Communication key to closing gender gap in eye care

Globally, the presence of women in ophthalmology has reached approximately 25% to 30% and has grown to 35% to 45% in training.

Nevertheless, women are still underrepresented in leadership positions, and disparities persist across many domains at almost every stage of their career.

Women also continue to experience a higher burden of vision impairment, especially in low- and middle-income countries. According to the International Agency for the Prevention of Blindness, of the 1.1 billion people with sight loss, 55% are women, and yet they are disproportionally less likely than men to receive care.

By engaging in action to promote gender equity, women in the ophthalmology profession can be true catalysts for change, reducing disparities that persist in medical career progression and access to care.

“Looking at the progress made in the past few years, we should stay positive and be part of that movement because change is happening,” Dagny Zhu, MD, a cornea, cataract and refractive surgery specialist at NVISION Eye Centers in Rowland Heights, California, said. “In our own lives, we should ask ourselves, how can we help accelerate it and make it more effective? There are always things we can do to contribute our own part within our local networks.”

In low-resource countries, signs of improvement are visible, according to Ciku Mathenge, MD, PhD, a retina and community ophthalmology specialist and founder of the Rwanda International Institute of Ophthalmology.

“The world has become much more open. It is easier for women to get information, and information is power,” she said.

More women are entering the profession and will help lift the barriers to women’s health care.

“If we have the honor of holding decision-making positions, the onus is on us to be conscious of what other women are experiencing and take action to improve their condition. The more women become aware of this, the more we can make little changes that in the end will add up and lead to big results,” she said.

The glass ceiling

In the U.S., one in six academic ophthalmology chairs are women, a substantial increase from 2015.

“When I took my first chair position, there were five women chairs. We had a rapid growth over the next couple of years, and we have stabilized around 20. There are about 125 academic programs, and so one in six department chairs are women. That’s not a lot,” Kathryn A. Colby, MD, PhD, the Elisabeth J. Cohen Professor of Ophthalmology and chair of the department of ophthalmology at the NYU Grossman School of Medicine, said.

Although the number of women faculty has gradually increased, most of them are at the assistant professor rank, and few are promoted to professor. Women are also underrepresented in surgical subspecialties, particularly retina and refractive surgery.

“There are more women than men in pediatric ophthalmology, and they are still a minority but up to about 40% in cornea and glaucoma,” Colby said.

The number of women who serve on society boards and congress panels, give presentations at meetings and receive society awards has increased in recent years but still does not equal the number of men.

“We are making progress, but there are congresses where there have been no women in the panels for many years, especially in surgical panels,” Colby said.

A 2021 retrospective study by Nguyen and colleagues found that of 2,506 recipients for 122 awards from 36 ophthalmologic societies in 99 years, 1,897 (75.7%) were men and 609 (24.3%) were women. The proportion of female recipients increased from 0% in 1922 to 41% in 2021.

“This year I gave the 24th David Easty Lecture at the annual meeting of the Bowman Club. I am the first and only woman who has given that lecture in 24 years. Meanwhile, several men have given it twice,” Colby said.

The pay gap

A pay gap between male and female ophthalmologists still exists in the U.S., becoming wider in surgical subspecialties. A study published by Jia and colleagues in Ophthalmology found that in the first year of practice, women received $33,000 less than their male counterparts, which adds up over the years.

This was the topic of a Healio Mend the Gap podcast, a series co-hosted by Zhu and Cathleen M. McCabe, MD, along with Laura Enyedi, MD, Laura Periman, MD, and Susan MacDonald, MD, that explores disparities in health care and seeks to move the needle toward equity.

“The gender pay gap in medicine exists partly because men are more likely to choose more highly paid subspecialties, such as vitreoretinal surgery, refractive surgery and oculoplastics, and tend to get more OR time than women. In large practices with a high patient volume, there is often competition for OR time, and women end up with the draw of a shorter stick,” Zhu said. “Some even go as far as to say that the gender pay gap isn’t real because women physicians choose to work fewer hours and see fewer patients. But how much of that is really a choice when you look at the pressure that society places on women (especially working moms) to be the primary child caretaker and homemaker? Plus, more studies are showing that women physicians are being paid less for the same work done.”

Notably, even controlling for factors such as subspecialty choice, practice settings, OR days and hours worked, women ophthalmologists were still found to be paid significantly less than men.

“The reasons for this are still unclear, and probably there are contract nuances that come to play, such as specific production percentages, bonuses and small parts of the agreements that may not be uniform across all employees. And we know that women are not as good as men at negotiating job contracts,” Zhu said.

As reported in Harvard Business Review, a growing body of research on gender in negotiations suggests that most women see negotiation as a chore and either do not negotiate or do so in ways that can negatively affect the outcome. When women focus on their own needs, it causes others to view them as overly aggressive.

“The advice there is to tone down our assertiveness and come off as more of a team player. That’s the reality of the world that we live in. We have to respond in a certain way in order to get what we want,” Zhu said.

Gender stereotypes and bias

Assertiveness from women is not seen in a positive light because it challenges the traditional gender stereotypes. Consciously or not, women are expected to be nurturing and submissive and care for others rather than themselves. Because of that, they are not seen as effective leaders, according to McCabe, an OSN Presbyopia Board Member.

“I would argue that the opposite is true because women are more emotionally intelligent and better-connected communicators, but maybe that’s a bias I have,” she said.

Another stereotype is that women are not business savvy and therefore less likely to be selected for management roles.

But the most common stereotype that significantly affects women’s career opportunities is that they will be sidetracked in their priorities by child care and family responsibilities.

“Once a patient called in and said, ‘I heard you have five kids, so you’re just doing this for the money,’ and he didn’t want to have surgery with me. It was just one patient, but I wonder how often any patient considers whether or not a man has any children, let alone how the number of children might affect their attention and dedication to their career,” McCabe said.

Zhu was encouraged by her grandfather, Qiu Wei-Liu, DDS, MD, PhD, a pioneer of oral and maxillofacial surgery/head and neck cancer surgery in China, to enter ophthalmology because he thought medicine needed more women in surgical specialties. But when entering the world of private practice, Zhu remembers being interviewed by mostly male practice owners, and one of the first questions she was asked was: “When are you planning to have children?” “I doubt that any of my male colleagues were asked the same question,” she said.

“It was quite shocking to me and made me realize how much further we need to go,” she said. “Even when this is not openly stated, there is a lot of subconscious bias that impacts on the hiring process, and women are perceived to be the predominant child caregivers, to prioritize family over work responsibilities, to want to work part time, and to be less hard-working and less committed to work,” she said.

Barriers to reaching full potential

Although men now play a more active role in parenting, with paternity leave options becoming standard in some countries, balancing a career and parenting is still more challenging for women than men.

“During the pandemic, a lot of research papers highlighted how the gap had widened even further because of lack of child care under those circumstances. As physicians, we are very fortunate to have the resources to pay for it, but in the U.S., child care is honestly unaffordable for many,” Zhu said.

In a 2020 commentary published in JAMA Ophthalmology, Colby wrote that she was involved in the search for a journal editor in chief. The chosen candidate, a man, was eager to have women as senior editors, but most of those he approached turned down the opportunity. They cited various valid family reasons: aging parents, children in the process of applying for college, grown children who had returned home with children of their own. Similarly, when Colby herself was looking for the chair of another department at the University of Chicago, many women she talked with were not willing to consider moving because of the effects on their families.

“Sometimes women don’t have the bandwidth to take on the responsibilities of a leadership when they have young children,” Colby said.

Women may also turn down opportunities because, more often than men, they tend to experience imposter syndrome, according to McCabe. Despite their accomplishments, they feel inadequate, and if they are successful, they may feel like they are frauds who do not deserve it. Insecurity builds up because women are more likely to experience discriminatory behavior and be criticized when they are successful.

“One of the things that we see with young women coming up in their career is that they don’t speak out quite as quickly as men. They are not as likely to join an advisory board or put their name in there if they are not 100% sure that they are the best person to talk about the topic,” she said.

Inequity in access to care

Vision impairment is more prevalent in women for several reasons. Women live longer in all parts of the world, and many blinding conditions are age related. Women are also more susceptible to specific disorders, such as dry eye disease and idiopathic intracranial hypertension, and are more often affected by trachoma because they spend more time with children, increasing the likelihood of infection.

However, when it comes to access to services, there are many barriers that women face, especially in low-income countries.

“Due to lack of financial independence, they cannot make decisions about their eye health when payment is needed. Men are given priority as head of the household. If the decision is whether to treat the man first or the woman first, even the women will choose the man first,” Mathenge said.

She recalled the case of a woman who came for treatment with advanced-stage disease, and when she was asked why she did not come earlier, considering that she lived near the hospital, she said that her husband was ill, and the decision was made with her son that all their resources should go to his care.

“The reason she had come eventually was because her husband had died. She had buried him the day before and suddenly felt that now it was the time for her to seek treatment,” Mathenge said.

Low literacy levels also contribute to the higher prevalence of vision impairment in women.

“They stay with conditions that they don’t know can be reversed,” she said.

Women everywhere need to educate themselves and gain knowledge on what treatments are available. When they reach presbyopic age, women in the West know that they can buy a pair of reading glasses, but the same does not happen in other parts of the world.

“They think it’s just part of aging and call a child to put the thread in the needle for them or to clean rice and grains. Women need to get more information, and the onus is on us as professionals to package that information in a way that can be understood,” Mathenge said.

Women help women

Self-empowerment and solidarity are the basis on which women can build a strong network of reciprocal support.

“Being a woman in leadership does have benefits that trickle down to the women who are our patients. And to get into those leadership positions, we need to invest in ourselves,” Mathenge said.

Early in her career, when she realized that the surgical list always had men first and women sometimes got canceled because of lack of time, she reversed the order “because women actually had a lot more to do after surgery, including looking after their husbands,” she said.

Small things can make a difference, such as having separate waiting rooms for women in places where Islam is the prevalent religion. Also, having more female physicians encourages women who come from conservative cultures to seek treatment because they feel more at ease.

“And then we need to look out for each other, to mentor and sponsor each other. I run a residency program in Rwanda and always look out for girls who want to train in ophthalmology. At first, there was not a single girl applicant, but I did not close the applications until at least one girl applied,” she said.

Mathenge is currently the president of the African Ophthalmology Council, and at the scientific congresses in which she is involved, she has introduced a “Women’s Breakfast,” one morning during which women ophthalmologists get together to discuss a theme of common interest.

“It is a great forum to bring not just women as women, but women as professionals and scientists and researchers under one roof. Lots of camaraderie and good discussions happen there,” she said.

Mentorship

Mentoring takes time and emotional bandwidth but is a key factor for elevating women’s position in the field.

Organizations such as Women in Ophthalmology have created successful mentorship programs, and online conferences such as Real World Ophthalmology provide opportunities for women from all over the world to connect with mentors and colleagues through their virtual platform. Mentorship was another topic widely discussed in the Mend the Gap podcasts, including an episode on men who champion women.

“We have some great male mentors and want to make sure that we recognize and encourage men to be mentors of women,” McCabe said.

Overall, social media services play an important role in making mentoring accessible and inclusive.

“They are a wonderful resource for finding mentors and for networking. Many female mentees don’t have ophthalmology departments within their medical school or don’t have any women in leadership positions who can be role models,” Zhu said.

Through social media platforms, including Instagram, where she has 75,000 followers, LinkedIn and TikTok, which add another 30,000 followers, Zhu is sharing a lot of content that can be useful to women and offers mentorship to many young colleagues.

“They contact me and ask if I can take them on as mentees. I regularly meet them virtually, and I invite those who are local to come to the clinic, watch surgery and see what an ophthalmologist actually does for a living. Many of them have ultimately decided to enter ophthalmology because of what they were able to see while working with me,” Zhu said.

Sometimes she shares her own research opportunities, and many have co-authored papers with her and presented at meetings.

“They have honestly helped me publish a lot of studies that I probably would not have been able to complete by myself. I feel that working for these intelligent and enthusiastic young women, for the next generation, benefits myself in terms of my own growth,” she said.

Diversity is strength

Awareness, communication and allyship are powerful instruments in the move toward true equity.

“The more we talk about these issues, the better we are able to address them, and the more women who are experiencing discrimination can feel comfortable having a discussion. So, the first thing is to take it into the light from the dark and share success stories of how we have managed obstacles to create road maps for others,” McCabe said.

“I take every opportunity to talk about the issue because the more we talk about it, the more the world becomes aware of it, and we can create alliances, also with men, who I don’t think are out to keep the figures as they are,” Mathenge said.

Allyship in closing the gender gap can ultimately improve health care experiences and health outcomes, according to Colby.

“We can better relate with patients when we have a diverse workforce, because diversity of opinions and the opportunity to look at problems from different perspectives are crucial for progress and make the team stronger,” she said.

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• For more information:
• Kathryn A. Colby, MD, PhD, of NYU Langone Health in New York, can be reached at kathryn.colby@nyulangone.org.
• Ciku Mathenge, MD, PhD, of RIIO iHospital in Kigali, Rwanda, can be reached at ciku@email.com.
• Cathleen M. McCabe, MD, of The Eye Associates in Sarasota, Florida, can be reached at cmccabe13@hotmail.com.
• Dagny Zhu, MD, of HyperSpeed LASIK, an NVISION Eye Center, in Rowland Heights, California, can be reached at dagny.zhu@gmail.com.

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