If you exclude 50% of the talent pool, it's no wonder you find yourself in a war for talent.

—Theresa J. Whitmarsh

Recent decades have witnessed a steady growth in female participation in medicine. Current United States statistics related to gender parity in this field are by now relatively well-known and show similar rates for men and women when training is considered. Recent medical school matriculation trends indicate that women actually constitute a greater proportion of matriculants.1 The Association of American Medical Colleges reported that 45.8% of residents and fellows in 2019 were female.2 However, the same association reported that women made up 36.3% of active physicians in 2020.3 When surgical specialties such as ophthalmology are considered, this disparity is even greater, with a study showing that 22.7% of practicing ophthalmologists at the end of 2015 were female, while the same study showed that women comprised 44.3% of residents in training in ophthalmology residency programs in 2014.4

Societies' surveys seem to suggest similar trends. The fourth annual ASCRS clinical survey, which was performed at the 2016 ASCRS annual meeting and through electronic follow-up, received more than 1500 responses from physicians.5 It showed a significant dropout of female responses as the number of years in practice increased, with little change observed in the most recent 2022 ASCRS survey (Tables 1 and 2).6 International survey responses seem to be similar. The ESCRS recently published a clinical trends survey providing a 6-year assessment of practice patterns among society delegates, with the largest cohort of respondents consisting of delegates practicing in Western Europe, followed by those practicing in Eastern Europe, Africa/Middle East, Asia, and then the Americas.7 The proportion of male and female respondents in 2021, segmented by years in clinical practice, showed that female respondents outweighed male respondents among those in training or with <10 years of experience. However, this trend was reversed among those with ≥11 years of experience, with 15.1% of male respondents having >30 years of experience compared with only 7.1% of female respondents.7

Table 1. - ASCRS clinical survey 2016; respondent demographics by gender and years in practice Years in practice Male (%) Female (%) Resident/fellow 65 35 0-5 y 67 33 6-10 y 70 30 11-20 y 82 18 21-30 y 86 14 More than 30 y 89 11
Table 2. - ASCRS clinical survey 2022; respondent demographics by gender and years in practice Years in practice Male (%) Female (%) Resident/fellow 62 38 1-5 y 63 37 6-10 y 66 34 11-15 y 69 31 16-20 y 76 24 21-25 y 81 19 26-30 y 87 13 31-40 y 89 11 More than 40 y 94 6

The issue of gender disparity in ophthalmology is front and center in the 2022 to 2023 ophthalmic literature, with a series of interesting articles published in the Journal of Cataract & Refractive Surgery (JCRS) approaching this issue from different perspectives, specifically in the area of cataract and refractive surgery. In this issue, Choudhry et al. (page 531) published a study on recent female authorship trends in this area of work. The authors focused on articles published in the Journal of Refractive Surgery and the JCRS. The number of articles published was recorded from 2015 to 2022 from Scopus, and the parameters considered were the gender of first and senior authors, affiliated country, type of literature, and number of citations. Women, either as first author or as senior author, made up less than 30% of authorship of all types of literature studies, except for prospective clinical studies as first author, when women made up slightly more than 30% (31.3%). Analysis of number of citations used as a metric of the scholarly value of publications authored by women compared with men, though, indicated that they published work that is of equal value to the field.

Another interesting finding of the study by Choudhry et al. was that female senior authors were predicted to have about a 1.4 times greater likelihood of having a female first author, which may be related to mentorship of women entering the field of cataract and refractive surgery by other women. Such mentorship roles also appear to be in play according to the cross-sectional study by Lam et al., in which demographic characteristics, educational backgrounds, and academic achievements among program directors of cornea and external disease and anterior segment fellowships in the U.S. in 2020 were investigated using the San Francisco match website.8 The study indicated that female program directors remain in the minority (23.9%) but are more common in departments with female chairpersons. It is noteworthy that a study published in 2018 revealed that 90% of the 111 chairpersons reviewed in academic ophthalmology departments were male.9 The study by Lam et al. also indicated that female program directors were entirely in academic programs, whereas men were split between academic, private practice, and hybrid programs.8

In the study by Cai et al., the authors evaluated differences in cataract volume among male and female surgeons in the Medicare database from 2012 to 2018.10 A total of 8480 unique cataract surgeons were included in the study, the majority of whom were male (78%). The study showed that between 2012 and 2018, the average male ophthalmologist performed approximately 1.80 times as many cataract surgeries as did women in the South, 1.53 in the West, 1.50 in the Midwest, and 1.16 in the Northeast, after accounting for general clinical productivity (female surgeons billed fewer office visits), and demographic and geographic factors. These differences in gender disparities did not significantly change from 2012 through 2018.

There are also significant differences in likelihood of surgeons to perceive, communicate, and document intraoperative “gray area” surgical complications (events not viewed by all surgeons as a true intraoperative complication) based on gender. In the study by Khan et al., an anonymous, online survey consisting of 11 potential intraoperative gray area surgical complication scenarios was developed and distributed to practicing and resident ophthalmologists in the U.S., issuing 389 responses.11 For both ocular-surface (eg, corneal abrasion occurring during cataract surgery) and intraocular (eg, zonular dehiscence of less than 3 clock hours occurring during cataract surgery) gray area surgical complication scenarios, female surgeons were more likely than male surgeons to disclose them in the operative report. Female surgeons were also more likely to both disclose intraoperative events to their patients and experience psychological anxiety regarding patient outcomes. The study also showed that trainees were more likely to believe that intraoperative gray area surgical complications could lead to vision-limiting outcomes when compared with attending surgeons. This is significant in light of the fact that female trainee surgeons have been described as the highest at-risk group for the condition known as “imposter syndrome,” in which individuals feel that they do not deserve their success despite objective evidence to the contrary.12,13 This syndrome has been associated with higher rates of burnout, and indeed, a survey designed to quantify burnout among ophthalmologists in the U.S. and identify related risk factors showed that female ophthalmologists are nearly twice as likely to self-report burnout compared with men.14

A discussion on the root causes of the mid-career dropout phenomenon related to women in medicine and on the other aforementioned gender disparities specifically in the area of cataract and refractive surgery is beyond the scope of this text because it would likely involve explicit and implicit bias and cultural factors, among others. It seems it will take many years for the incoming trainees to shift the balance as women climb the career ladder. However, progress has been made, and we have been witnessing an increasing number of women taking on leadership roles at societies such as ASCRS, a trend also observed regarding ESCRS. Having more women available as mentors and role models in surgical specialties will likely continue to have a significant impact on closing gender gaps. Moreover, although this text focuses on gender disparities, the bigger picture requires improving diversity in ophthalmology as a whole, the backbone toward the major goal of reducing overall disparities in eyecare.

1. 2021 FACTS: Applicants and Matriculants Data. Association of American Medical Colleges. Available at: https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data. Accessed February 8, 2023 2. ACGME Residents and Fellows by Sex and Specialty, 2019. Association of American Medical Colleges. Available at: https://www.aamc.org/data-reports/interactive-data/acgme-residents-and-fellows-sex-and-specialty-2019. Accessed February 8, 2023 3. 2020 Physician Specialty Data Report: Executive Summary. Association of American Medical Colleges. Available at: https://www.aamc.org/data-reports/workforce/interactive-data/2020-physician-specialty-report-data-highlights. Accessed February 8, 2023 4. Xierali IM, Nivet MA, Wilson MR. Current and future status of diversity in ophthalmologist workforce. JAMA Ophthalmol 2016;134:1016–1023 6. ASCRS Clinical Survey 2022. Eyeworld. Available at: https://supplements.eyeworld.org/eyeworld-supplements/12-22-clinical-survey-final. Accessed February 27, 2023 7. Kohnen T, Findl O, Nuijts R, Ribeiro F, Cochener-Lamard B. ESCRS Clinical Trends Survey 2016–2021: 6-year assessment of practice patterns among society delegates. J Cataract Refract Surg 2023;49:133–141 8. Lam SS, Garg K, Shalaby WS, Rapuano CJ, Syed ZA. Descriptive analysis of cornea and anterior segment fellowship program directors in 2020. J Cataract Refract Surg 2022;48:1419–1426 9. Dotan G, Qureshi HM, Gaton DD. Chairs of United States Academic Ophthalmology Departments: a descriptive analysis and trends. Am J Ophthalmol 2018;196:26–33 10. Cai CX, Klawe J, Ahmad S, Zeger SL, Wang J, Sun G, Ramulu P, Srikumaran D. Geographic variations in gender differences in cataract surgery volume among a national cohort of ophthalmologists. J Cataract Refract Surg 2022;48:1023–1030 11. Khan A, Murphy DA, Kloek CE, Dvorak JD, Woreta FA, Riaz KM. Surgeons' perspectives on intraoperative gray area surgical complications of cataract surgery. J Cataract Refract Surg 2022;48:954–960 12. Gottlieb M, Chung A, Battaglioli N, Sebok-Syer SS, Kalantari A. Impostor syndrome among physicians and physicians in training: a scoping review. Med Educ 2020;54:116–124 13. Wilson GA. The imposter phenomenon and cataract surgery. J Cataract Refract Surg 2022;48:1216 14. Sedhom JA, Patnaik JL, McCourt EA, Liao S, Subramanian PS, Davidson RS, Palestine AG, Kahook MY, Seibold LK. Physician burnout in ophthalmology: U.S. survey. J Cataract Refract Surg 2022;48:723–729