Introduction In 1849 when Miss Elizabeth Blackwell (of British origin) became the first lady to get a medical degree from Geneva Medical College (New York) in United States of America, there was a letter to the New England Journal of Medicine (NEJM) stating that “it is much to be regretted that she has been induced to depart from the appropriate sphere of her own sex, and led to aspire to honours and duties, which by the order of nature and the common consent of the world devolve alone upon men”.[1] This statement reminded me of the article which the Editor -in-Chief of this journal had written in the Women in Nephrology (India) newsletter in which she stated that pioneering lady medical professionals in India also had to struggle to get acceptance.[2] I will not be surprised if the sentiment expressed in the NEJM letter in the nineteenth century is still prevalent in some of our colleagues’ mindset, especially when it concerns women doctors practising in specialities which are still considered as exclusive male domains. Nephrology, a relatively young subspeciality of medicine was dominated by male professionals in it’s earlier years. Over the years, gratifyingly, more and more young women are taking the plunge and are studying to become nephrologists. This is despite the fact that nothing much has changed in society to facilitate their pursuit of this demanding speciality. This article traces the journey of women nephrologists and the barriers and challenges they faced and continue to face. It also tries to look at measures which will improve the lot of women who take up nephrology as their profession. Women in Nephrology - The Journey As far as mankind’s existence is known, the task of caring was the responsibility of a woman. The first known healthcare workers were the shamans, (shamanism is a spiritual healing process dating back to 17000-25000 years) in whom majority were women.[3] The role of women in healthcare was not emphasized in medical texts as most of the authors were males. Metrodora (c 200-400 CE) was a woman Greek physician who discussed about etiology and symptomatology of diseases in her book “On the Diseases and Cures of Women”. Even though her textbook was widely referenced, she limited her expertise to women healthcare.[4] In ancient India, medical practice was the domain of priests. As this was a male dominated profession, absence of the mention of female medical practitioners is to be expected. The only mention of a female vaidya is that of Rusa whose work on Ayurveda was translated into Arabic on the order of Harun al Rashid in the eighth century. Also, in ancient India, medical education began after the age of maturity, which the women students could not pursue since they were married off by that age.[5] In the last two hundred years women were often excluded from studying medicine and when they did there was a lot of consternation and uproar. Despite these adverse circumstances, women took up medicine and allied subjects like physiology, immunology and genetics in the beginning of the 20th century. Nephrology was formally recognised as a subspeciality of medicine in the late 1950s and early 1960s. Even before the speciality got its formal recognition, it is worthwhile to note that there were many pioneering women scientists who worked tirelessly in the field of renal physiology between 1918 and 1960. The works of Marian Minor Crane, Anna Josephine Eisenman, Pauline Merrit Hald, Lois L. McKay, Grace Medes, Gladys Cameron, Alma Elizabeth Hiller, Phyllis Adele Bott, Muriel Combes MacDowell and Margaret Mylle were only recognised in 1999.[6] In the last 60 to 70 years of the existence of nephrology as a speciality, women nephrologists have made seminal contribution in the progress of this speciality. The following names were recognised by the International Society of Nephrology (ISN) for their work in the development of this subspeciality:[7] Dr Josephine Briggs for her work in the renin angiotensin system, diabetic nephropathy, blood pressure at the National Institutes of Health (NIH), USA. Dr Renee Habib, a pioneer in nephronpathology in France who helped establish nephrology as a speciality. Dr Vidya N Acharya, the first woman nephrologist in India, who did pioneering work in kidney diseases and helped establish one of the oldest nephrology departments in Mumbai, India. Dr Hai Yan Wang, the head of the nephrology department in Peking University First Hospital since 1983. She is instrumental in developing the nephrology services in China and is the editor of many Chinese nephrology journals. Dr Mona Al-Rukhaimi, a strong leader in nephrology in the middle east (UAE) and an advocate of ethical practice of transplantation. Dr Saraladevi Naicker, a pioneering nephrologist from South Africa who created the first training programme for nephrology in Africa. Her initiatives have led to the development of nephrology services all over Africa. Dr Batya Kristal, the first woman head of department of Nephrology in Israel. She is the founder of Israel’s National Kidney Foundation. Dr Priscilla Kincaid-Smith, the first woman President of International Society of Nephrology, is known for her work on analgesic nephropathy. She has been a towering inspiration for women nephrologists world-wide. It would be extremely difficult to collate all the names of women nephrologists who have enriched this speciality by their work. The list is not complete, but it is an honour to mention Agnes Fogo (the current President of ISN), Vivette D’Agati (nephropathology), Gabriella Moroni and Liz Lightstone (Lupus Nephritis), and Sharon Moe and Teresa Adragao (vascular calcification) for their contributions over the years in this speciality. These pioneers have constantly encouraged us and the younger generation to take up this exciting but demanding speciality despite numerous hurdles. Women in Nephrology - Today Even though women continue to collaborate and contribute to the development of nephrology, till now there have been only three women Presidents in the history of ISN, an organization which is more than 60 years old. The first President was in 1972, followed by a hiatus of more than 43 years when Dr Adeera Levin was appointed as the next woman President of ISN in 2015. The American Society of Nephrology (ASN) was founded in 1966 by 17 men. The ISN was founded by Prof Jean Hamburger and the initial meetings and committees had very little female representation. Today women make up almost 40% of the nephrology workforce. This change over the years is commendable and mostly because of the changing attitudes of both the students and their mentors. Dr Alfonso Palma, a senior Spanish nephrologist who has witnessed the slow but steady increase in the representation of women in nephrology says “when students would come to ask me about the speciality after sitting their Internal Medical Resident exam, the men always asked me if you could earn money working in nephrology, but the women never asked about this, they had more of an interest in the patient. Nephrology is an unusual speciality because it requires a great deal of effort, a lot of dedication, a lot of studying, a lot of work.... And it is not very well paid. Kidney patients consume you. If they die under your care it leaves a huge mark on you and this is something a lot of people can’t tolerate, although women can”.[7] The inclusion of more women in various strata of nephrology work force bodes well for the speciality. To encourage and enhance their participation, we need to look at the barriers and challenges faced by young nephrology trainees and develop systems that remove / reduce these challenges and help facilitate a hassle-free fellowship program. Women in Nephrology: Barriers and Challenges In ASN and other organizations where the representation of women nephrologists are progressively increasing (25%-36%), leadership positions still are mostly the domain of men. In fact, creating an ecosystem where women automatically reach higher echelons and break the glass-ceiling is not the only challenge faced by us. We need to continuously evolve and develop infrastructure and systems which will encourage young women medical graduates to pursue nephrology. For this to happen we need to understand the barriers and challenges faced by these young women. In many countries, it takes more than 5 years to graduate as a nephrologist after your with the primary medical school training. This is the period when women contemplate motherhood and to pursue their training, they often restrict their desire to become one. This ‘deferred parenthood’, so as to complete their training is described in many studies.[8] Having a baby during training is fraught with difficulties. Sometimes leave taken during pregnancy may lead to termination of training contracts and often extension of the training duration. There are global discrepancies of maternity leave duration and reimbursement. Then, there is the guilty feeling of leaving the department under-staffed. Returning to work after delivery is often very stressful as the long hours of nephrology training is often not compatible with child care centre working hours. Often the mother misses out -of work hours meetings and this negatively affects her career advancement.[9] Maintaining a work life balance is difficult at this stage. This leads to feelings of low self-worth. Female physicians have a higher divorce rate than their male counterparts, especially those who work longer hours.[10] Women nephrologists face numerous hurdles in career advancements and professional growth. Numerous studies have reflected on the gender disparities in remuneration and grant approvals in the speciality.[11] A third of nephrology articles have women as primary authors and majority (80%) of peer reviewers are males.[12] Women often skip conferences because of lack of on-site childcare facilities and exclusion of children from the conference venue. The challenges of women nephrologists attaining leadership positions has been already alluded to before. Women in Nephrology: From here to the future To encourage women to join nephrology we need to learn more about them, their issues and concerns. We need more work in understanding the barriers which prevent women nephrologists to join research and difficult subspecialities like transplantation and interventional nephrology.[13] We need to have more childcare facilities at work, rationalise maternity leave policies, fair re-integration policies to facilitate return to work after childbirth, fund refresher courses, promote women participation in mentorship programs and support the mother to combat imposter syndrome. Organisations should have more flexible working hours for the mother.[14] They should consciously reject gender discrimination and have transparent salary practices and encourage women to ascend to leadership position in their organisation. Nephrology societies should look at gender parity in their committees and conferences. In this regard societies like Women in Nephrology can play a leadership role and be the voice of women nephrologists. Women who wish to attain leadership positions in nephrology should do it because they love nephrology and want to make a difference. They should take charge of their careers, chase their goals, and accept all opportunities which allow them to participate or lead, even if they are small roles. They should learn the rules of the game and play by them.[15] They should never miss any occasion which allows them to expand their network, even if it does not directly benefit them. And finally, learn to accept criticism and use adversity as a learning experience. Women of this generation are made differently and have true grit and determination to succeed, whatever the adversity. Summary and Conclusions From the early years of nephrology, women have played a major role in the growth and expansion of this speciality. Now, they are increasingly becoming a substantive part of the nephrology workforce. Their unusual qualities make them well suited for this difficult speciality. Addressing their issues and challenges will help not only them but the speciality as a whole. By removing barriers and prioritizing gender parity, inclusion of women nephrologists will ensure an efficient and effective workforce. Source of funding: Nil Conflict of Interest: None