Gender inequality in ophthalmology

[caption id="attachment_16824" align="alignleft" width="1024"] Sorcha Ní Dhubhghaill and Diana Carmen Dragnea[/caption]

"Are women actually upset they get paid 77 cents for every dollar a man gets, or that they get paid in change?” – Adam Carolla, Comedian

Jokes aside, women make up more than 70% of the healthcare workforce and the proportion of women to men entering medical school is now approximately 50:50. While almost half of the assistant professors in the US are women, only about a third of full professors and even fewer (15%) heads of department are women.1 Women are also less likely to write journal articles, to be on editorial boards or to be speakers at top-level conferences. While ophthalmology may not be the worst offender, the data from the EBO-ESCRS examination serves as an example from our own field. This subspecialist exam is geared towards accrediting experts in the field of cataract and refractive surgery but only 8% of successful candidates carrying the FEBOS-CR title are women.2 This drop-out phenomenon has been described as the “leaky-pipeline”, where the gender balance at entry level diminishes as you climb the career ladder.3 While some of the leaky pipeline effect can be attributed to time, assuming that the incoming candidates will start to shift the balance, this has not occurred at the pace expected and the gender imbalance at the uppermost levels remain. Are women less capable or less ambitious than their male counterparts? A Canadian study showed that postoperative surgical outcomes are slightly better for female surgeons.4 While I do not think that this should be interpreted as women being better surgeons, it does help debunk the myth that women make worse surgeons. So, if the talent and capacity is there, where and why do we lose the women in ophthalmology? When we think about gender inequality in any profession, we tend to focus on a number of problems areas such as payment, treatment at work, responsibilities, mentorships and opportunities for career progression. Regarding pay, a statement from the Association of Women Surgeons reported that at the current rate that we will not reach parity in wages until the year 2152.5 Women earn approximately 90% of what a man earns until the age of 35, after which the gap significantly widens. Transparency in the remuneration process can be effective in balancing the scales as women tend to accept what they are offered rather than negotiating and pushing for more. Treatment at work can be a trickier issue to tackle. Every woman in medicine will have multiple anecdotes to attest to a time when they were asked to perform tasks that would never be asked to a man.6 Myself, I was once asked if I would be free to babysit for a consultant surgeon. There was no question of asking my two male colleagues present. We also sometimes feel the need to minimise our femininity to fit in. Shorter haircuts, avoiding skirts and dresses in favour of power suits and adopting colder, harsher personalities are often used as coping methods in a less than welcome environment.7 If women cannot be themselves and bring their own approach to the job, the whole idea of diversity is lost. Another huge challenge is addressing mid-career dropout during a woman’s childbearing years. Asking a woman what her family plans are during a job interview is not permitted but some employers still ask about it either directly or indirectly. And even those who don't might be considering it in the background. One (female) employer admitted to us that when given the choice of two candidates with equal qualifications, she chose the male because he would not take maternity leave in the near future. This can often put a woman into a position of choosing between her surgical career or her family plans. The reality is that, while maternity leave is disruptive to service provision, it comes with a lot more advanced warning than other forms of medical leave, and perhaps we can work towards a flexible solution to manage it without putting our mother-surgeons on a lower career track. There is hope though. Role models, mentors, institutions and professional societies can all participate in improving the situation. Fortunately, there is no lack of female role models in ophthalmology. From ESCRS President Béatrice Cochener-Lamard and former President Marie-José Tassignon, to tireless educators like Soosan Jacob and the inventor of the YAG laser for posterior capsulotomy, Daniele Aron Rosa, to name a few. There are so many inspirational women in our field and it is our job to celebrate them and continue their work. The University of Glasgow recently launched a new initiative called “Developing Female Medical and Academic Leaders Scholarship Programme”, and Drexel University in the US offers the Executive Leadership in Academic Medicine (ELAM), which provides training and a support network of alumni to help women in their mid-career, preparing to take the next step up. On a larger scale, national programs like the Athena SWAN encourages and recognises the institutions that take on the cause of gender balance in science, technology, engineering, mathematics and medicine.8 Societies have their own parts to play. The Association of Research in Vision and Ophthalmology (ARVO) has a programme known as Women in Eye and Vision Research (WEAVR) that arranges meetings, workshops and mentorship programs for women in our field. Some travel fellowships now add additional funding for childcare to encourage mothers to attend the conferences that will help forward their careers. At the end of the day, rights for women are just rights in general and achieving a work-life balance is not just for the ladies. All families are unique and should be able to make choices that fit them best. Flexible hours, job-sharing as well as maternity and paternity leave for partners and adoptive parents would help not only keep talented women working but the homestead ticking over too. 1. Year of reckoning for women in science. The Lancet 2018:531. 2. FEBOS-CR successful candidates. https://education.escrs.org/fellows-by-year/. 3. Krishnan N, Szczepura, A. The glass cliff effect for women in STEM. The Lancet 2018;391:2320-1. 4. Wallis CJ ea. Comparison of postoperative outcomes among patients treated by male and female surgeons: a population based matched cohort study. BMJ 2017;10. 5. AWS. Womensurgeons.org. 6. Bellini M, et al. A woman’s place is in theatre: women’s perceptions and experiences of working in surgery from the Association of Surgeons of Great Britain and Ireland women in surgery working group BMJ Open 2019:e024349. 7. Breaking the barriers. EuroTimes 2017. 8. Khan H, Moosajee M. Facing up to gender inequality in ophthalmology and visual science. Eye 2018;32:1421-2.