Discussion

This is the first study to map Greek academic otolaryngologists (local and diaspora). More than half of Greek academic otolaryngologists are based in Greece. The majority of them are pursuing a career in otolaryngology in clinical or research positions, but do not possess an academic post. Academic otolaryngologists have a significantly higher number of total citations and a higher h-index compared to otolaryngologists working in positions independent from academic institutions. It is not surprising that there is a clear, linear association between the level of academic position and the number of total citations and h-index, with the average number of citations ranging from 1640 for professors to 492 for lecturers. Interest in academic positions among otolaryngology residents seems to be increasing, and more and more residents plan to pursue an academic career.^{Reference Rosenberg, Kelley, Dowdall, Replogle, Liu and Raol14}

Otolaryngologists working in the diaspora have a higher mean number of citations compared with local otolaryngologists. This trend is even more visible in the highest-ranked otolaryngologists, with only 3 out of the 10 most cited otolaryngologists working in Greece. Cyprus, the USA and Great Britain seem to be the countries where these otolaryngologists are located. This finding might be associated with the ‘brain drain’ process, which has affected many scientific fields, including otolaryngology.^{Reference Ioannidis, Koutsioumpa, Vakka, Agoranos, Mantsiou and Drekolia7,Reference Ifanti, Argyriou, Kalofonou and Kalofonos8} The results regarding otolaryngologists’ country of work might reflect the migration trends of Greek society, both in the past and in the present.^{Reference Clogg15} Greek diaspora has been an entity since Homeric times. In the modern era and especially after World War II, Greeks departed from traditional homelands, both for economic and political reasons, to earn a living in a new country. Countries like the USA, Great Britain, Germany and Australia became the home of the Greek diaspora. Residents and consultants continue to leave Greece, temporarily or permanently, to pursue a career in a country with more scientific opportunities.^{Reference Anastasakis, Nicolaidis, Pratsinakis, Anastasakis, Pratsinakis, Kalantzi and Kamaras16} The higher productivity of Greek otolaryngologists in Great Britain over Germany demonstrates that Great Britain is probably the most popular European destination for Greeks who want to develop an academic output.

Another important factor is the difficulty in promoting research in Greece, as journals might be biased towards English-speaking researchers, increasing difficulties in presenting and promoting academic work. Research funding and opportunities in Greece have been severely curtailed during the years of financial crisis.^{Reference Vrachnis, Vlachadis, Iliodromiti, Valsamakis and Creatsas17} More direct collaboration and an extrovert outlook are vital, and have been shown to reduce the negative impact of reduced research opportunities and to encourage research in Greece.^{Reference Vrachnis, Vlachadis, Deligeoroglou, Mastorakos and Iliodimiti18} The Greek diaspora is an obvious and the easiest way to build bridges and achieve this goal, by enabling mutually beneficial collaboration that could help to extinguish such discrepancies. This could include, without being limited to, sharing research projects, participating in multi-centre studies, sharing doctoral (PhD) and/or post-doctoral research, and being appointed in clinical and research fellowships.

Our study found that women are inappropriately represented in otolaryngology. Female otolaryngologists have a statistically significantly lower number of citations compared to their male counterparts. This finding is in accordance with other studies which reported that female members are underrepresented in otolaryngology societies.^{Reference Choi and Miller11,Reference O'Connell Ferster and Hu19–Reference Eloy, Blake, D'Aguillo, Svider, Folbe and Baredes24} In an effort to explain gender differences among otolaryngologists, some assumptions can be made. As more women have entered medicine in general and otolaryngology in particular in recent years, the average graduation year of women otolaryngologists is more recent, resulting in fewer research-productive years than men. This assumption is partly validated by the fact that the average age of women otolaryngologists in our study is indeed slightly lower than that of men.

Moreover, gender seems to be associated with career advancement. Raising children without adequate state and institutional support places an additional burden, and possibly delays career advancement and reduces academic productivity. Women in otolaryngology and other fields of medicine feel that having children negatively affected their careers.^{Reference Epperson, Gouveia, Tabangin, Takiar, Howell and Altaye10,Reference Carr, Ash, Friedman, Scaramucci, Barnett and Szalacha25} Data on women's representation in leadership positions demonstrate that while women are proportionately represented among programme directors, they are underrepresented as department chairs.^{Reference Smith, Chiu, Sykes, Eck, Hierl and Villwock22} The leadership still seems to remain predominately male, even though evidence shows that women are equally effective.^{Reference Rosser26} Eloy et al. reported that men in all specialties have higher research productivity across all ranks.^{Reference Eloy, Svider, Chandrasekhar, Husain, Mauro and Setzen9} Men in otolaryngology have statistically significantly higher h-indexes compared to their female counterparts.^{Reference Eloy, Svider, Chandrasekhar, Husain, Mauro and Setzen9} However, women in otolaryngology seem to have more difficulty in publishing their research compared to men, as shown in a recent Canadian study.^{Reference Mavedatnia, Payandeh, Neocleous, Davidson, Dzioba and Strychowsky27} Female representation is expected to increase through the years, as more women seem to enter medical school and more barriers impairing their advancement are lifted. Indeed, a greater percentage of women seem to follow surgical residency than in the past.^{Reference Okafor, Tibbetts, Shah, Tillman, Agan and Halderman21,Reference Chorfi, Schwartz, Young, Joseph and Nguyen28} Therefore, monitoring female representation in otolaryngology will ensure equal gender representation both in residency and in leadership positions.

There are no historical data on the evolution of female participation in otolaryngology in Greece. Data from Canada demonstrate a 13 per cent increase in the female proportion of otolaryngologists over an almost 18-year period.^{Reference Fu, Wu, Campisi, Witterick and Chan23} It is encouraging to see that the number of female otolaryngologists seems to increase through the years, promoting equality in medicine. Future studies based on gender proportions of Greek otolaryngologists could permit a comparative evaluation to be conducted. Addressing disparities in representation requires action. Removing the obstacles that prevent career advancement could result in a larger proportion of women in otolaryngology. Mentorship for female otolaryngologists could empower women's academic productivity and support women in leadership positions.^{Reference Shrestha29} A culture of inclusivity is vital. Training programmes during residency should promote equality in medicine, an interest in research, and collaborations with other institutions. There is evidence that programmes which provide diversity and inclusion initiatives tend to have more female residents.^{Reference Smith, Chiu, Sykes, Eck, Hierl and Villwock22}

The main limitation of this study is associated with potential missing names of otolaryngologists. Although the first name, last name, country of work and institution of work were assessed meticulously by two authors (PK and AP) to identify if the otolaryngologist was of Greek origin or not, some otolaryngologists' names may have been missed. Moreover, we assessed academic rank and productivity through the academic position and the number of citations and h-index respectively. Other aspects such as participation in teaching, committees and clinical leadership roles are also very important. However, objective and measurable numeric data on such factors are much more difficult, if not impossible, to gather and compare. Exact data on the age of otolaryngologists could not be retrieved from the individuals’ own professional websites or institutional websites for all of the otolaryngologists included in the database.