“More gender diversity… can translate to increased productivity, greater innovation, better decision-making... .”
—2017 Report on Gender Diversity, Morgan Stanley1
Research in the business world has shown that greater gender balance in a company translates into better returns and less volatility for investors. The case for greater gender balance in medicine is similarly compelling.
Most retina physicians, men and women alike, are proponents of gender diversity within our field, but increasing diversity remains challenging. The reasons behind continued gender inequality are complex. They are not limited to medical education and physician practice, but rather stem from all aspects of society. Among the ophthalmology subspecialties, retina attracts the smallest percentage of women. As of 2018, 19% of US retina specialists were women, compared to 26% in oculoplastics, 29% in cornea, 34% in glaucoma, and 47% in pediatric ophthalmology.2
A major step toward improving gender balance in our field is understanding why the imbalance exists. Lack of leadership, support, and mentorship during surgical training, sponsorship of research, and equality in pay are all potential barriers to gender balance in retina.3-7 For this article, we interviewed several female leaders who are at the forefront of mentorship, research, and clinical care in retina and asked them to share their thoughts on gender imbalance in the field.
NOT JUST RETINA
Shlomit Schaal, MD, PhD, Professor and Chair of the Department of Ophthalmology and Visual Sciences at the University of Massachusetts Medical School, commented, “I see evidence of gender inequality not only in our field of retina, but also in academic medicine as a whole. The 2019 report from the Association of American Medical Colleges clearly shows that at the highest levels of academic medicine (department chairs and deans) women are underrepresented. I'm optimistic that this is going to change in the future as more women take on these challenges and serve as role models for the younger generation, both for women and for men.”
This anticipated change is likely to have a trickle-down effect: Having women in leadership roles not only sets an example for younger trainees but also broadly changes the perceptions of what a woman in ophthalmology can achieve.
As Carol L. Shields, MD, Director of the Ocular Oncology Service at Wills Eye Hospital and a Professor of Ophthalmology at Thomas Jefferson University, noted, “It is difficult to break into a field without support from a seasoned player, whether that be a male or female physician. Those of us in retina and ocular oncology have a special opportunity to influence younger women and men, and this likely impacts their choice of specialty.
“Once in the field, there is another factor to consider, and that is the sense of belonging,” Dr. Shields added. “This depends on all of us welcoming new members and including them in all the aspects of our field, regardless of age, race, or gender. This allows these new members to grow into their careers and contribute to their fullest.”
The gender imbalance extends beyond the leadership gap. The very nature of the specialty—the challenges that interest and captivate us—may be the same ones that turn some trainees away.
Nancy M. Holekamp, MD, a Professor of Clinical Ophthalmology and Visual Sciences at Washington University School of Medicine and the Director of Retina Services for Pepose Vision Institute, had some thoughts on this. She said, “I think a gender imbalance exists in retina for the same reason it exists in general surgery and neurosurgery: Extra years of training, more emergency calls, less predictable schedules. We are the ones getting called in the middle of the night to surgically fix emergency problems—infections, posteriorly ruptured globes, retinal detachments. Retina is distinct enough from other ophthalmology specialties to create a gender disparity not observed in those specialties.”
Sharon Fekrat, MD, a Professor of Ophthalmology, Associate Professor in the Department of Surgery, and Surgical Retina Fellowship Director at Duke University School of Medicine, agreed. “Although many women definitely think that vitreoretinal surgery is fun and exciting, they likely make a work-life balance decision not to enter the field,” she said. “However, what they may not realize is that, irrespective of which ophthalmic specialty they choose, they still have to deal with complex ophthalmic conditions.”
María H. Berrocal, MD, Director of Berrocal & Associates, noted that changes and innovation in the field may increasingly attract more women and calls attention to the need to close disparities in salaries between male and female retina specialists.
“Fortunately, with retina cases being shorter and with the trend toward in-office, pharmaceutical treatment of diseases, I think more women will be choosing retina as a subspecialty,” she said.
“Transparency in salaries is necessary, particularly in academia, to reduce the gender disparity in wages,” she added. “Sadly, women retina specialists' base salaries in many academic settings are less than their male counterparts' salaries. This practice persists because of the lack of transparency.”
ATTITUDES ARE CHANGING
Despite what may seem like a gloomy landscape as described above, thoughts and attitudes toward gender in the workplace are changing due to the work of leaders and pioneers in the field. The leaders we interviewed pointed to important ways to close the gender gap and shared their optimism for the future.
Dr. Fekrat noted that the field is already evolving.
“Medical schools are now more than 50% female, and, as a result, more women will choose ophthalmology and thus retina,” she said. “In fact, an increasing percentage of retina fellows are female, so we are almost there. Seeing strong and accomplished female role models within our field who have both a successful career and personal life will ultimately attract more women to our field.”
Dr. Shields remarked, based on her own experience, that barriers may be a matter of perception.
“I did not see the gender gap as a problem, but rather as an opportunity,” she said. “Women can be exquisitely talented, both intellectually and surgically, and achieve high standards similar to men. Women tend to be precise, with excellent delicate fine motor skills—traits that are of utmost importance to our field.”
Dr. Shields said she has observed the increasing number of women in the field during the tenure of her career.
“Over the past 33 years of my career, there has been a slow rise in the number of women in both retina and ocular oncology. Now, when I attend an ocular oncology symposium, I estimate that 50% or more of the attendees and speakers are women. This has been a gradual evolution. Part of this is due to female (and male) mentorship, changing workplace philosophies, and women believing in their skills. I feel that the presence of women in both retina and ocular oncology has and will continue to push these fields forward and to higher levels, with top performers providing new insights and more creative thinking.”
Our interviewees agreed that mentorship is crucial to bring about change. As Dr. Holekamp remarked, “Young, talented, and smart women in ophthalmology training programs simply need encouraging role models (both female and male) to tell them they can do it.”
Dr. Schaal similarly underscored the importance of female leadership and guidance within the field.
“It may seem quite daunting for a young rising female retina specialist to adequately balance her life between her developing demanding career and her beloved growing family,” she said. “As a mother of four daughters, I can certainly relate to these feelings of anxiety, restlessness, and uncertainty. It is not easy to navigate an ambitious career with a happy home. We must recognize that support, reassurance, and guidance are needed, both from mentors and from peers.”
Just as our patient populations are diverse, a diverse group of vitreoretinal surgeons is necessary to best serve the individual patient's needs. Dr. Berrocal noted how women can increase value in the field of retina: “Women can bring a lot to the field and to their practices—connection with patients, improved patient satisfaction, greater empathy, and, as a recent article showed, better outcomes and reduced mortality.8 At present, we have a system that values and remunerates seeing as many patients as possible, as quickly as feasible. With the current trend toward valuing results-oriented outcomes, I am sure women will start to be valued more. Also, as more women enter the field, we will become not a rarity but a familiarity.”
Raising awareness of potential barriers can help lead to transformation. There have already been incredible changes in our field in the past few decades. Female membership in the American Society of Retina Specialists has increased from 11% to 19% over the past decade.9 The proportion of female fellows-in-training members is even higher, at 30%.
Mentorship of women by both men and women, including sponsorship and promotion, in addition to societal changes in perceptions of gender roles, will bring about change. Women must take their seats at the table by seeking and accepting committee memberships, speaking engagements, and leadership roles. We in the field must collectively and continually analyze shortcomings in gender diversity. The retina community must strive to be at the forefront of change to improve gender balance in our field and propel our subspecialty to its fullest potential.
1. An Investor's Guide to Gender Diversity. Morgan Stanley. January 127, 2017. https://www.morganstanley.com/ideas/gender-diversity-investor-guide. Accessed February 18, 2020.
2. Personal communication with George Williams, MD. American Academy of Ophthalmology, 2018.
3. 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.
4. Gong D, Winn BJ, Beal CJ, et al. Gender differences in case volume among ophthalmology residents. JAMA Ophthalmol. 2019;137(9):1015-1020.
5. Reddy AK, Bounds GW, Bakri SJ, et al. Representation of women with industry ties in ophthalmology. JAMA Ophthalmol. 2016;134(6):636-643.
6. Reddy AK, Bounds GW, Bakri SJ, et al. Differences in clinical activity and Medicare payments for female vs male ophthalmologists. JAMA Ophthalmol. 2017;135(3):205-213.
7. Kramer PW, Kohnen T, Groneberg DA, Bendels MHK. Sex disparities in ophthalmic research: A descriptive bibliometric study on scientific authorships. JAMA Ophthalmol. 2019;137(11):1223-1231.
8. Tsugawa Y, Jena AB, Figueroa JF, Orav EJ, Blumenthal DM, Jha AK. Comparison of hospital mortality and readmission rates for Medicare patients treated by male vs female physicians. JAMA Intern Med. 2017;177(2):206-213.
9. Personal communication with American Society of Retina Specialists staff. January 2020.
Author Caroline Baumal, MD
• Professor of Ophthalmology, New England Eye Center, Tufts Medical Center, Tufts University, Boston
• Editorial Advisory Board Member, Retina Today
Author Avni Finn, MD, MBA
• Vitreoretinal Surgeon, Northern California Retina Vitreous Associates, Mountain View, California
Interviewee María H. Berrocal, MD
• Director, Berrocal & Associates, San Juan, Puerto Rico
• Editorial Advisory Board Member, Retina Today
Interviewee Sharon Fekrat, MD
• Professor of Ophthalmology and Associate Professor in the Department of Surgery, Duke University School of Medicine, Durham, North Carolina
• Surgical Retina Fellowship Director, Duke University School of Medicine, Durham, North Carolina
Interviewee Nancy M. Holekamp, MD
• Professor of Clinical Ophthalmology and Visual Sciences, Washington University School of Medicine; Director of Retina Services, Pepose Vision Institute, both in St. Louis
Interviewee Shlomit Schaal, MD, PhD
• Professor and Chair, Department of Ophthalmology and Visual Sciences, University of Massachusetts Medical School, UMass Memorial Medical Center, Worcester, Massachusetts
Interviewee Carol L. Shields, MD
• Director of the Ocular Oncology Service, Wills Eye Hospital, Thomas Jefferson University; Professor of Ophthalmology, Thomas Jefferson University, both in Philadelphia
• Editorial Advisory Board Member, Retina Today