Equal Vision Women in Ophthalmology

But that was 20, 30 years ago. With the increasing numbers of women in ophthalmology – and concerted efforts to ensure representation on College committees and speaking platforms – that’s changed, right?

inequality exists with women at a disadvantage at multiple junctures in their professional life

While it would be easy to assume this anecdote was an illustration of a bygone era, sadly, despite the increasing number of women entering ophthalmology, female ophthalmologists still confront an undercurrent of sexism in the workplace.

Dr Tanya Trinh – a specialist in cornea, cataract, and refractive surgery – in a YouTube presentation,¹ recounts the story of being gifted a surgical cap with her name, title and the word ‘ophthalmologist’ emblazoned across the brow after hospital staff assumed she was a student – because they felt she needed it.

Although she recalls mixed initial feelings about the cap, seeing it initially as an unnecessary crutch, she has found that it does help to counter assumptions from patients as well as hospital staff.

“If you had asked me as a registrar, or a fellow – which was me not that long ago – I could always rationalise the mix-up away because I was not the most senior person in the room,” Dr Trinh told mivision. “I never thought too much about how they saw me.

“Now that I am the consultant, and the buck does stop with me, you realise that that isn’t really the reason or a good excuse…you realise that people have such ingrained behaviours of seeing women in specific roles. You realise it is not just because you were junior, and it’s a bit confronting when you become aware of the assumptions underpinning the behaviour.

“I have since learned that being a minority woman – something I was quite insensitive to before, as it was never quite forefront in my mind as part of my core identity… many women in nursing, technician, orthoptic, surgical scrub, and scouting roles, are women of colour. And because I am a woman of colour, I have noticed that it is easier to associate me with being any other role than the consultant first and foremost. It has been a really interesting lesson on ingrained human bias.”

Backed By Data

Beyond anecdote, the empirical evidence is startling. Globally, approximately 25–30% of ophthalmologists, and 35–45% of trainees, are women.

“Nevertheless, women remain under-represented in key areas, including positions of professional and academic leadership and ophthalmic surgical subspecialisation,” a ground-breaking study by New Zealand’s Professor Helen Danesh-Meyer, from the University of Auckland, and colleagues concluded.²

The study found “inequality exists, with women at a disadvantage at multiple junctures in their professional life”.

“… there is evidence that women in ophthalmology encounter more bias and discrimination across multiple domains than men, including a gender-pay gap that is wider than in many other surgical subspecialties. Women ophthalmologists and trainees report sharply differing training experiences from male peers, including fewer opportunities to operate, more bullying and harassment, less access to mentorship, and contrasting expectations around contributions to family life,” the study authors said.

“One of the things, being a scientist, is that it is important to bring evidence,” Prof Danesh-Meyer told mivision. “In ophthalmology, while we are doing better than some, we are really still not at gender parity.

“The review basically showed we are improving but the rates of improvement are variable, and some areas remain frustratingly behind other areas.”

It is a sentiment echoed more recently by Dr Grace Sun, the President of the United States Women in Ophthalmology (WIO). In a public letter on the WIO website she lamented that while women were “in the room… those rooms continue to be overwhelmingly led by men”.³

Representation Targets

One of the key metrics set by The Royal Australian and New Zealand College of Ophthalmologists (RANZCO) in its Women in Ophthalmology Strategic Plan is to ensure at least 35% female representation on College committees.

It is a milestone that has been all but met, with female representation on Committees at 33% in 2022–21 and 34.9% in 2021–22.⁴

RANZCO has also worked to promote the visibility of women on speaker platforms, providing a Speakers’ Bureau of female ophthalmologists at all career stages. In addition, a RANZCO WIO ‘tick’ of approval is available for events that meet or exceed the target of 35% female representation.⁵

“The numbers are indicative of change, and the fact that we have almost reached the representation target in a relatively short space of time is a real achievement,” former RANZCO Director Dr Catherine Green AO told mivision.

“We should now be aiming higher, so the ongoing commitment to diversity must remain an important part of the strategy of the College going forward.

“The genesis of this was back in 2015. There was a lot of publicity around bullying and harassment in surgery generally… but there was a sense of disbelief among male ophthalmologists that this was a problem in our profession,” said Dr Green, who is head of the Glaucoma Unit at the Royal Victorian Eye and Ear Hospital.

She said a survey was conducted and “our results were not that dissimilar”.

“We went from a situation where ‘There is no problem’ to ‘oh, actually there is a problem’ and then quantifying it and… offering some solutions. One of those solutions was to have diversity targets on all committees and in other aspects as improving diversity has a positive influence on organisational culture.

“The evidence shows that without the targets, change just doesn’t happen,” Dr Green said.

Support In Numbers

Dr Diana Semmonds, a cataract and refractive surgeon, has held positions on numerous RANZCO Boards and Committees. She was elected Vice-President of the organisation in 2016 and is a current member of the Diversity and Inclusion Committee. Dr Semmonds said “the College does well with making sure women are on all their Committees and Boards” and she has welcomed the fact that she is no longer the lone female voice.

“When there is one woman in a group of men… it’s the same as if you are a different ethnicity or just one minority person, it’s often much harder to get your view across. It is very easy for you to be dismissed. I was the lone woman on committees and boards for many, many years. Some time ago, I actively tried to get more women onto these committees and it was, and has been, a great support.

“There will be times when there is a discussion and you will feel that you are putting a somewhat female point of view forward. Having other women on the committee can help to express and support this view. This has been one of the changes that has strengthened the College in more recent times.

“Having said this, the men on these committees are often supportive and amazing,” Dr Semmonds said.

Got To See It To Be It

All of the ophthalmologists who spoke to mivision acknowledged the importance of their male sponsors and mentors but talked of the importance of learning from other women.

Dr Sonia Moorthy, who practises on Queensland’s Sunshine Coast and sits on the RANZCO Ophthalmic Sciences Board of Examiners and Women in Ophthalmology committee group, said women must be able to ask for help, without fear of stigma or embarrassment.

“I was in my third year, and I still felt I needed a lot of help. I rocked up to Lismore and I had someone take me under their wing and that’s what you need. It was a female ophthalmologist who took me under her wing – Dr Lisa Cottee – and I will always be grateful to her for saying ‘it’s okay, just do your best and I will help you along the way’.

“Looking at what I am able to do today compared to what I did then, I never thought I would be here today.”

For others, there were few – if any – females to follow.

“There was definitely a lack of female role models as I was doing my training and coming through,” said Dr Rebecca Stack – a Christchurch-based cataract surgeon with subspecialty interests in oculoplastic orbital and lacrimal surgery.

She nominated Prof Danesh-Meyer as the “epitome” of the successful female New Zealand ophthalmologist. “She was a consultant when I went through and everyone looked up to her and there was a smattering of others, but not many,” Dr Stack said.

Dr Stack said she now “happily” takes on mentorship roles. “I think it is really important. You have got to see what you can become… if you can see someone who is a successful ophthalmologist who can also manage a family and have a successful relationship and also have College positions…if they can juggle all that, then you can see that’s something achievable for you.

“You have got to see it to be it.

“We’ve got a lot more female trainees coming through now and they all come with those questions: How did you decide when to have children? And what did you do about moving around? How do you manage to do all these extra things? How do you fit everything in?”

For her part, Prof Danesh-Meyer tells the story of once turning down a very prominent role overseas because it was made clear that one of the reasons she was a candidate was because she was a woman.

“I got really angry. Why would I want to be in a position where one of the main criteria is that I’m a female? However, now when I look at that, in my older and wiser days (this was 15 years ago) I kind of see their point. If there is a capable woman, then putting her in that position can help the next wave of women. I didn’t see that when I was younger… I didn’t want to be acknowledged for any aspect of being a woman because I thought, if I did, I was undermining the fact that I could do it as well as, you know, one of the guys.”

The Motherhood Penalty

Dr Kerrie Meades, one of the pioneers of laser cataract surgery and founder of PersonalEyes, did her training while the mother of young children, which was “extremely rare”.

“It was the 1980s, there were very few women working (as ophthalmologists), and certainly very few women working full time, and virtually no-one as a registrar with children. I was very conscious of that.

“But I wouldn’t have gone on with the career if I didn’t have children. I was doing it for the children. I was working to give them a better start in life. I needed that motivation to put that much into it.”

She remembers one unsuccessful job application, “I was told I had too many children, and that was by a very senior person in the faculty… it was that era”.

Dr Meades said she encountered resistance in her early career when she sought positions on boards and committees.

“No-one tapped me on the shoulder. To be fair to them, maybe they looked at me and said ‘gosh, she’s got a lot on her plate’. I had two kids and had a third one virtually as soon as I graduated. They didn’t relate to where I was in my life. Certainly, men passed me by, and I wondered why.

“It was easier to step outside and start PersonalEyes, which when I left was one of the largest privately owned Australian ophthalmic companies.”

Dr Moorthy said the pause required when women have children causes “a lot of disruption, especially in microsurgical training… I know this myself because I had a pause of about 18 months from intraocular surgery”.

With young children but no extended family nearby, Dr Moorthy said juggling the demands and family was “challenging”, especially while establishing her independent practice. “Fortunately, I have a husband who now manages the practice and can largely work from home. He has really stepped up and become the domestic director.
I’m fortunate that I have been really supported by him. I couldn’t have done it otherwise.”

Medical retina and cataract surgeon Dr Angela Jennings said changes to the training scheme to make it faster have been beneficial for everybody, but particularly female trainees, who are coming out of training at a younger age.

As the current Managing Director of PersonalEyes, she mentors both men and women “but the flavour of the conversations might be a little bit different”.

“You can have very frank conversations (with women) about those factors that can be really challenging, like trying to balance the needs of a demanding training scheme and career with the desire to have a family and be a good parent.

“I think that in our society, the domestic responsibilities for that still fall unequally on women in many relationships so it can be more of a challenge for females to balance those things.

“I think that is something that is changing…my younger male colleagues have this expectation that they are going to be hands on as a parent and be there for important events. So, I think we’re moving towards more equality in parenting responsibilities.”

Creative Solutions

Having been instrumental in the establishment of the RANZCO representation targets for women, Dr Green said it was “pleasing” they have been met.

Now no longer directly involved in College governance, Dr Green said rather than adopting an attitude of ‘tick, we have done that, it is all ok’, conversations on new goals were needed.

“The fact that we have achieved these targets is pleasing. I still think we should be looking for a target of 50% applicants to our training programs.

“Just over 50% of graduating medical students are women but only about 30–35% of the applicants to our training program are female.

“What are the reasons for it? We need to look at ‘pipeline’ issues and look for opportunities such as mentoring for medical students as well as dispelling myths about selection and training.

“The other issue is the gender pay gap which is still significant in ophthalmology. Even taking into account women may be more likely to work part time, it is still a significant disparity,” Dr Green said.

“Women who are in ophthalmology now have such an opportunity,” said Dr Meades, but they “need to be very brave and assume the power positions”.

“In ophthalmology that means who is selected into the College and I think until they have a grasp of those positions – the positions that change generations – then I don’t think they have made it.”

Dr Trinh said she believed it was necessary for both men and women to change their assumptions around inviting women in ophthalmology into those positions.

“When it comes to women who are juggling multiple roles, we need to give her the power and opportunity to say yes or no… whether this be a committee position, or a panel, or an editorial, or some other opportunity.

“Too often we make the assumption that ‘she’s going to be busy; she’s got three kids; she’s not going to have time for that’. So, this means we don’t even ask them; which means we don’t even give them the opportunity – because we’ve made the decision for her already by our assumptions. They don’t even get the opportunity to decide to sit at the table – because we never even invited them.

The process should be that we actively ask her, and if she wants to do it, let her make that decision. Don’t make the decision for her.”

She said it should also be role-modelled and normalised for men to access paternity leave and take time out for family life. “If men are questioning what it will do to their careers by taking time off for parenting leave, then it means that at some level, they do realise there is some penalty or cost… that women have traditionally been expected to shoulder alone. Sharing that responsibility and role-modelling this for other men is so important.”

And it was crucial, she said, for men to be the other half of the conversation.

“If we’re only having these conversations with other women, then we are not being as effective as we could be. It means we are only trying to enact change within an echo chamber. Men are absolutely crucial. Champions of change need to come from both men and women.

“Some of my most powerful agents of change have been men, because they have been the directors of fellowship programs, key opinion leaders, the gatekeepers… who have recognised the importance of their own roles in role modelling and enacting change. They are the ones who have actively created opportunities for women to have a voice and their needs recognised and supported. This isn’t just a ‘women’s problem’ for women to solve,” Dr Trinh said.

Prof Danesh-Meyer expressed a similar sentiment.

“It is very powerful for women to have male supporters. The male network… is a very powerful endorsement pathway and to see a large group of men wanting to promote dynamic, capable women is going to be very important in changing the statistics.”

But referencing papers that indicate women generally take on more domestic and familial responsibilities, Prof Danesh-Meyer said the base issue for women in ophthalmology was that they were “time poor”.

“We need everyone to keep thinking of creative ways to address that, and I’m not sure we have all the answers at the moment.

Certainly, supporting part time work for women who want to train and continue their family, that is much better now than it was 10 years ago, but we need to continue to find creative ways we can combine all the things that are part of their lives.

“We need everyone to put on their thinking caps to address some of these issues that will help women with the fundamental issue that we are time poor.”

They Said What?

“You got comments like ‘Why did you bother having children, if you weren’t going to bring them up? I did apply for a job… and was told I had too many children…”
Dr Kerrie Meades.

“I was blatantly told that… female graduates weren’t worth the same as a male graduate because they were only ever going to work part time, and it was kind of a waste of money training them, so that was very disheartening.”
Dr Angela Jennings.

“I had a fellow… he’s this tall, commanding-looking man… everyone assumed he was the professor and would turn to him and say, ‘Is she saying the correct thing?’ Even though he was my junior, he had the presence of the way we expect a professor to look.”
Professor Helen Danesh-Meyer.

“Even just six weeks ago, a male patient of mine… I was discharging him after his final post op check and he said, ‘please give my regards to the surgeon’. In surprise I responded, ‘I am your surgeon… and I just operated on both of your eyes!” I’m really not sure who he thought I was the entire time we were invested in this process together.”
Dr Tanya Trinh.

References
1. Trinh, T., In gendered lenses we trust: The quest for clarity, YouTube Presentation, available at: youtube.com/watch?v=HSS7pT7FgIM [accessed 11 May 2023].
2. Gill, H.K., Niederer, R. L., Shriver, E.M. et al., An eye on gender equality: a review of the evolving role and representation of women in ophthalmology, Am J Ophthalmol. 2022 Apr;236:232-240. doi:
10.1016/j.ajo.2021.07.006. Epub 2021 Jul 17. PMID:34283980.
3. Sun, G., President’s message: Our mothers, our daughters, and ourselves, Women in ophthalmology website, available at: wioonline.org/about/ [accessed 9 May 2023].
4. RANZCO Statistics, annual report figures, supplied.
5. RANZCO, Women in Ophthalmology (webpage), available at ranzco.edu/home/about-ranzco-2/wio/ [accessed 16 May 2023].

Raising The Profile

Wanting to raise the profile of regional ophthalmologists generally – and female regional ophthalmologists in particular, Dr Sonia Moorthy – with funding from Bausch and Lomb and in partnership with RANZCO and the Vision 2030 Initiative – is developing a podcast series, to be recorded in coming months. “When you look around, there are not many females in regional Australia. I think you can literally count the number of regional female ophthalmologists on one hand, certainly here in Queensland; it’s not hard to do.” Dr Moorthy anticipates the podcast will be released later this year.