Women in Spanish institutional medicine leadership: The glass ceiling remains seemingly invulnerable

Gómez-Durán, Esperanza; Gassó, Aina M.; Bisbe, Elvira; Virumbrales, Montserrat
doi:10.1016/j.medcli.2022.12.009
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Many female doctors began practicing before the end of the 19th century&#44; paving the way for generations to come&#46; Nevertheless&#44; despite the massive incorporation of women into medicine since then&#44; leadership is still a pending issue&#46; The leadership pipeline theory&#44; launched four decades ago&#44; states that over time&#44; a larger number of women on lower rungs of organizational hierarchies will yield a larger number of women on higher ones&#44; being simply a matter of time&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> Over the last decades&#44; the number of women graduating from medical schools has increased to the point where it equals or even exceeds that of men in many countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;3</span></a> Yet&#44; even though they represent the majority of the medical workforce&#44; women in healthcare remain significantly underrepresented in top leadership positions&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">4&#8211;9</span></a> With the large number of highly qualified women in the current medicine scenario&#44; the pipeline has been considered a pipe dream&#46; It is assumed that&#44; once women are in the system&#44; they will ascend to the top at a rate similar to that of men&#44; that no gender bias will impede women&#39;s progress&#44; and that organizational systems work as well for women as they do for men&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">1</span></a> However&#44; Arrizabalaga et al&#46; described the &#8216;leaky pipeline phenomenon&#8217;&#44; illustrated by the significant differences in medical positions held by men and women&#44; with a disproportionately low number of women achieving leading medical positions&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">10</span></a> Terms such as the &#8220;Glass Ceiling&#8221; or the &#8220;sticky floor&#8221;&#44; can also be applied to women&#39;s roles of leadership in Medicine&#46; These metaphors imply that &#8220;invisible or subtle barriers&#8221; are present but cannot be seen from below or from above &#40;by either men or women&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">11</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Barriers to promotion and advancement are evident in the academic field&#46; Data from the most recent report &#8220;The State of Women in Academic Medicine&#44;&#8221; published by the Association of American Medical Colleges &#40;AAMC&#41;&#44; found that by 2019 almost half of medical students graduating at U&#46;S&#46; were women &#40;47&#46;9&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Yet&#44; only 18&#46;9&#37; of Department Chairs and 18&#37; of medical school deans were women&#46; Since 2009&#44; the number of women deans increased by about one each year&#44; on average&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Richter et al&#46; compared the percentages of women who would be expected to be promoted on the basis of the proportion of graduating women&#44; with the actual percentages of promoted women&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> Among medical students who graduated between 1979 and 2013&#44; women who went into academic medicine were less likely than men to advance into upper faculty ranks&#44; and the gap did not narrow during the 35-year time frame of their study&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">12</span></a> Li et al&#46; recently published a pooled analysis of the difference in the proportion of men versus women with full professorship among academic physicians&#44; including studies from Europe&#44; Asia and North America &#40;not Spain&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a> They concluded that men are more likely than women to be full professors after controlling for experience&#44; academic productivity and specialty&#44; and this gender inequity exists across all specialties&#44; geographical regions and multiple measures of success&#44; however&#44; they described some improvement over time&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain&#44; since the beginning of the 21st Century female presence in medicine has duplicated and in 2019&#8211;2020 almost 70&#37; of medicine students were females&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Accordingly&#44; 77&#46;7&#37; of healthcare professionals are women&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">14</span></a> Yet&#44; once women finish their studies and begin their professional teaching and research career&#44; gender inequalities are accentuated&#46; Specific data of Medicine Schools are lacking&#44; but only the 23&#46;4&#37; of University Department Chairs are women and males are 2&#46;5 times more likely to achieve Chair positions&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> The lower the rank position in the university&#44; the higher the degree of gender equity in Spain&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">When looking at Spanish University Governing Bodies &#40;Deans&#44; Vice Deans and other members of University Boards&#41;&#44; data shows that highest rank positions are mainly held by men&#44; whilst as the rank of the position decreases&#44; the number of women increases&#46; Data from 2017 shows that only 29&#37; of University Deans and 46&#37; of vice-deans were women&#44; but again no specific data about Medicine Schools was reported&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Beyond academia&#44; leadership in Medicine is also exercised from scientific societies or professional associations&#46; These institutions speak for the profession of medicine or for their fields and influence the direction of medicine&#46; Out of the total number of members of health professional associations in Spain&#44; 53&#37; are women&#44; and specifically for the age group under 40 years old the number of female working doctors grows up to 68&#37;&#44; in comparison to 32&#37; of male doctors&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">6</span></a> In 2015&#44; Botello-Hermosa et al&#46; examined the presence of women in leadership roles in Medical Associations&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Out of the total number of members from the Board of Directors&#44; only 42&#37; were women&#46; However&#44; the percentage of women decreased to 35&#37; when looking at executive roles and only 22&#37; of medical associations&#8217; presidents were women&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> The Organizaci&#243;n M&#233;dica Colegial &#40;OMC&#41; acknowledges that women are still underrepresented in leadership positions in Medical Associations&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> In 2018&#44; the OMC found that only 6 out of 52 presidents of Spanish Medical Associations were women &#40;11&#46;5&#37;&#41;&#44; and only 13 out of 55 vice presidents were women &#40;23&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> The reported leadership gender gap in Spanish Medical Associations was 47&#46;8&#37;&#44; with a tendency to increase as the responsibility of the task increased&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Figures at leadership roles of women in medical scientific societies are similar&#46; Casado-Mej&#237;a and Botello-Hermosa found that only 16&#37; of presidents and 23&#37; of vice presidents in scientific societies were women&#44; with the number increasing when looking at the Board of Directors&#44; with 30&#37; of their members being women&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We believe that&#44; although efforts are being made by different medical communities to reduce the gender gap in formal leadership in medical institutions&#44; the gap is still wider than it should be&#46; Furthermore&#44; there is a lack of data regarding the Spanish scenario&#46; Few studies have been performed in Spain regarding different scientific and academic leadership position&#44; and specific studies about medicine leadership have only been performed for the associative field&#46; In addition&#44; there is no data on how the gender gap has evolved over time&#46; A deep understanding of the demographics of leadership of Scientific societies&#44; medical associations and academic medicine in Spain is essential to provide a comprehensive picture of gender gap in formal medicine leadership&#46; Objective data can create the environment to stimulate change and improve the participation of women in leadership positions&#46; Through the current study&#44; we collected and analyzed data on leadership and gender across all these Spanish institutions&#46; We aim to &#40;1&#41; provide figures of sex disparity in medicine formal leadership within Medicine Schools&#44; Medical Scientific Societies and Medical Associations&#44; and &#40;2&#41; identify gender gap changes between 2010 and 2020&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Methodology</span><p id="par0040" class="elsevierStylePara elsevierViewall">We conducted a transversal descriptive study&#46; We obtained the lists of analyzed institutions from their respective original official sources at a national level&#58; the list of Spanish Medical Associations was obtained from the official source of the &#8220;Consejo General de Colegios Oficiales de M&#233;dicos de Espa&#241;a&#8221; &#40;<a href="http://www.cgcom.es/">http&#58;&#47;&#47;www&#46;cgcom&#46;es&#47;</a>&#41;&#59; the list of Spanish Scientific Medical Societies was obtained from the Spanish Ministry of Science &#40;<a href="http://www.mscbs.gob.es/profesionales/socCientificas/especialidades.htm">www&#46;mscbs&#46;gob&#46;es&#47;profesionales&#47;socCientificas&#47;especialidades&#46;htm</a>&#41; and the list of Spanish Medical Schools from the Ministry of Universities &#40;Ministerio de Universidades&#41; <a href="https://www.educacion.gob.es/notasdecorte/compBdDo"><span class="elsevierStyleUnderline">https&#58;&#47;&#47;www&#46;educacion&#46;gob&#46;es&#47;notasdecorte&#47;compBdDo</span></a>&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Once the institution&#39;s full list was completed&#44; we identified through their public-facing websites the sex of &#40;1&#41; the elected dean and vice-deans at Medicine Schools&#44; &#40;2&#41; the elected president and vice-president of Medical Associations and &#40;3&#41; of Scientific Societies&#46; Spanish Universities can have more than one Vice-Dean&#44; when so&#44; they were all included for analysis&#46; We identified and extracted the sex of presidents and vice presidents according to their given first names&#46; When proper information was not available through the institution&#39;s website&#44; we made contact by email&#46; When our requests were not answered&#44; we made follow-up requests by telephone&#46; Similarly&#44; when the given first name was genderless or could be misleading&#44; the gender of the person was corroborated with the institution either by phone or email&#46; Those institutions for which information was missing or unclear and that were not reachable either by phone&#44; email or via their website were excluded from the study&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The original sample comprised 52 Medical Associations&#44; 120 Medical Scientific Societies and 49 Medical Schools&#44; out of which 10 institutions were excluded for not being able to obtain information &#40;5 Medical Scientific Societies and 5 Medical Schools&#41;&#44; with a final sample of 211 total institutions&#46; For each of the remaining institutions&#44; we collected data regarding 2020&#46; In order to conduct a temporal comparison&#44; we selected an additional time point &#40;2010&#41; and collected data from the different medical institutions&#46; However&#44; only data regarding the highest rank figure was available for 2010 in most cases&#44; therefore comparatives only include this leadership figure&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Once the data was coded&#44; we conducted descriptive analysis using SPSS 25&#46; The crossing of variables was carried out using SPSS crosstabs with Pearson&#39;s Chi square test and the level of significance statistic stood at 0&#46;05&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">The final sample consisted of 211 Spanish medical institutions&#46; Of those&#44; 52 were Medical Associations&#44; 115 were Medical Scientific Societies&#44; and 44 were Medical Schools&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">When analyzing results from the overall sample and from the different institutions by gender&#44; results showed a difference between men and women in different leadership positions&#46; For the overall sample&#44; the highest rank position &#40;Dean or President&#41; was held by a woman in 19&#46;6&#37; of the cases&#44; whilst the 45&#37; of Vice-Deans or Vice-Presidents were women&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">When looking at specific institutions&#44; in Medical Associations only 11&#46;5&#37; of Presidents&#44; and 42&#46;3&#37; of Vice Presidents were women&#46; In the Medical Scientific Societies&#44; women were in charge of the Presidency in 23&#37; of the cases&#44; and 50&#37; of Vice Presidents were women&#46; Finally&#44; when examining results from Medical Schools&#44; only 20&#46;5&#37; of Deans&#44; and 42&#37; of Vice-Deans were women&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Additionally&#44; our results showed that there were significant differences between the number of women and men and the different leadership roles&#46; Results from the overall sample and the specific institutions can be found in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">When comparing data between 2010 and 2020&#44; results from the overall sample indicate that in 2010 13&#46;4&#37; of presidents&#47;deans were women &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>27&#41;&#44; whilst 19&#46;6&#37; of them were women in 2020 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>41&#41;&#46; Data from the Medical Associations showed that 13&#37; of Presidents were females in 2010&#44; and 11&#46;5&#37; in 2020&#46; For Medical Scientific Societies&#44; results showed that 18&#46;6&#37; of women were Presidents in 2010&#44; and 23&#37; in 2020&#46; Finally&#44; for Medical Schools&#44; 5&#46;1&#37; of Presidents were women in 2010&#44; and 20&#46;5&#37; in 2020 &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Furthermore&#44; our global data suggests a lack of significant differences between male and female presidents&#47;deans when comparing the two temporal points &#40;2010 and 2020&#41;&#46; More specifically&#44; when examining results from the overall sample&#44; in 2020 men were as likely to be presidents of Medical Associations and Scientific Societies as in 2010&#44; and women were as unlikely to be presidents as in 2010&#46; Yet&#44; in Medical Schools we did found a significant increase in women leadership positions between 2010 and 2020&#46; Results can be found in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Discussion</span><p id="par0090" class="elsevierStylePara elsevierViewall">Although laudable efforts to improve diversity are being made&#44; our results show that despite the majoritarian presence of women in medical education&#44; in the healthcare workforce and in medical associations&#44; there is still a gender gap in formal leadership roles in medical institutions&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">5&#44;18</span></a> Women constitute the majority of physicians in Spain&#44; so nowadays there are thousands of female physicians theoretically eligible for consideration for leadership positions&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a> Yet&#44; our study confirms that men are still significantly more likely to hold a leadership role in medicine than women&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The pipeline theory is clearly insufficient in the current context of medicine feminization&#46; Women&#39;s underrepresentation in leadership positions has been explained in organizational theory from several perspectives&#44; all of which agree that women nowadays are highly qualified for leadership posts&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#44;11</span></a> Because the lack of female options available is no longer a possible explanation in medicine&#44; a number of other well recognized phenomena need to be addressed&#46; Narratives of physician self-reported reasons highlight a lack of later career stage role models&#44; difficulty in obtaining research funding&#44; work&#8211;life balance challenges&#44; and an institutional culture that favors men&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Many issues likely contribute to the relative paucity of women seeking or receiving medicine leadership positions&#44; including implicit bias &#40;commonly held beliefs about a certain group&#41;&#44; organizational bias &#40;woven into the organization&#39;s culture such that decisions are not based on merit&#41; or stereotype threat &#40;a phenomenon whereby members of a certain group characterized by negative stereotypes perform below their actual abilities&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> Unconscious bias can also be the basis of micro-inequities&#44; which are less likely hostile or aggressive than micro-aggressions but still additive and burdensome &#40;ex&#46; a woman physician introducing herself as Dr&#46; X yet being called by her first name&#41;&#46; Inequities in speaking opportunities&#44; lectureships&#44; and award recognition&#44; together with macro-inequities such as funding allocation or underrepresentation on editorial boards&#44; lead to a lack of visibility of women that prevent them from reaching leadership positions&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> Nomination processes involved in medicine leadership are frequently led by former elected leaders&#44; what can perpetuate a lack of diversity because of identification processes or previous model replication&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">21&#44;22</span></a> The fact that men occupy the majority of senior research positions&#44; may be critical when it comes to ensuring the fair ascent of women in an academic system&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">23</span></a> Furthermore&#44; women face greater work-life integration challenges in societies regarding a gendered division of domestic labor and child care&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Women&#44; who are mothers&#44; report being passed over for leadership positions&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> &#8216;Family-friendly policies&#8217; could certainly help&#44; yet even in countries that offer considerable support to families with children and working partners&#44; women are still underrepresented in top positions&#46; To carry out leadership tasks assumes total availability&#44; which parallels the uncontained demands of care work and domesticity&#46; Time is a major obstacle for leadership expectations of people who hope to achieve some kind of balance between private life and work&#44; but it has particular implications for women&#46; In exploring the dilemma this creates among male and female top managers and politicians&#44; the gendered asymmetry that allows men to mobilize female altruism while women have at best been able to get men to split housework and care&#44; or pay for someone else to do it&#44; emerges as significant in explaining persistent leadership inequalities&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">24</span></a> There are well-documented gender gaps in publications&#44; grant support&#44; recognition awards and speaker invitations&#44; and promotions committees rely heavily upon these traditional measures of academic success to select candidates for career advancement&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a> Therefore&#44; when academic and family demands compete&#44; it may be difficult to meet the criteria for academic success within the traditional time limits&#44; which usually overlap with the competing demands on their time in their early career&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> This challenge is even more complicated if we take into account that when female physicians hold leadership roles&#44; they work more clinical hours and are paid less than male physicians&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">10&#44;12</span></a> Additionally&#44; gender differences in behaviors ranging from social interactions to self-promotion may systematically bias selection processes against women&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Men are more often assertive about wanting leadership roles and may tell search committee representatives that they would like to be considered&#44; whilst women rarely do this&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> Gender paradigm operates at individual level&#44; and this kind of statements rely on an agentic vision of women in relation to their path toward decision-making that ignores how national culture can contribute to women&#39;s &#8216;choices&#8217;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">According to our data&#44; the disproportionate representation of men in leadership positions is especially true for top-ranking leadership positions in Spanish medical institutions&#44; since in the overall sample the highest rank position &#40;Dean or President&#41; was held by a woman in only 19&#46;6&#37; of the cases&#44; whilst the 45&#37; of Vice-Deans or Vice-Presidents were women&#46; Previous literature has reported low percentages of women in Dean&#47;President positions&#44; with a narrower gender gap for Vice Dean or Vice-President positions in Spain&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">15&#44;17&#44;18</span></a> Similarly&#44; over the years&#44; a substantial number of international associate editors of biomedical journals have been women&#44; but the number of women editors-in-chief was&#44; until recently&#44; extremely small&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Nevertheless&#44; our results indicate that women are becoming more represented in institutional medicine leadership roles in the last decade&#44; although it only reached statistical significance for the Medical Schools subgroup &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;040&#41;&#46; The comparison in our study was limited to dean or president positions&#44; but the review of the previous literature at a national level suggests that the gap reduction could be greater in second-line leadership positions&#46; For Medical Associations&#44; the OMC reported in 2018 that only 6 out of 52 presidents of Medical Associations were women &#40;11&#46;5&#37;&#41;&#44; and only 13 out of 55 vice presidents were women &#40;23&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a> Similarly&#44; Casado-Mej&#237;a and Botello-Hermosa reported that only 11&#46;3&#37; of females occupied Presidency roles in Medical Associations&#44; whilst 23&#46;7&#37; occupied Vice Presidencies&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">18</span></a> The percentage of presidential positions remains unchanged in 2020 &#40;11&#46;5&#37;&#41;&#44; but the percentage of women in vice-president positions has increased to 42&#46;3&#37;&#46; The percentages identified in our study for Medical Scientific Societies leadership positions also exceeded those reported by Botello-Hermosa et al&#46; in 2015&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> They indicated that 16&#37; of Presidents and 23&#37; of Vice Presidents of Medical Scientific Societies were women&#44; whilst our 2020s percentages were 23&#37; and 50&#37; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a> Finally&#44; regarding the government bodies of the Spanish University&#44; Puy-Rodr&#237;guez et al&#46; reported that 29&#37; of University Deans were women&#44; whilst women occupied 46&#37; of Vice Dean positions in 2017&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> Data from Medicine School are not available&#44; but according to our results the figures seem worse in Medicine than in the Spanish university community as a whole&#44; since three years later only 20&#46;5&#37; of Medicine School Deans&#44; and 42&#37; of Vice-Deans were women in 2020&#46; Successful experiences from other academic fields could guide us in promoting women leadership in Medical Schools&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Women in Medicine face many challenges that hinder them from achieving leadership positions that exhibit final decision-making and budgetary power&#44; and&#44; in academic medicine&#44; being promoted&#46; However&#44; it is critical for health care systems to promote workforce diversity in medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> Visible female role models are needed not only to encourage half of the available talent pool but also to reflect the patient population&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Women&#39;s leadership has been pointed to as an indicator of gender equality promotion across institutional spheres and the need for greater representation of women leaders in medicine has been qualified as both a moral and a business imperative&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The time is overdue for organizations to ensure that all members are aware of opportunities for service and advancement&#44; so that medicine reaps the benefits of the diversity and inclusion of the full talent pool&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">22</span></a> Women&#39;s under-representation in decision-making has been a strong focus of EU policy since the mid-1990s when the topic was inscribed in the Beijing Platform for Action and incorporated in key strategic documents&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> In the medicine field&#44; there are very interesting initiatives worldwide aimed at supporting women leadership&#44; by promoting&#44; measuring&#44; and improving diversity&#44; equity&#44; and inclusion&#46; At an international level&#44; we could provide examples such as the Executive Leadership in the Academic Medicine program in the United States<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">30</span></a> or the NIH longstanding policy focused on the inclusion of women on panels and other speaking opportunities in the UK&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> In Spain&#44; we highlight the Women&#44; Science and Innovation Observatory or the Women and Science Unit from the Spanish Government&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a> as well as the Equality Plans developed by different universities or the Equity Commissions and Position Documents of several Medical Associations or Societies &#40;ex&#46; <a href="https://www.metgesses.cat/qui-som/">https&#58;&#47;&#47;www&#46;metgesses&#46;cat&#47;qui-som&#47;</a>&#41;&#46; Hereby we provide a comprehensive picture of the Spanish scenario&#44; adequately reflecting the national situation&#44; but our results cannot be generalized to other realities&#46; Moreover&#44; despite the possible underlying factors described in the discussion section&#44; the descriptive nature of the study prevents us from establishing cause-effect relationships&#46; Nevertheless&#44; according to our data&#44; it remains imperative that politicians&#44; organizations&#44; academic institutions in the medical community&#44; as well as current medicine leaders&#44; address the systemic inequities that are preventing half of our medicine workforce from reaching its full potential&#46; Further progress is required to acquire gender equity and initiatives promoting increased leadership roles for women in medical careers are still necessary&#46; Without specific resources to support women&#39;s development and advancement and promote conducive workplace climates&#44; efforts to recruit&#44; retain&#44; and promote women physicians into leadership roles may be futile&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="par0125" class="elsevierStylePara elsevierViewall">Based on our results&#44; it cannot be argued that a significant change in the presence of women in Spanish institutional medicine leadership roles has been achieved in the last ten years&#46; The number of women in leadership positions hasn&#8217;t grown significantly&#44; although there is an increasing tendency toward gender equity&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Future research should try to access a broader range of data on professionals who occupy leadership positions in medicine in our country to inform about the influencing factors and also analyze the intragroup particularities of female doctors&#46; The discussion of gender equality and leadership must progress beyond simple numeric parity&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a> but providing figures can be the initial step that helps to make visible what seems obvious&#46; Our study makes up in part for the scarcity of reliable statistical data about medicine leadership broken down by sex in our country&#44; which is a fundamental matter if we are to obtain an adequate view of both the actual situation and the occurring changes&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">We hope that these small steps that we have objectified toward a greater presence of women in positions of responsibility in Spain&#44; encourage women to move into leadership roles&#44; and make the medicine community and general society more receptive to their medicine leadership&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Author contributions</span><p id="par0140" class="elsevierStylePara elsevierViewall">E&#46;L&#46;G&#46;D&#46; designed and conceived the study&#44; reviewed and contributed to writing the first draft of the paper&#44; discussed the results and reviewed the final version of the manuscript&#46; A&#46;M&#46;G&#46; contributed in collecting the data&#44; analyzed the results and wrote the first draft of the paper&#46; M&#46;V&#46; and E&#46;B contributed in discussing the results and reviewing the final version of the manuscript&#46; All authors have read and agreed to the published version of the manuscript&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Institutional review board statement</span><p id="par0145" class="elsevierStylePara elsevierViewall">This work was considered &#8220;research on organizations&#8221; &#40;it has not been considered &#8220;human subjects research&#8221; requiring institutional review board approval&#41; and no individual-level or private data was obtained&#59; therefore&#44; no institutional review board approval was needed or sought&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">This research has been conducted without financial funding&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflict of interests</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests&#46;</p></span></span>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">Overall sample &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">211&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dean&#47;President&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;6 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#40;1&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>211&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>30&#46;21&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;37&#44; 95&#37; CI &#91;2&#46;16&#44; 5&#46;25&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vice-dean or Vice-President&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">55 &#40;107&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">45 &#40;88&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Medical associations &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">52&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>President&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;5 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;5 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#40;1&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>12&#46;51&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#46;62&#44; 95&#37; CI &#91;2&#46;04&#44; 15&#46;49&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vice President&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">57&#46;7 &#40;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42&#46;3 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Medical scientific societies &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">115&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>President&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">77 &#40;82&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">23 &#40;26&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#40;1&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>115&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>15&#46;18&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;000&#44; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#46;15&#44; 95&#37; CI &#91;1&#46;75&#44; 5&#46;68&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vice President&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">50 &#40;51&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Medical schools &#40;N</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#61;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">44&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Dean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;5 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">20&#46;5 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#40;1&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>7&#46;04&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;008&#44; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;82&#44; 95&#37; CI &#91;1&#46;28&#44; 6&#46;20&#93;</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Vice Dean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">58 &#40;109&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Percentage of Deans&#47;Presidents and Vice-Deans&#47;Vice-Presidents by Medical Institution in 2020&#44; by sex&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
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            0 => array:1 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Men &#37; &#40;<span class="elsevierStyleItalic">N</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Women &#37; &#40;<span class="elsevierStyleItalic">N</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sig&#46; test&#44; OR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Overall sample</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;6 &#40;175&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#46;4 &#40;27&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#40;1&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>211&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#46;91&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;088&#44; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#46;58&#44; 95&#37; CI &#91;0&#46;93&#44; 2&#46;69&#93;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">80&#46;4 &#40;168&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;6 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Medical associations</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;5 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;5 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " rowspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">&#967;</span><span class="elsevierStyleSup">2</span>&#40;1&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>52&#41;<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; OR<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#44; 95&#37; CI &#91;0&#46;30&#44; 3&#46;33&#93;</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2020&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;5 &#40;46&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11&#46;5 &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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