelines on best practices.

Mentorship in Neurology
In neurology, more than 60% of residents attribute their choice of residency to a mentor. 12 Informal mentorship can be established through AAN's Student Interest Group in Neurology, present at most medical schools and similar programs. 12 An example of a longitudinal mentorship program is Comprehensive Opportunities for Research and Teaching Experience, where mentorship begins as early as the first year of medical school. 13 This program significantly augmented the number of students matching into neurology and increased the students' academic productivity during medical school while providing guidance on the residency application process. 13 Mentorship is important at all career levels, and many national organizations recognize this through programs such as the AAN's Director Mentorship 14 and the American Neurologic Association's MentorLink. 15 Gender Gaps in Neurology: Need for Women-Specific Mentorship in Neurology Despite roughly equal numbers of men and women entering medical school, women occupy fewer high-ranking academic positions compared to their male peers: this is a problem termed the "leaky pipeline." The leaky pipeline in medicine is most evident in the loss of women at a higher academic rank (i.e., associate and full professors). 16 This has resulted in disparities along the professional continuum and an evident inequality within all major metrics of academic success, including compensation, 16 publication rates, 17 grant funding, 18 and society-level or national recognition 19 despite similar clinical and academic productivity. 8,20 Regardless of the physicians' experience and productivity, based on Medicare reimbursements, they are reimbursed less. 20 Another specific example of similar productivity between men and women fulltime faculty that had a gap in compensation is a study in internal medicine where work allocation, grants funded, abstracts accepted, and publication rate were similar among women and men, but compensation received by women was less than men ($72,000 vs $79,600; p < 0.001). 21 Within these broader categories, specific gaps have been identified. Women give grand rounds less frequently, 22 serve on fewer medical journal editorial boards, 23 receive less funding on initial NIH grants, 18 and spend, on average, more time on parenting and domestic activities 19 than their male peers. In one study analyzing NIH grantees, men who previously had NIH grant funding were likely to have a higher application and success rate than women of similar career stage, despite grant funding being generally similar. 24 Whereas medical school has been roughly evenly split across gender lines, in 2018 the American Association of Medical Colleges (AAMC) reported that, across clinical subspecialties for well over a decade, women accounted for 58% of instructors and 46% of assistant professors, but only 37% of associate professors and 25% of full professors. 25 Neurology has exhibited some of the most considerable disparities. 26 Women compose 51% of students going into medical school and compose an increasing proportion of the physician workforce, 27 yet continue to occupy a disproportionately low number of senior faculty positions. 26 AAMC's most recent data indicate that only 12% of neurology departments are chaired by women. 25 Female representation in medicine has been ;40% since the 1990s. However, female leadership is lacking, signaling that the pipeline, although intact, is not moving towards leadership as frequently as expected. The lack of female leadership is linked to gender inequality in compensation, such that the wage gap in neurology is one of the largest among the medical specialties, where women make roughly ;15 cents less per dollar, after adjusting for several factors including age, years of experience, specialty, faculty rank, NIH funding, clinical trial participation, PubMed indexed publications, and Medicare payments. 29 Male neurologists were twice as likely to be professors compared to female neurologists when controlling for years since medical school graduation and clustering at the facility level. 30 First and last author publications in several high-impact neurology journals, including Neurology ® , also demonstrate a publication gap, with women publishing less than expected when considering the proportion of all neurologists who are female. 31  awards see men being recognized more frequently than expected given the proportion of female AAN members: 78.1% of the 187 awards given between 2008 and 2017 were awarded to men, while the proportion of female neurologists increased from 24.7% (2008) to 31.5% (2016). 32 The proportion of female neurologists at 31.5% 27-32 is on par with other specialties under the category of "specialties with the smallest proportion of full-time women faculty," which included radiology, surgery, and orthopedic surgery, with the proportion of women ranging from 19% to 30%. 33 The potential of the impact of this disproportionate representation of women in the field of neurology probably perpetuates both microinequities and macroinequities, 34 both short-term and long-term. This should be taken into consideration when incorporating the impact of the #MeToo movement in mentorship programs.
Mentorship has the potential to narrow these gaps. [35][36][37] In a review of 20 studies on gender-stratified academic medical mentorship programs in the United States, same-gender mentors may offer advantages in career planning specific to women, such as timing maternity leave 8,37 and guidance on time management. It can be postulated that the leaky pipeline may improve with better mentorship for junior and mid-level women faculty. There is an opportunity for organizations like the AAN to address the mentoring needs of women, SGM, and URM physicians.
Women, URM, and SGM: Similarities and Implications URM are defined as "racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population." 38 SGM are individuals who "identify as lesbian, gay, bisexual, transgender, or queer." 39 In neurology, there is a notable lack of data on the impact of mentorship for URM or SGM physicians. Similarities among women, URM, and SGM include underrepresentation at the assistant, associate, and full professor level. 33 In a survey of department chairs in neurology, 65% of departments had fewer than 10% URM faculty. e41 In another study to estimate the proportion of AAN members and their identified gender that sampled 1,000 AAN members, with a response rate of 13.5%, 10% identified as gay, lesbian, or bisexual, with most of them being open about their identity at work. e42 In addition to academic underrepresentation, there are notable race-and ethnicity-based gaps in promotion e40,e43 and compensation, e44 and URM physicians face unique challenges in job obligations and duties e45 and in battling stereotypes. 39 Other issues commonly faced by women and URM and SGM include lack of mentorship, coaching, sponsorship, and funding, e46 in addition to harassment, 19 while SGM, similar to Reciprocal benefits with mentees 2 Greater employment well-being 34,e78 Organizational recognition with potential organizational incentives e77 Higher career personal satisfaction 36 Improved retention due to relationships established e77 Academic productivity 2,36 Intellectual stimulation e77 Greater research protected time 22,30,e63 Positive relationships with residents and faculty members 2 Faster rate of promotion 35 Personal satisfaction e77 Enhanced confidence, self-efficacy, and self-esteem 35,e63 Improved job satisfaction e77 Learning to be a mentor e77 Renewed sense of purpose e77 Networking and increased professional visibility 36 Faster promotion rate, more noticeably by their superiors e77 Decreased burnout 7 Opportunity for increased salary derived from additional responsibilities e77 Improved health and well-being and overall quality of life 11 Less likely to burn out e77 Faculty retention 6,36

Speed
Brief meeting between mentees (10 minutes) and mentors to jump start further mentoring relationships but does not often result in long-term mentorships 1

Functional
Specific project for which a mentee is mentored 1

Group
Mentor facilitates group discussions usually in a conference setting 1

Distance
Involve mentors outside of one's institution 1 women and URM, experience burnout, e47 all of which contribute to the "leaky pipeline." e48,e49 The "intersecting identities," when an individual identifies with multiple underrepresented groups, add another layer of complexity in providing support for SGM, URM, and women. For example, gay women of color may face a "triple disadvantage" that can affect compensation, career development, and relationships with colleagues. 19,e50 Awareness of these unique situations is key to adapting mentorship methodologies especially since intersectional classifications contributed to the difficulty in searching for a mentor because some mentors may be amenable to racial differences but have a bias towards SGM. e51 More specific issues on mentorship that exist among URM and SGM are beyond the scope of this article, but we highlight parallel issues among women, URM, and SGM.

Women-Specific Mentorship Programs: Primary Components and Lessons Learned
Mentorship programs explicitly geared towards women result in a high level of satisfaction and positive impact on promotion and retention in academic medicine. 37 Nineteen unique mentorship programs were included in a recent review, 15 of which were developed specifically for female physicians, while 10 of the 19 had exclusively female faculty mentors. 37 In this review, gender concordance was not highly valued when selecting mentors, emphasizing that men can play important roles in these programs and in the pursuit of closing the gender gaps. 37 Another aspect of professional development where mentorship is needed is in tackling imposter syndrome, wherein someone has doubts about their competency, ability, and qualifications, despite being accomplished. e52 This syndrome is ultimately associated with lower motivation to have an academic career, poor career planning, and a decreased drive to pursue leadership opportunities because of feelings of inadequacy. e52 Institutionally, one way to address the gap in mentorship for women is the assignment of a faculty mentor or a mentorship committee to trainees and junior faculty, ensuring equal access to mentorship. 3 Successful approaches include incorporating women-specific faculty development programs, e53 where topics surrounding career development, research, promotion, conflict management, communication, supervision, time management, teaching, and ethical issues can be discussed. In a recent work analyzing the utility of an individualized, longitudinal institutional mentoring program for junior faculty women, high satisfaction was reported from both mentors and mentees. e53 Workshops aimed at developing women's career and research skills are also beneficial. e54 Early-career women-mentorship programs focused on enhancing teaching skills, grant and manuscript writing, and development of scientific presentations, alongside institutional support via access to biostatisticians and research stipends, should also be considered. e55 A distinct sponsorship program, in parallel to a mentorship program, should also be established. There is added value in having a sponsor in addition to a mentor for professional development. In addition to providing career advice, a sponsor helps secure professional advancement opportunities, including leadership opportunities through advocacy and increased visibility. e56 Sponsors help in career advancement, particularly for women physicians by "taking risks" and actively opening opportunities. The "sponsorship effect" has shown that if men and women have sponsors, their satisfaction with career advancement did not differ between sexes and in general, having a sponsor offers a quantifiable career benefit on workload or compensation from up to 22% to 30%. e56 Although a mentor can also act as a sponsor, ideally, one should also have a sponsor in addition to the mentor that is actively looking for and providing opportunities for the mentee. This parallel mentorship-sponsorship strategy may accelerate the ability of a mentee to succeed in their career. In medicine, components of a strong mentorship relationship include reciprocity, mutual respect, clear expectations, personal connection, and shared values. e57 Primary components of a strong mentorship program that may also apply to SGM are shown in table 3. The figure summarizes the key factors that influence a successful women-specific mentorship program. Formalized mentorship programs can lead to further development of positive talent and leadership capable candidates, while improving stability e58 and promoting gender equity. 8 The first step to formalizing a mentorship program is identifying key stakeholders in the mentorship process (table 4). This may involve a representative from the promotions and appointments committee or human resources who can provide information about how taking leave would affect the promotion or tenure process. Diversity committee representatives should address societal, personal, and professional concerns and cultivate a diverse and representative workforce. Such infrastructure allows mentees to focus on finding a mentor that meets their needs by aligning their short-and long-term goals with the pool of mentoring resources available.
The second step is initiating mentor training through the institution, rooted in best practices and the establishment of metrics that can track a mentee's progress. Their model included mentorship as one of the baseline metrics. Not only does the establishment of EVUs potentially protect the time of mentors to perform their necessary duties, but it also lends legitimacy to the mentor role. e59,e62 Ten hours annually has been reported to be an estimated expected time obligation for mentorship. e59 Mentorship must be rewarded so that mentors' efforts are incentivized, possibly similar to teaching, research, and clinical rewards. 12 Capitalizing on technological supports available for teleconferencing can expand opportunities for mentoring beyond the walls of individual institutions, providing networking opportunities that may more effectively align with individual mentees' needs. 63 Engaging in individual mentoring at a regional or national level can foster academic productivity and build long-term personal and professional alliances, with the added reward of a heightened sense of professional satisfaction. e64 The same rationale behind promoting mentorship for women applies to all underrepresented groups.

Mentorship Program Components
A formal mentorship program specifically for women at an institutional level allows for the development of curricula to

Women Mentoring Excellence in Neurology
The WoMEN pilot program is a collaboration between the Women's Issues in Neurology section of the AAN and the Women Neurologist Group Facebook group. It is currently in a pilot year and has matched 127 mentor/mentee pairs. WoMEN was created to be a 1-year near-peer mentoring program for women neurologists at all career levels. Residents are matched with fellows or individuals who just completed their training, junior faculty members are paired with midcareer neurologists, and so on. Mentor/mentee pairs are matched on similar subspecialty interests, shared demographics, and specific characteristic requests. The program is in its inaugural year and outcome assessment is pending.

Women in Neurocritical Care
The WINCC mentorship program was created and developed by the Neurocritical Care Society (NCS) WINCC section. e67 Launched in 2019, the WINCC coordinated with the NCS trainee section mentorship program, establishing 7 mentor/ mentee multidisciplinary pairs for 2019. Each pair received monthly emails of applicable discussion points and came up with a project. Pairs submitted a progress report a few months before the end of the mentorship year. The WINCC mentorship program also initiated a speakers list that promotes speaker diversity by providing connections to a diverse panel of available speakers for organizations in need.

International Women in Multiple Sclerosis
The key aims of this initiative are to "support and inspire women working in MS clinics and research." e68 This paradigm "unites clinicians and researchers committed to advancing scientific discoveries and improving care for people with MS and related disorders." e68 While the organization was founded by women, meritocracy, diversity, parity, and ingenuity in MS research and patient care for individuals of any background are the focus of iWiMS advocacy. More than 28 peer groups and 80 mentor/ mentee pairs have already been created. With such high demand, identifying sufficient numbers of mentors has been an ongoing challenge. e68

Women in Neuro-oncology
The Society of NeuroOncology e69 formed the WiN subcommittee in 2018, with the primary mission to provide multifaceted support to women through education, mentorship, funding, and data collection. e69 This subcommittee consists of neuro-oncologists from various practice settings.

Ongoing Challenges Facing Mentorship of Women in Neurology
Role of Gender Concordance in the Perpetuation of Gender Being a Factor in Career Development The importance of gender concordance in mentorship varies. There is variability depending on the mentee's role. 2 From the faculty perspective, according to one study, although most mentors were men, 80% of the women faculty reported that gender concordance was not important when selecting a mentor. e70 On the other hand, women residents were likely to choose a same-sex mentor due to the perception that the samesex mentor will be more understanding. e71 Mentorship outcomes such as the number of publications or percentage of time spent on research are not influenced by gender concordance. 2,e72 Role of the #MeToo Movement in the Mentorship of Women by Men The #MeToo movement brought to light the social inequities associated with gender. In health care, there is a push to improve organizational structures, processes, and outcomes toward the goal of eliminating gender-related harassment and discrimination. e73 An unintended consequence of this movement is a hesitation for men to mentor women, e74,e75 with the possible perpetuation of gender inequity. e75 This movement should not deter men from mentoring women because of the fear of a sexual misconduct accusation. e75 It can be argued that it is an obligation as physicians to train physicians the same way that a physician has an obligation to treat all patients regardless of gender. e75 As part of self-reflection and analysis of their fears surrounding the #MeToo movement, men should familiarize themselves with what sexual harassment encompasses if they are unfamiliar with the concept and avoid engaging in it. e75 It is critical for men to continue to support and mentor women and to stand with them in this movement e73,e76 and at the same time view interactions as mentors with the concept of agency and responsibility as an opportunity for open dialogue, self-reflection, and system-wide change.

Open Questions and Future Directions
A lack of scientific rigor in most mentorship research with inconsistent follow-up, no comparison groups, and variable usage of validated assessment measures has resulted in incomplete information on how best to mentor women in academia. 36 Nonetheless, most programs use an approach where participants need to opt into the program and devote time and attention to it (a "bottom-up" approach). Understanding similarities of women, URM, and SGM, although briefly touched upon in this review, was not extensively discussed. A gap of research into URM, SGM, and intersecting identities and the impact on a physician's career and psychosocial development in the setting of mentorship exists. There is a lack of demographic data to enable the foundation of this gap.
One concept receiving increasing attention is sponsorship and the concern that women can be overmentored and undersponsored. Men are 46% more likely than women to have a sponsor and, as a result, are much more likely to obtain leadership positions. e56 Interestingly, 46% of women respondents in the Harvard Business Review study chose men as sponsors for reasons including better connections and network; they are perceived to be more powerful and "know how to succeed." e56 In neurology, processes to facilitate structured sponsorship for women are lacking. This is another gap to explore to support professional development among women neurologists.
Despite nearly even proportions of men and women applying to and matriculating in medical schools for well over a decade and a half, 19 women are poorly represented throughout all measures of clinical and academic achievement, even after accounting for time since completion of training. This disparity is mirrored in academic neurology, highlighting a need for better career development efforts focused on women and other underrepresented populations. Research on mentorship demonstrates benefits on academic advancement and faculty retention, both essential needs for ensuring equitable representation of women in neurology. Formal mentoring programs in neurology departments should be available in all career stages for women, URM, and SGM. AAN's mentoring initiatives should be expanded and other subspecialty societies must be encouraged to follow suit. Positive trends are welcome; further work remains to be done.

Study Funding
No targeted funding reported.

Disclosure
Dr. Farheen reports no disclosures.