Copyright 2014 American Medical Association. All rights reserved. full professors among the clinical faculty in 2004. That lag of 32 years for women to climb from medical student to full pro- fessor is approximately 10 years longer than for men. More- over, other data 5 confirm that women are disproportionately represented at the lower rungs of the academic ladder, then they stall and become associate or full professors, if at all, at an older age than their male counterparts. Why the lag? One factor is probably the reward system in academic medicine. As Jagsi et al 2(p281) point out, “advance- ment is largely driven by peer-reviewed original research,” par- ticularly that published in prestigious journals. Publication is the coin of the realm. I believe men are more likely than women to devote themselves single-mindedly to research, partly be- cause women are disproportionately tapped for various aca- demic citizenship duties (every committee needs at least 1 woman), and because the child-bearing years coincide with the time of applying for first research grants. Research grants im- pose a fairly rigid schedule that can conflict with the flexibil- ity needed in those early years. Greater flexibility in the tim- ing of first research grants would help women pursue research careers. Young male physicians are also beginning to value flex- ibility when their children are young because, unlike their older male colleagues, very few of them have spouses that are house- wives; however, the difficulties are not equal. A final possible explanation for the slow advancement of women—one that will surprise very few women—is good old-fashioned sexism. This is demonstrated by Lawrence Summers, PhD, the former presi- dent of Harvard University, who said the most likely explana- tion for the relatively low numbers of women scientists is that, compared with men, their brains just aren’t up to the job. 6 (Summers did not explain how their brains evolved fast enough to account for the recent dramatic influx of women in science.) Despite the difficulties, women are pressing hard against the glass ceiling, and it will inevitably shatter. But progress is too slow. One reform that should be instituted—not just because it would further equality between men and women, but because it would be of great benefit to academic medicine—is to change the re- ward system. Anecdotal evidence suggests that women do more than their share of teaching and mentoring. Those activities should be a basis for promotion, at least as much as publica- tions are. The primary mission of medical schools is, after all, to educate the next generation of physicians. Clinical research and medical practice are important parts of that mission, but sec- ondary. Faculty researchers often do little or no teaching, yet ad- vance rapidly on the basis of their publications, while excellent teachers languish at the lower rungs of the academic ladder. Too many men (and women) are doing pedestrian research simply to be promoted. Doubtless, one reason institutions reward re- search over teaching is that research grants bring in more money than does tuition. Yet, medical schools have an obligation to do better by their students and the physicians who teach them. In recent years, there has been a certain amount of hand wringing about the reward system, with some increased recognition of teaching, but there is still nothing close to parity. This is not a matter of suggesting that standards for pro- motion be lowered so that women have an easier time getting to the top. On the contrary, I am recommending that the top be redefined. I do not advocate a lowered glass ceiling, but rather, placing the ceiling over a different edifice. Research productiv- ity should no longer be considered the primary measure of aca- demic success. If teaching and mentoring are rewarded com- mensurately with research, women will do very well. In fact, men might well have to work harder than they are now to catch up with women in these areas. In any case, I have no doubt that physicians would be better educated and that the medical lit- erature would be less voluminous but of higher quality. And the glass ceiling would shatter that much faster. Marcia Angell, MD Author Affiliation: Department of Global Health and Social Medicine, Harvard Medical School, Cambridge, Massachusetts (Angell). Corresponding Author: Marcia Angell, MD, Department of Global Health and Social Medicine, Harvard Medical School, 13 Ellery Square, Cambridge, MA 02138. Published Online: February 24, 2014. doi:10.1001/jamainternmed.2013.13918. Conflict of Interest Disclosures: None reported. 1. Erren TC, Groß JV, Shaw DM, Selle B. Representation of women as authors, reviewers, editors in chief, and editorial board members at 6 general medical journals in 2010 and 2011 [published online February 24, 2014]. JAMA Intern Med. doi:10.1001/jamainternmed.2013.14760. 2. Jagsi R, Guancial EA, Worobey CC, et al. The “gender gap” in authorship of academic medical literature—a 35-year perspective. N Engl J Med. 2006;355(3):281-287. 3. Jagsi R, Tarbell NJ, Henault LE, Chang Y, Hylek EM. The representation of women on the editorial boards of major medical journals: a 35-year perspective. Arch Intern Med. 2008;168(5):544-548. 4. Gender progress (?). Nature. 2013;504(7479):188. doi:10.1038/504188a. 5. Leadley J, Sloane RA. Women in US Academic Medicine and Science: Statistics and Medical School Benchmarking Report, 2009-2010. Washington, DC: Association of American Medical Colleges; March 2011. 6. Summers LH. Remarks at NBER Conference on diversifying the science & engineering workforce. Office of the President, Harvard University. http://www.harvard.edu/president/speeches/summers_2005/nber.php. January 14, 2005. Accessed January 17, 2014. COMMENT & RESPONSE Optimizing the Impact of Drugs on Symptom Burden in Older People With Multimorbidity at the End of Life To the Editor We commend Chaudhry et al 1 on their excellent article that reported high prevalence of symptoms that nega- tively affect functioning and quality of life in a cohort of older community-dwelling people with multimorbidity and a life ex- pectancy of less than 1 year. In older people, mulitimorbidity often coexists with poly- pharmacy, commonly defined as the use of 5 or more drugs. In her Invited Commentary, Ritchie 2 highlights that pharma- cological treatment of 1 symptom may exacerbate another or a coexisting condition, which may in part explain the in- crease in symptoms in this population. To minimize drug-related symptoms in older people at the end of life, pharmacological treatments should be prioritized and rationalized. Symptomatic relief should take preference over preventive treatments, and drug therapies deemed no lon- ger necessary should be stopped to minimize cumulative drug- related adverse effects. For instance, among patients in their Letters 636 JAMA Internal Medicine April 2014 Volume 174, Number 4 jamainternalmedicine.com Copyright 2014 American Medical Association. All rights reserved.