CPG publishing: ‘Man’‐uscripts reign supreme

In medicine, gender bias impacts both patients and healthcare practitioners. Sex-biased clinical trials1 and healthcare algorithms2 can impact care of women patients, who are made to wait longer to be seen by physicians,3 and are more likely to have their symptoms attributed to mental illness.4 Meanwhile, women's career development in medicine and research can be hampered by lower salaries,5 under-representation in prominent authorships6 and skewed citation practices.7 Gender bias also negatively impacts men, who are confronted with gender stereotypes of which career choices in medicine are suitable,8, 9 expectations of how they should behave in a given specialty8, 10 and limited availability of paid paternity leave.11 Unfortunately, the impact on men of gender inequality, and the initiatives devised to address this, are severely under-studied.12 Eliminating gender bias is necessary to ensure the highest standards of medical care for all patients, to allow all individuals to pursue careers of their own choosing, and to ensure that career development of practitioners and scientists is based on performance. Clinical societies provide forums to share knowledge and shape the future of the field, and several major gastroenterology societies have dedicated committees or policy statements formalizing their intent to reduce gender bias within their field. A major function of clinical societies is to publish and disseminate clinical practice guidelines (CPGs) and thus support evidence-based clinical decision-making. These influential publications inform medical practice13 and are among the most highly cited journal content, contributing to high impact factors of society journals.14 As such, CPGs are a powerful tool with which societies can both influence medical practice and determine which members of their societies are selected to contribute to CPGs as authors. In this issue, Tang and colleagues investigate authorship gender patterns in CPGs issued by major gastroenterological societies over the past 15 years,15 to determine whether women are under-represented as authors. Tang et al. reviewed hepatology guidelines published by the American Gastroenterological Association (AGA), the American College of Gastroenterology (ACG), the American Association for the Study of Liver Diseases (AASLD), the Asian-Pacific Association for the Study of the Liver (APASL), the British Society of Gastroenterology (BSG), the European Association for the Study of the Liver (EASL) and the Korean Association for the Study of the Liver (KASL) between January 2008 and September 2022. Based on 103 guidelines from these societies, they could identify the gender of 99.6% of the authors (1096 of 1100 authors). Of these, women represented 20.4% of the senior authorships, but only 14.6% of first authorships. Encouragingly, there was a statistically significant increase in first, senior and total women authors between 2008 and 2022, and in 2022, women authors constituted 33.3% of first authors and 44.4% of senior authors. Nonetheless, these numbers do not appear to reflect the gender composition of the different societies: in 2017, a year for which such demographics could be obtained, the proportion of women authors was lower than the proportion of women members in the relevant societies. The authorship gap thus seems to be closing but has not yet reached parity. Previous reports have shown that women senior authors are more likely than men to be associated with women first authors.16, 17 This association was not observed in the study by Tang et al.,15 who instead show that while women senior authors are more likely to work with more women authors in general, the gender of the senior author was not associated with that of the first author, the total number of authors, nor with the number of men authors. Strikingly, between 2009 and 2014, not a single CPG was published with a woman as the first author, and in the three following years, there were only 3 CPGs with a woman as the first author of 25 published CPGs. This could perhaps be related to sub-specialty, since all CPGs within the non-alcoholic fatty liver disease, intrahepatic cholestatic liver disease or liver failure had men as the first authors (a total of 27 guidelines).15 These data suggest that although established women in the field are included in CPG writing, younger women colleagues are not included to the same degree. The paucity of women as first or last authors of clinical guidelines reflects tendencies across life sciences and medicine, wherein women are particularly under-represented in publication-related leadership positions such as corresponding author, editor-in-chief and editorial board membership.6, 18 This mirrors other work domains, for example the S&P 500 (500 of the largest companies listed on stock exchanges in the United States), in which you are more likely to be CEO if your name is James or Michael than if you are a woman.19 Last year, a tweet from David Ubilava (University of Sydney) went viral (https://twitter.com/DavidUbilava/status/1575973354099462150) when it presented the first names of authors in the top 5 Economy journals in a Wordcloud, depicting in colourful terms the prevalence of Davids, Johns and Michaels among first authors, and an almost complete absence of women's names. A similar Wordcloud for first authors of a selection of interdisciplinary and hepatology journals (Cell, Science, Nature, Nature Reviews Gastroenterology and Hepatology, Gastroenterology, Journal of Hepatology, The Lancet Gastroenterology and Hepatology and Hepatology and Clinical Gastroenterology and Hepatology) shows a similar pattern (Figure 1) as well as low international diversity. The gender patterns identified by Tang et al. are thus similar to wider trends across science but could be further improved by societies. So how can suitable women co-authors be identified for guideline drafting? Other than assessing the literature for contributions from women scientists, there are databases of excellent women scientists, such as https://www.academia-net.org/. Excellent women researchers are nominated to this database according to strict selection criteria, but this database encompasses all scientific disciplines and is largely focused on European scientists. Some fields have dedicated databases for finding women speakers, including neuroscience (https://www.winrepo.org/) and microbiology (https://microbiomedigest.com/sample-page/women-in-microbiology-for-keynote-lectures/), but no such database (to my knowledge) exists for hepatology or gastroenterology. Such a list could be established jointly by collaborating societies, serving the dual purpose of highlighting excellent women clinician scientists or basic scientists and facilitating international representation, for example at conferences. Even with such databases, and strategies to identify excellent women, the paucity of senior women in leading positions in hepatology presents obvious problems for reaching equity in authorships or elsewhere. Much has been written of ‘the leaky pipeline’—the progressive reduction in women across STEM and medical career stages,20 which can be further exacerbated by race or ethnicity.21 Interventions to address the leaky pipeline include peer mentoring, career skills training and support to return to work after having children,22 while interventions for more senior faculty include leadership training and strategies to overcome systemic barriers.22 Although mentoring and training can improve career trajectories, typically the onus is on women22 to dedicate additional time to breaking through the glass ceiling. Fewer interventions address systemic inequalities or include men as contributors to address inequality, although these appear to be successful once implemented.23 Furthermore, the inclusion of highly respected peers in such initiatives, including male faculty, has been suggested to be instrumental in their success.23 As such, efforts to address gender bias should include everyone, and diversity initiatives in medical societies should be well-balanced groups to be most efficient. Of the seven gastroenterological/hepatological societies included in the analyses by Tang et al., only four have explicitly dedicated committees or work groups to address equity or gender issues, and three of these are headed by women. A notable exception is the AGA Equity Project which is led by two co-chairs, a man and a woman (https://gastro.org/aga-leadership/initiatives-and-programs/aga-equity-project/), conveying that this is an issue everyone is working towards addressing. Inclusion of these diversity and equity groups in CPG drafting could also be a strategy towards balanced authorship of CPGs. A more controversial question is whether societies should author guidelines and disease definition statements. John P.A. Ioannidis argues14 that these publications promote careers, establish hierarchies of ‘clan power’, boost society journal impact factors and increase the visibility of the societies and their conferences, but do not necessarily improve medicine. Concerns he raises in this Commentary include ‘sponsoring by a professional society with substantial industry funding, conflicts of interest for chairs and panel members, stacking, insufficient methodologist involvement, inadequate external review, and non-inclusion of nonphysicians, patients, and community members’. The use of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation, http://www.gradeworkinggroup.org) by societies has helped to ensure their objectivity and methodology and many hepatology guidelines are based on high or moderate evidence.24 To further address these potential risks, Ioannidis14 proposes that writing groups should avoid the inclusion of specialists in the drafting of CPGs for their own field and to recruit medical specialists from unrelated fields. In this model, methodologists, patients and/or medical experts from other fields would write the guidelines and field-specific specialists would be invited to comment. With such an approach, it could also be easier to find women authors, no longer limited to potentially smaller niche fields with a dearth of established women experts. Gastroenterological societies embody an unparalleled pool of knowledge, expertise and membership diversity, and their CPGs are welcome guides for the field. The societies also strive to foster the next generations of clinicians and scientists. The proportions of women authors of society-issued CPGs increased significantly during recent years,15 but several societies had no women first authors, and authorship representation was not proportional to society gender demographics. A true meritocracy is only possible without bias, and science and medicine would thus both be well-served by eliminating gender bias. Several strategies could be undertaken to continue to work towards achieving parity in this domain, and others within the field. This would entail better work conditions for both men and women, allow all individuals to succeed based on their own performance, and could lead to CPG authorship patterns better reflecting the diversity of individuals contributing to healthcare, patient advocacy, and science. I thank Professor Abigail Stewart (University of Michigan) and Associate Professor David Ubilava (University of Sydney) for their kind and rapid replies during the drafting of this editorial and their sharing of resources (articles, codes, etc.). I also thank the Karolinska Institutet library for their fast and friendly help extracting data for the figure.