GENDER DIFFERENCES IN SELF-REPORTED PROCEDURAL VOLUME AMONG VITREORETINAL FELLOWS

Sex Disparities in Ophthalmology From Training Through Practice: A Systematic Review

Importance

Sex-based research in medicine has revealed inequities against females on almost every metric at almost every career stage; ophthalmology is no exception.

Objective

To systematically review the experiences of females in ophthalmology (FiO) from training through practice in high-income countries (HICs).

Evidence Review

A systematic review of English-language studies, published between January 1990 and May 2022, relating to FiO in HICs was performed. PubMed, MEDLINE, and Embase electronic databases were searched, as well as the Journal of Academic Ophthalmology as it was not indexed in the searched databases. Studies were organized by theme at each career stage, starting in medical school when an interest in ophthalmology is expressed, and extending up to retirement.

Findings

A total of 91 studies, 87 cross-sectional and 4 cohort, were included. In medical school, mentorship and recruitment of female students into ophthalmology was influenced by sex bias, with fewer females identifying with ophthalmologist mentors and gender stereotypes perpetuated in reference letters written by both male and female referees. In residency, females had unequal learning opportunities, with lower surgical case volumes than male trainees and fewer females pursued fellowships in lucrative subspecialties. In practice, female ophthalmologists had lower incomes, less academic success, and poorer representation in leadership roles. Female ophthalmologists had a greater scholarly impact factor than their male counterparts, but this was only after approximately 30 years of publication experience. Pervasive throughout all stages of training and practice was the experience of greater sexual harassment among females from both patients and colleagues. Despite these disparities, some studies found that females reported equal overall career satisfaction rating with males in ophthalmology, whereas others suggested higher burnout rates.

Conclusions and Relevance

Ophthalmology is approaching sex parity, however, the increase in the proportion of females in ophthalmology had not translated to an increase in female representation in leadership positions. Sex disparities persisted across many domains including recruitment, training, practice patterns, academic productivity, and income. Interventions may improve sex equity in the field.

Gender related trends among Israeli ophthalmologists professional career and personal life performance

BACKGROUND

Gender-diversity trends in ophthalmology in Israel have not been studied despite a high proportion of female ophthalmologists. Our purpose was to evaluate gender-related trends in ophthalmology professional career and personal life performance in early and advanced careers in Israel.

METHODS

A survey based on a nationwide voluntary anonymous web questionnaire was distributed to the members of the Israeli Ophthalmological Society. The questionnaire included questions referring to professional career and personal life performance. Gender differences were analyzed.

RESULTS

Out of 252 respondents, 116 (46%) were women, with a mean age of 47.97 + -11.3 and 53.18 + -12.4 (P = 0.01) years, respectively. Marital status, post-residency fellowship performance or duration, an additional academic degree, academic appointments, and managerial positions were similar between genders. Fellowship predominance of males was found in cornea/cataract/refractive and of females in strabismus, pediatric ophthalmology, and neuro-ophthalmology (P < 0.01, P = 0.032, respectively). Men had significantly more publications and appointments in peer review journals and work hours (P = 0.04 and P = 0.02, P = 0.027, respectively). Both genders responded similarly regarding work satisfaction, combination between family life and work. More women felt inequity during and post-residency in clinical (P = 0.011, P = 0.001, respectively) and surgical work (P = 0.001, P = 0.035, respectively). More women experienced inappropriate remarks from patients and sexual harassment (P = 0.001, P < 0.001, respectively), and supported the need for affirmative action (P < 0.0001).

CONCLUSIONS

Several gender disparities were found among ophthalmologists in Israel, including subspecialties distributions, publications, appointments in peer review journals, working hours, work inequity sense, harassment events, and support the need for affirmative action.

Sex-Based Differences in Medicare Reimbursements among Ophthalmologists Persist across Time

PURPOSE

To evaluate differences in Medicare reimbursements between male and female ophthalmologists between 2013 and 2019.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Ophthalmologists receiving Medicare reimbursements between 2013 and 2019.

METHODS

The Centers for Medicare and Medicaid Services Physician and Other Supplier Public Use File was used to determine total reimbursements and number of services submitted by ophthalmologists between 2013 and 2019. Reimbursements were standardized to account for geographic differences in Medicare reimbursement per service. Data from the American Community Survey (ACS) were used to determine socioeconomic characteristics (unemployment, poverty, income, and education) by zip code for the location of each physician's practice. A multivariate linear regression model was used to evaluate differences in annual reimbursements by sex, accounting for calendar year, years of experience, total number of services, ACS zip code data, and proportion of procedural services.

MAIN OUTCOME MEASURES

Annual Medicare reimbursement and use of billing codes (e.g., outpatient office visits and eye examinations, diagnostic testing, laser treatment, and surgery).

RESULTS

Among 20 281 ophthalmologists who received Medicare reimbursements between 2013 and 2019, 15 451 (76%) were men. The most common billing codes submitted were for outpatient visits and eye examinations (13.8 million charges/year), diagnostic imaging of the retina (5.6 million charges/year), intravitreal injections (2.9 million charges/year), and removal of cataract with insertion of lens (2.4 million charges/year). Compared with men, female ophthalmologists received less in median annual reimbursements (median, $94 734.21 [interquartile range (IQR), $30 944.52-$195 701.70] for women vs. $194 176.90 [IQR, $76 380.76-$355 790.80] for men; P < 0.001) and billed for fewer annual median services (median, 1228 [IQR, 454-2433] vs. 2259 [IQR, 996-4075, respectively]; P < 0.001). After adjustment for covariates, female ophthalmologists billed for 1015 fewer services (95% confidence interval [CI], 1001-1029; P < 0.001) and received $20 209.12 less in reimbursements than men (95% CI, -$21 717.57 to -$18 700.66; P < 0.001).

CONCLUSIONS

Female ophthalmologists billed for fewer services and received less in reimbursement from Medicare than men over time and across all categories of billing codes. Disparities persisted after controlling for physician and practice characteristics.

Gender Representation Among Presenters in Ophthalmology Subspecialties in 2019: A Retrospective Review

PURPOSE

To describe gender representation at eight national ophthalmology conferences, stratified by role, session category, and sub-specialty.

DESIGN

Retrospective cross-sectional study.

STUDY POPULATION

3,817 presenters at the 2019 American Academy of Ophthalmology subspecialty days, American Society of Cataract and Refractive Surgery, American Glaucoma Society, American Society of Retina Specialists, American Society of Ophthalmic Plastic and Reconstructive Surgery, American Association for Pediatric Ophthalmology and Strabismus, North American Neuro-Ophthalmology Society, and American Uveitis Society meetings.

MAIN OUTCOME MEASURES

Gender of presenters in seven sub-specialties stratified by category and role.

RESULTS

The proportion of female presenters was less than the ABO-estimated proportion of women in their respective fields in glaucoma (28.0% vs. 39.8%), neuro-ophthalmology (35.3% vs. 45.3%), and pediatrics (42.1% vs. 53.3%) and greater than expected in retina (24.6% vs. 19.8%). Overall, the proportion of female presenters exceeded the ABO-estimated proportion of females in ophthalmology (24.5%) for clinical (mean: 38.5%, 95% CI: [35.8%, 41.4%]) and scientific (39.4% [30.3%, 49.2%]) sessions. For clinical sub-specialty sessions, the proportion of female leaders exceeded the overall proportion of female leaders in the respective sub-specialty in cornea (35.1%, [30.4%, 40.1%] vs. 24.6% all sessions). Females represented fewer than the expected number of surgical session leaders in cornea (22.0% [19.9%, 24.3%]), glaucoma (18.0% [13.2%, 24.1%]), pediatrics (22.0% [14.4%, 32.1%]), and retina (18.6% [14.2%, 24.1%]).

CONCLUSIONS

Gender representation varied, with fewer than expected female presenters in glaucoma, neuro-ophthalmology, and pediatrics. Females led relatively more clinical sessions, but were underrepresented in surgical sessions, in most sub-specialties.

Gender Differences in Ophthalmic Procedural Volume: A Study of Male versus Female Glaucoma Specialists

PURPOSE

To investigate whether differences in procedural volume exist between practicing male and female glaucoma specialists.

DESIGN

A cross-sectional analysis SUBJECTS: A total of 213 female and 666 male glaucoma specialists who performed greater than or equal to 11 traditional incisional glaucoma procedures for Medicare beneficiaries between 2014 and 2018.

METHODS

The 2014-2018 Medicare Provider Utilization and Payment Data was queried using Current Procedural Terminology (CPT) and Evaluation and Management (E&M) codes to identify clinic visits, cataract, glaucoma drainage implant (GDI), trabeculectomy, minimally invasive glaucoma surgery (MIGS), and office-based glaucoma laser procedures. The number of procedures performed per provider was averaged and compared between male and female specialists. Univariate ordinary least squares linear regression analysis was used to investigate the effects of gender on procedural volume. Multivariate ordinary least squares linear regression analysis was used to examine the effects of gender, number of group practice members, and years after medical school graduation on cataract, GDI, trabeculectomy, MIGS, and glaucoma laser procedural volume.

MAIN OUTCOME MEASURES

Mean difference in the number of procedures by gender and predictors of procedural volume.

RESULTS

In the univariate analysis, males performed an estimated 7.8 more MIGS (95% Confidence Interval [CI] 2.7-12.9; p=0.003), 138.9 more cataract (95% CI 59.6-218.3; p=0.0006), and 1.99 more GDI procedures (95% CI 0.03-3.95; p=0.046) than their female counterparts. This relationship remained true for MIGS and cataract procedures in the multivariate analysis after controlling for clinical volume, number of group practice members, and years after medical school graduation (MIGS, ß=6.1 [95% CI 0.5-11.8], p=0.03; cataract, ß= 110.2 [95% CI 16.9-203.5]; p=0.02). Glaucoma drainage implant procedures were no longer associated with the gender of the surgeon in the multivariate analysis (ß= 2.1 [95% CI -0.1-4.2], p=0.06). The volume of trabeculectomy and office-based glaucoma laser procedures did not differ between genders in both the univariate (glaucoma laser, ß= 7.0 [95% CI -4.4-18.5], p=0.23; trabeculectomy, ß= 2.7 [95% CI -0.8-6.2], p=0.13) and multivariate analyses (glaucoma laser, ß= -7.3 [95% CI -18.7-4.1], p=0.21; trabeculectomy, ß= -1.7 [95% CI -5.6-2.1], p=0.38).

CONCLUSIONS

Female glaucoma specialists performed fewer MIGS and cataract procedures compared to their male counterparts, even after controlling for clinical volume, which can be seen as a relative measure of work productivity, years after medical school graduation, a proxy for experience, and number of group practice members. After controlling for these factors, there were no differences in incisional glaucoma or glaucoma laser procedure volume between male and female specialists. Further research is needed to understand factors contributing to these differences.

Single Ophthalmology Program Trends in Resident Surgical and Research Productivity by Gender, Underrepresented Minority Status, and Welcoming a Child

Objective The aim of the study is to identify differences for cataract surgery, total procedural volume, and publication rates between residents by gender, underrepresented minority (URM) status, and welcoming a child during ophthalmology residency.

Design This is a retrospective, cross-sectional study.

Participants A total of 89 residents graduating from 2002 to 2020 at a single program were included.

Methods A multiple linear regression model was created to determine factors predictive of the number of cataract surgeries performed as the primary surgeon, total procedural volume, number of publications, or first author publications. Independent variables included resident gender, URM status, PhD degree, welcoming a child during residency, and graduation year.

Results Of the 89 graduating residents included in this study, identifying as female (45 women, 50.6%) and as URM (eight identifying as URM, 9.0%) was not associated with a difference in surgical or research volume. Female residents performed a mean (SD) of 240.1 (55.1) cataract surgeries while male residents performed 210.6 (46.1) cataract surgeries. Residents identifying as URM completed 228.1 (41.9), while non-URM residents completed 234.8 (51.9) cataract surgeries. Since 2008, eight female residents (22.2%) and two male residents (6.9%) added children to their families. Welcoming a child to the family was also not associated with decreased surgical or publication volume. Number of cataract surgeries, total procedures, and number of publications did increase over time (p <0.001), as each graduation year was associated with 5.4 (95% CI: 3.9, 7.1) more cataract surgeries and 30.5 (95% CI: 25.7, 36.9) more procedures. Each year was also associated with 0.24 (95% CI: 0.09, 0.38) more publications and 0.18 (95% CI: 0.08, 0.28) more first author publications.

Conclusion Surgical and research productivity has increased, and female residents and residents who identify as URM did not have fewer cataract surgeries or procedures. Welcoming a child also did not correlate with differences in surgical or procedural volume. Programs should continue to promote equitable surgery and procedural distributions as well as identify more targeted strategies to encourage and recruit underrepresented medical students into ophthalmology.