When you're settling in to watch a movie, and the music starts playing, it's hard to ignore the names that flash first in the opening credits: The Director. The Big Stars.
Name placement matters in academia, too. A recent study reveals there's a gender gap in who gets top billing on medical studies published in several of the most prestigious research journals.
Dr. Carolyn Lam, a cardiologist and faculty member of the Duke-NUS medical school in Singapore, says getting top billing isn't just about ego. The number of times you nab that "first author" spot on a research paper shapes how you're evaluated at work — everything from tenure possibilities to pay.
"This is our livelihood," Lam says. "It's important."
Traditionally, the last name in a series of authors on a science paper is also prestigious — it's reserved for the most established colleague. First and last in the series is best. That's why she was upset when she heard about the study in the British Medical Journal showing women are under-represented in that first position.
Giovani Filardo and Briget da Graca, with Baylor Healthcare System in Dallas, took a close look at the names atop original research articles published in six of the world's leading medical journals over two decades.
While women were better represented as first authors in 2014 than 20 years earlier, their numbers have plateaued in recent years, the scientists found, and have declined in some journals.
Though women have been attending U.S. medical schools in roughly equal numbers as men since 2003, "substantial gender differences in rank and leadership remain in academic medicine," notes Dr. Kathryn M Rexrode, an associate professor of medicine at Harvard Medical, in an editorial accompanying the study.
And that may also be a problem for women's health, it turns out. In the same way that having more women as writers and directors in the movie business makes it more likely a film will have a female protagonist, research shows that studies of new drugs or therapies that have women as first authors are more likely to include a significant number of women as research subjects.
Dr. Deborah Diercks, who chairs the department of emergency medicine at UT Southwestern, says when she designs studies of why women are more likely to die from heart attacks, she approaches it differently than some male doctors do.
"I think a little bit more than some of my colleagues do about outside pressures," Diercks says. "Such as, the reasons women delay going to the hospital — is because they're a caretaker or because they have pressures to finish the wash or pick up the kids?"
She wonders if those pressures might also help explain why women less often get top billing on research papers. Another factor that might contribute, she says, is bias in the review process. The editors who make the decisions about who gets published are often men.
"I struggle with that a lot," Diercks says. "I do believe it's truly unconscious and unintentional but it amazes me that [that bias] is still there."
Gender bias, intentional or not, is something Carolyn Lam thinks about often.
Just one in five students in her medical school class in Singapore in the early 1990s were women. After graduation, Lam entered a male-dominated specialty — cardiology. Still, she doesn't fault the system entirely for the gender gap among first authors. In part, she blames herself.
For example, Lam was recently working with two male colleagues on a journal submission when they started talking about whose name should appear first. She stayed silent. And her name went second.
"I started examining myself a bit," Lam says. "Why didn't I ask to be first author?" She realized she should have advocated for herself.
"I think that sort of behavior is pervasive in many, many fields," she says.
So, last month, when Lam was finishing up another study she'd worked on with two different men and the question of authorship came up, she spoke out.
"My colleague — whom I totally respect — he wrote himself as first author, our senior colleague as last, and me as second," she says. "I was about to shoot off an email saying, 'OK, as long as our data get published.' "
But she caught herself and, instead, asked to be first author. Her colleague agreed.
This story is part of a NPR's reporting partnership with local member stations and Kaiser Health News.