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Glaucoma Experts | Sept/Oct '19

Women in Glaucoma

An exploration of challenges and progress in the field.

1. What, if any, challenges have you faced professionally that are specific to your being a woman? What did you learn from these experiences?

Sarwat Salim, MD, FACS: Sometimes women are not given opportunities to unveil their full potential and are not perceived as natural leaders. It seems to me that women sometimes have to work harder to prove their worth, and it also takes them much longer to be recognized and acquire leadership positions. From these observations, I believe that the leadership of various departments or organizations should try to understand and respect the aspirations of all of their members (men and women), identify their talents and gifts, and empower them to make meaningful contributions.

Ruth D. Williams, MD: Many ophthalmologists discover gender-related issues mid-career. This is because our educational systems have mostly put protections and guidelines in place, but the small business world hasn’t done so yet. I faced many challenges mid-career that were mostly related to two issues. First, my career had a different arc than my male colleagues’. I pulled back career-wise when my three children were young. Not everyone does this, but I needed and wanted to be more available to my family. This did not limit my career over the long term, but it certainly did so in the short term. At the time, I was frustrated because I knew I was talented and ambitious. Now I devote my energies to my career when many of my colleagues are pulling back and spending more time on leisure activities. I am enjoying it immensely and do so wholeheartedly. Because of my career arc, I like to think of myself as 10 years younger than I am.

A second issue is that women professionals are sometimes discounted in subtle ways. It is more difficult to define this, and I can see it more in retrospect than I could in real time. The most obvious example is when women’s comments are ignored or when they are interrupted. I have learned to point this out in a nonreactive manner. Simply saying “I wasn’t finished with my comments” is effective. If another person’s comments are discredited or ignored, I have learned to circle back later in the meeting and say, “Jane made an important point earlier.” It is not just women who need this support; sometimes it is a young ophthalmologist or a person who does not typically seem like a leader. We all have unconscious bias, and our culture more easily gives men respect and gravitas. We can change this gradually by our presence and our persistence.

Michele C. Lim, MD: When I was an intern, someone mistakenly asked me to use the nurses’ locker room in the OR rather than the doctors’ locker room. Sometimes people may not view women as leaders because of our gender.

JoAnn Giaconi, MD: During my internship at a private community hospital, patients frequently mistook me for a nurse. However, once I started residency in a large university hospital system where women were frequently in the role of doctor and men in the role of nurse, this no longer happened. More recently, I have perceived that some of my younger male colleagues may have much higher starting salaries than I had. I am not sure if this is due to gender or due to us starting our careers in different hiring markets. I also think one of the challenges is networking. Many times, men will network with other men around golf or via a predominantly male activity, which sometimes makes it difficult for women to be involved.

Mildred M.G. Olivier, MD: Pay inequity has been a consistent experience since I graduated from medical school. Discrimination was less public then but has now become a major characteristic of everyday life. I have encountered many blockades in life and people who have tried to define me, but I have found the strength to get back up and try again. Often, as women, we may tend to give up after a negative experience, even though we know it is not the right thing to do. My women colleagues and I deserve to be taken seriously. Sexual harassment still exists and needs to be addressed for our young women and all women.

Yvonne Ou, MD: There are different challenges at each career stage. In earlier years as a student, I experienced inappropriate comments and behaviors but didn’t have the tools, wherewithal, or power to take a stand. Recently, a survey study published in Ophthalmology1 reported that more than 59% of survey participants experienced sexual harassment. Although most of the harassment occurred in medical school or residency, it also happened at later career stages. Survey participants reported a median of 10 sexual harassment experiences. Since the #MeToo movement has taken hold, it seems that a light has been shone on previously accepted behavior. Women and men should all play a role in shaping a culture that promotes inclusiveness and an environment that is free of harassment. This includes speaking up when we witness inappropriate behavior.

As a mother of young children who started my family on the later side, I can say from firsthand knowledge that the alignment of one’s personal and professional aspirations does not always match perfectly. I have a wonderfully supportive partner, but there are unique biological demands on a mother and later self-imposed (and sometimes societal) demands that the role of mother entails. Of course, none of this is new. What is newer are family-friendly policies, but there is still room for improvement.

Oluwatosin Smith, MD: My biggest challenge is juggling the many hats that I wear at work and at home. With all of my competing priorities that are equally important, I sometimes need to work twice as hard as some of my counterparts to accomplish similar goals without letting any aspect suffer. Through this experience, however, I have learned the importance of being efficient, mastering time management, delegating or paying to outsource certain responsibilities, having a dependable support system, finding time for myself, and drawing inspiration from my faith.

Sahar Bedrood, MD, PhD: I wholeheartedly believe that a woman can be an accomplished physician while also being married, having children, and enjoying her family life. I chose to have a child in residency because I didn’t want to stop “living” during that time. I found that the basics of maternity leave and having a newborn were met with significant challenges. I did not have the same rights as a nonphysician or someone out of training. I found myself trying to hide these challenges and normalize them, but I learned that we should not apologize for wanting to have children and lead a normal life. I now talk about my children and my personal life with pride and try to normalize this situation so that other women do not have to feel ashamed or abnormal.

Lama Al-Aswad, MD, MPH: It is hard to distinguish whether challenges faced are related to gender, situation, or a combination of both. Personally, I do not think of it as a binary answer. I think the challenges are multifactorial, and gender can play a small or big role in them.

STUDY IN BRIEF: Gender Differences in Case Volume Among Ophthalmology Residents1

  • Although almost equal numbers of male and female medical students enter into ophthalmology residency programs, whether they have similar surgical experiences during training is unclear. The investigators set out to determine differences in cataract surgery volume and total procedural volume between male and female residents during ophthalmology residency.
  • The retrospective, longitudinal analysis of resident case logs from 24 US ophthalmology residency programs spanned July 2005 to June 2017. A total of 1,271 residents were included. Variables analyzed included mean volumes of cataract surgery and total procedures, resident gender, and maternity or paternity leave status.
  • Among the 1,271 residents included in the analysis (815 men and 456 women), being female was associated with performing fewer cataract operations and fewer total procedures. Male residents performed a mean 176.7 cataract operations, and female residents performed a mean 161.7 cataract operations; men performed a mean 509.4 total procedures, and women performed a mean 451.3 procedures. Eighty-five male residents (10.4%) and 71 female residents (15.6%) took parental leave. Male residents who took paternity leave performed a mean 27.5 more cataract operations compared with men who did not take leave, but female residents who took maternity leave performed similar numbers of operations as women who did not take leave. From 2005 to 2017, each additional year was associated with a 5.5 increase in cataract volume and 24.4 increase in total procedural volume. This increase was not different between genders for cataract procedure volume, but it was different for total procedural volume such that the increase in total procedural volume over time for men was greater than that for women.
  • Female residents performed 7.8 to 22.2 fewer cataract operations and 36.0 to 80.2 fewer total procedures compared with their male counterparts from 2005 to 2017. The study authors concluded that this finding warrants further exploration to ensure that residents have equivalent surgical training experiences during residency regardless of gender. They noted that this study included a limited number of residency programs (24 of 119 [20.2%]) and that future research including all ophthalmology residency programs may minimize the selection bias issues present in this study.

1. Gong D, Winn BJ, Beal CJ, et al. Gender differences in case volume among ophthalmology residents [published online July 18, 2019]. JAMA Ophthalmol. doi:10.1001/jamaophthalmol.2019.2427.

2. Would you say that women’s presence on the podium has changed since you entered ophthalmology? What about other areas of leadership?

Dr. Smith: There is more diversity on the podium now than when I first started—not just women but other minority groups. It is a work in progress, not just in ophthalmology but in many professions all over the country. There is definitely an infusion of women into ophthalmic leadership positions as well. Programs to empower and position women in leadership are starting to take root, and we are thankful for the women who have taken these opportunities and done fantastic jobs as role models to the generations behind them. Sometimes we feel we can’t take on the responsibility because of our many other responsibilities, but it helps to see that others have made it work.

Dr. Ou: Even in the past few years, I’ve noticed an increasingly diverse cast of speakers at the podium. But it is far from parity, especially when we consider that 50% of ophthalmology residents are women. It isn’t hard to get women up there. My personal experience in helping to select speakers for our department’s grand rounds has demonstrated that all it takes is attention to the issue. Once our department’s Diversity, Equity, and Inclusion faculty leader brought to our attention the areas of potential improvement in the diversity of our speakers, we were easily able to fill a calendar with outstanding ophthalmologists, clinician-scientists, and vision scientists who happen to be women and underrepresented in medicine. Sometimes all it takes is attention and intention.

Dr. Olivier: We may have women present on the podium, but often it is the same individuals speaking on particular topics. Women need to be encouraged to learn how to communicate at professional events. We also do not yet have a diverse group of women in terms of age and race or ethnicity representing the concerns of women in medicine. The AAO has done a great job in having diversity in its leadership, and the organization is now trying to increase minorities in ophthalmology as well. However, many of the awards are still predominantly given to our male counterparts. That may be a matter of generational groups, as maybe there were not as many senior women qualified for the awards, but there are some individuals who deserve recognition.

When I served as President of Women in Ophthalmology (WIO), I made an effort to convene women leaders from other organizations to discuss how we could increase the presence of women on the podium. Even today, when there is a symposium of young ophthalmologists, many of the presenters and panelists are men. First, we must identify women who are willing to be on the podium, and we must help them prepare so that they are ready when the opportunity arises. Then, we must encourage them to apply or submit abstracts and provide any support needed. Additionally, pharmaceutical companies should not sponsor a program unless it involves a balance of women and men.

Dr. Bedrood: In my experience, the presence of women on the podium has not changed much over the past 5 to 8 years. I still find that the major society meetings are largely run by and represented by men. Although there is, however, a more concerted effort to include women, the numbers are still not representative of the capable, well-trained women in ophthalmology. Organizations such as WIO allow women to connect with one another and to recognize how many accomplished, eloquent women can take the podium and represent their fields in a profound way. These venues will allow people to recognize new faces and hopefully put them on the podium more often. I also think the role of industry is crucial in involving women on the podium and on advisory boards.

Dr. Lim: I first attended the American Glaucoma Society (AGS) meeting in 2001, and I remember seeing that the majority of speakers and attendees were older white men. Now, when I look at the speakership and attendees at AGS, I see diversity of gender and ethnicity.

Dr. Giaconi: It has definitely changed, with more women frequently on the podium since my first meetings. These days, I don’t think it goes unnoticed if a speaker panel is homogeneous in any way (all male, all female, all one ethnicity). However, having been on program planning committees, we have sometimes gotten stuck thinking of women to speak on certain topics—either the committee hasn’t been aware of women with expertise in an area, or it isn’t apparent that there are women doing research on certain topics. But, since I’ve been in ophthalmology, there have always been strong female leaders, such as Anne L. Coleman, MD; Ruth D. Williams, MD; Cynthia A. Bradford, MD; Tamara R. Fountain, MD; Cynthia Mattox, MD; and many others involved with the AAO and AGS.

Dr. Salim: First of all, the overall number of women in medicine is increasing. According to statistics reported by the Association of American Medical Colleges, women comprised 50.7% of the entering medical school classes in 2017. In 2018, the majority of applicants and first-year enrollees for medical schools were women. Approximately 22% of AAO members and 44% of trainees are women. These changes in demographics will continue to be reflected on the podium. Additionally, as women acquire more leadership roles, their presence and visibility will continue to increase. Women in leadership positions should extend opportunities to other women. Having organized many national and international meetings, I believe it is very important for a program chair to maintain a good balance among speakers to ensure the success of a meeting in terms of gender distribution and representation of speakers from different career stages, different geographic locations, and academic institutions and private practices.

Dr. Williams: Most important, a woman at the podium is no longer token, but often there are several women who were chosen for their expertise. Organizations are more thoughtful about creating balance at the podium. For example, the AGS program committee is encouraged to include women in each symposium if possible. It is important to invite younger and less experienced speakers, both male and female, to the podium because there is only one way to learn the craft of giving a great talk. As each presenter tends to say the same thing over and over, it is great for our profession to hear from new and diverse voices. At every meeting I attend, I am impressed by the poise, crisp delivery, and gravitas of an ophthalmologist I’ve never met before. What a trove of talent we have and get to discover only if we broaden our ideas of whom to invite.

Dr. Al-Aswad: I agree that the era of the token woman on the podium is gone. Today, merit dictates the presence of women on the podium.

3. What is the role of mentorship in a woman’s career journey?

Dr. Smith: Everyone needs an individual—male or female—whom they can look to for direction or sound counsel. I have found it helpful to have in my career, and it may be valuable to have more than one perspective. Knowing your life goals and finding the right person or persons to advocate for you or guide you is wise. However, in order to make the right choices, you must first acknowledge who you want to be. We do not all share the same career goals, so it is important to have a general idea of who you are or who you want to be in the future.

Dr. Salim: Mentorship is crucial for both men and women. Clearly, one has to be knowledgeable, skilled, and ambitious to be successful, and the ultimate responsibility lies with the individual. The journey can be facilitated with appropriate guidance and constructive feedback provided by a mentor. A sincere mentor can offer opportunities for visibility, through which the mentee can manifest his or her talents in terms of writing, speaking, and developing organizational or leadership skills. Not everyone is fortunate enough to have a mentor; however, it is still possible to succeed with a strong work ethic, passion, and commitment. It just takes time, patience, and resilience.

I would also say that both men and women make excellent mentors. Although there is a perception that women frequently mentor other women and are more supportive than men, that is not always the case. I believe that many men welcome and value the opportunity to mentor women. They may also provide a different perspective and strategy for a successful career path.

Dr. Al-Aswad: It is very important to have mentorship throughout the individual’s career, but that is not specific to women. Both men and women need mentorship. The difference is that men have more access and at an earlier stage of their careers than women.

Dr. Williams: Most of my mentors have been men, simply because there weren’t a lot of women around when I was starting out. There are a couple of women who have mentored me—not because I knew them well, but because I watched them from afar. If someone else could have a career in ophthalmology, garner the respect of her colleagues, raise multiple children, negotiate marriage with another professional, and become a national leader, then so could I.

Dr. Olivier: Women need all kinds of mentors during their career journeys. Sometimes it is someone older or male or in a different medical specialty or health care position entirely. A mentor must be committed to sustaining another individual’s career. Women must be able to identify the mentors who fit their needs, and future ophthalmologists will have access to many more female role models. We must also recognize that we have gotten to this point because of the women who came before us. It is important to note that mentorship is different from sponsorship. Sponsors can help in trying to promote an individual for a job or position.

Dr. Giaconi: Mentorship is important in every physician’s career, but what is more important in terms of leadership and education is sponsorship. All young physicians need senior people to suggest their name for positions, committees, and speaking engagements—they are not going to be sought out on their own, but they all need a chance to do the job.

Dr. Ou: Mentorship and sponsorship are of supreme importance. Many of my mentors have been men, and they have been truly supportive and have helped me learn how to advocate for myself. Over the years, I’ve learned to seek out many different people who played important roles in my career development, and no single person will be the mentor who can help with all facets of career and life. Peer mentoring has also been extremely valuable, as there is nothing like being able to learn from one another’s life experiences while you are in the trenches together.

Dr. Bedrood: Mentorship is critical in fostering new relationships and helping women help other women. Mentorship allows people with experience and power to inspire and bring other women to the table. Mentorship is about inspiration and empowerment. It is a way to hand off the baton to the next generation and truly emphasize the importance of reaching out and lifting other women up.

Dr. Lim: Women can mentor by example. Women can mentor proactively by talking about their work-life balance. Women can mentor by having special gatherings such as a well-being dinner, serving as research mentors, or serving as residency or fellowship mentors.

4. What can male colleagues do to help minimize the gender gap?

Dr. Lim: Keep an open mind.

Dr. Olivier: Help when someone asks for support. This is why WIO was founded, to offer a greater opportunity for mutual support. Men can also give credit where credit is due. It is not uncommon that a woman suggests an idea but a man receives the credit. We need all sorts of champions. Recently, there was a study (on which Dr. Al-Aswad was a coauthor) of the differences in the number of surgeries performed by male and female residents (see Study in Brief, page 41). Program directors and chairs need to watch for these factors. We also need individuals in academic medicine to ensure that promotions are given when deserved, regardless of gender.

Dr. Giaconi: I think many male colleagues are sensitive to the gender gap and try to help their female and underrepresented minority colleagues advance their careers. Organizations and male leaders need to remain cognizant of their own biases and establish target goals for diversity.

Dr. Williams: Closing the gender gap requires commitment from leadership, and that leadership is often still male. In June, Francis Collins, MD, the Director of the National Institutes of Health (NIH), posted a letter on the NIH website entitled, “Time to End the Manel Tradition.” Manels—all scientific male panels—have come under fire and even get called out on social media with their own hashtag. Dr. Collins announced that he will participate in a scientific program only if it includes women and participants from other underrepresented groups. Following Dr. Collins’ lead, George A. Williams, MD, a well-known retina specialist and current AAO President, also pledged to participate only in scientific panels that include women. This is leadership! It is just one example, but it is practical and implementable.

Dr. Smith: Over the years, I have had many male colleagues who have helped me to be my best self by being collegiate, fair, and open-minded—and I applaud them for it. I think these characteristics, as well as a conscious effort to put equal opportunity on the table every time a need arises, would be helpful. Some of my greatest recognitions and recommendations have come from my male colleagues and mentors.

Dr. Salim: Most leadership positions are still held by our male colleagues. Some have been progressive and supportive of women throughout their careers. Others are beginning to understand and acknowledge these issues as their daughters enter medical school, residency, or the workforce. I am also noticing that women are being more proactive and seeking advice and opportunities from male colleagues. As I mentioned earlier, given the trends in demographics with the increased number of women in medicine, these changes are inevitable.

Dr. Bedrood: Male colleagues have a huge role to play. They first need to recognize the demographics of the department, podium panels, or anything else they put together, and they should deliberately make sure they include well-qualified women. I assure you: They exist!

Dr. Al-Aswad: I think the responsibility falls on both men and women. In my opinion, men need to promote and support women, and women need to evaluate and address their shortcomings to decrease the gender gap, too. For example, women have difficulty negotiating. Negotiation training is crucial to decreasing the gender gap in pay.

Dr. Ou: I believe men should play a major role in partnering with women to minimize the gender gap. As Dr. Williams noted, one simple move that men in leadership positions can make is to follow the lead of Dr. Collins and refrain from participating on manels. I hope that men can also become our partners and nominate well-qualified women for leadership positions and awards.

5. Do you think there will be a time in the future—even if that future is 100 years from now—when there won’t be a need to discuss differences between men and women in the field of medicine?

Dr. Smith: Men and women will always be different in the way they approach, discuss, understand, and address issues. In the future, I envision a time when the disparity in wages, promotion, and representation would be corrected to a point where it does not need active discussion. The fact that there are more women enrolling in medical school and entering ophthalmology may help even the playing field, but a concerted effort to reduce the gap by empowering subsequent generations, crafting and enforcing labor laws, and engaging our colleagues will make a difference. Hopefully there will come a time when this will be like a woman’s right to vote—the norm.

Dr. Giaconi: That time won’t come unless our culture drastically changes. On second thought, it might change in a generation or two. With more and more mothers working full time and fathers staying home with children, boys and girls are being brought up with a different view of the world.

Dr. Lim: As a mother of a boy and a girl, I see innate differences in gender that will not change in the foreseeable future. However, the economics of medicine may change, and this could influence the proportion of men and women in our field. Veterinary medicine is a prime example of this. The average salary of a US veterinarian is so low that it is considered a second-income profession. Thus, some veterinary school classes are 90% women because men want to choose a profession that pays better.

Dr. Al-Aswad: I do think that time will come, as things have changed a lot in the past few decades since the feminist movement. The question is, could the pendulum swing so far that we must start discussing gender difference to support men? In reality, both men and women should have the ability to choose their career paths and their priorities without judgment.

Dr. Olivier: We will get there one day, just like we hope to achieve health equity and eliminate all disparities and racism!

Dr. Bedrood: Yes, but the sad part is, it may actually be 100 years in the future. Women got voting rights in 1920, and now we are approaching 2020 and still discussing gender inequality.

Dr. Williams: The next two AAO Presidents are women (Drs. Coleman and Fountain). When we have had several women in a row, then it becomes much less relevant whether it is a man or a woman. Then, when we can quit talking about the differences between men and women, we can talk about a much more interesting topic: the differences between people. We are individually gifted and diverse. I imagine a future where each ophthalmologist can craft a career that fits his/her/their talents and aspirations. Our male colleagues might be free to leave work early to pick up their kids—such a wonderful task!—and our female colleagues may be free to be as aggressive and ambitious as they wish. Our profession is best served when all its people are empowered to craft a meaningful career.

1. Cabrera MT, Enyedi LB, Ding L, MacDonald SM. Sexual harassment in ophthalmology: a survey study. Ophthalmology. 2019;126(1):172-174.

2. Reddy AK, Bounds GW, Bakri SJ. Differences in clinical activity and Medicare payments for female vs male ophthalmologists. JAMA Ophthalmol. 2017;135(3):205-213.

3. Salim S, Christmann LM. Medicare billing and reimbursement differ for women and men in ophthalmology. JAMA. 2017;135(9):1005-1006.

4. Reddy AK, Bounds GW, Bakri SJ. Representation of women with industry ties in ophthalmology. JAMA Ophthalmol. 2016;134(6):636-643.

author
Lama Al-Aswad, MD, MPH
  • Professor of Ophthalmology; Vice Chair of Innovations; Director of Teleophthalmology, Artifical Intelligence, and Innovations; and Codirector of the Glaucoma Fellowship, NYU Langone Health, New York
  • lama.al-aswad@nyulangone.org
author
Sahar Bedrood, MD, PhD
  • Glaucoma and Cataract Surgeon, Acuity Eye Group, Los Angeles
  • Assistant Clinical Professor of Ophthalmology, USC Roski Eye Institute, Los Angeles, California
  • saharbedrood@gmail.com
author
JoAnn Giaconi, MD
  • Health Sciences Associate Professor of Ophthalmology, Jules Stein Eye Institute, David Geffen School of Medicine, University of California, Los Angeles
  • giaconi@jsei.ucla.edu
author
Michele C. Lim, MD
  • Professor of Ophthalmology and Vice Chair and Medical Director, UC Davis Eye Center, Sacramento
  • mclim@ucdavis.edu
author
Mildred M.G. Olivier, MD
  • Professor of Surgery, Assistant Dean for Diversity, and Director of Global Health for the Chicago Medical School/Rosalind Franklin University of Medicine and Science
  • Glaucoma Specialist, Midwest Glaucoma Center PC, Hoffman Estates, Illinois
  • molivier@midwestglaucoma.com
author
Yvonne Ou, MD
  • Associate Professor of Ophthalmology, University of California, San Francisco
  • yvonne.ou@ucsf.edu
author
Sarwat Salim, MD, FACS
  • Professor of Ophthalmology, Vice Chair of Clinical and Academic Affairs, and Director of the Glaucoma Service at Tufts University School of Medicine, Boston
  • ssalim@tuftsmedicalcenter.org
author
Oluwatosin Smith, MD
  • Partner Physician, Glaucoma Associates of Texas, Dallas
  • Assistant Professor of Ophthalmology at UT Southwestern Medical Center, Dallas
  • tsmith@glaucomaassociates.com
author
Ruth D. Williams, MD
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