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 revealed there’s a gender gap in who gets top billing on medical studies published in several of the most prestigious research journals.

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 underrepresented in that first position.

Giovanni Filardo and Briget da Graca, with Baylor Health Care 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 the past 20 years.

Although 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.

And that can 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 study participants.

Deborah Diercks, who chairs the department of emergency medicine at the University of Texas 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 get top billing less often on research papers. Another possibility, she says, is bias in the review process. The editors making decisions about who gets published are often men.

“I struggle with that a lot,” she says. “I do believe it’s truly unconscious and unintentional, but it amazes me that it 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. “Some may be surprised that it’s even in medicine, where it may seem cut and dried — but it’s not.”

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 NPR’s reporting partnership with local member stations and Kaiser Health News. It has been slightly modified to reflect Spectrum‘s style.

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