Gender-related differences in the career of Austrian intramural ophthalmologists

During the past decade the proportion of women in medicine has increased significantly. Today women account for over 50% of enrolled medical students [1]. Moreover, more women are entering surgical professions, including ophthalmology, which traditionally have been male-dominated [1‐3]. However, it was shown that while 44.3% of residents were female, this applied to only 22.7% of practicing ophthalmologists, which indicates a leak in the career pipeline of ophthalmologists [4]. As compared to their male colleagues, female surgeons still have increased family responsibilities, especially with regard to childcare and housework [5, 6]. They are more likely to have to take a step back in their career ambitions [7], which probably contributes to the fact that women are still underrepresented in leading roles or on scientific or editorial boards [8].

This survey employed data collected through a self-designed, objective, anonymous questionnaire, which is available as Supplement 1. The first section of the questionnaire included questions about the head of department. The second section dealt with the number of physicians and included gender, educational status, and part-time versus full-time working conditions. The last section included two tables in which the surgical sub-specializations of each surgeon had to be selected, thus differentiating between supervised and unsupervised surgery. It was sent to all the heads of ophthalmology departments in Austria in June 2023 and responses were accepted up to September 2023. We asked for the responses to refer to the situation dated 1 June 2023.

In addition, data on the number and genders of ophthalmologists in hospitals and practices in Austria were requested from the Austrian Medical Chamber. Also, data of the Austrian Ophthalmologic Society were collected, including the gender of the speakers as well as of the award winners at the annual meetings of the last decade.

On 1 June 2023, 1168 ophthalmologists were working in Austria. Austria has 25 ophthalmologic departments, of which six (24%) are affiliated with a university. Of the 25 departments, we received a reply from 23 (92%), of which 22 completed the entire questionnaire, including the tables regarding surgical sub-specializations (88%).

This study analyzes the working profiles and gender-based differences among intramural Austrian ophthalmologists. Across academic medicine and also ophthalmology, women remain underrepresented in leading positions [9]. We report a 24% rate of departmental heads, which is a number comparable to recent data from the United States, which shows women account for 24% of professors [10]. Data from Australia point to a 19% rate of female full professors [11]. Therefore, in proportion to their total numbers, women have clearly not yet advanced to leadership positions [8]. The reason is not that women do not seek leadership positions, as demonstrated by Wright and colleagues [12], but rather a lack of mentorship, inflexible academic timelines, and difficulties in networking and balancing professional and family commitments [2].

In Europe, approximately 50% of physicians identify themselves as female. Within ophthalmology, data from Germany and France show a female percentage of 44%and 43.5%, respectively [13]. Whereas data from other countries such as the United Kingdom and Australia have shown that approximately 30% of consultants are female (compared to 43% of trainees; [13‐15]), this imbalance was not observed in the current study, which points to only an insignificant minority of female consultants. However, data are difficult to compare, as in Austria becoming a consultant is not linked to a specific clinical sub-specialization, but has to be seen as the natural next step after completing a residency while continuing work in the intramural sector.

Studies from Australia have shown that female ophthalmologists work significantly fewer hours per week and, in general, more part-time [2, 16]. Several studies have indicated that female ophthalmologists spend more time on childcare compared with their male colleagues [1, 2, 6, 16]. Conversely, male ophthalmologists spend more time working privately [2]. Despite the noted increase in part-time work for male ophthalmologists, the main reason stated was a personal preference rather than family issues [16]. Accordingly, a survey by The Economist in 2017 reported that as opposed to 13–37% of men, 44–75% of women stated that since becoming parents they had begun to work fewer hours or had switched to a less demanding job [17]. In addition, female ophthalmologists place emphasis on the difficulties posed by the struggle to balance professional and family commitments. An Australian survey has revealed that women are significantly more likely to feel frustrated by the lack of time available to devote to their career. In total, 57% of female respondents reported that they often had to choose between career and family, whereas only 26% of male respondents were faced with the same dilemma [2].

In addition, women criticized unequal career advancement opportunities [6]. In one study, as opposed to 16% of the male respondents, 75% of female respondents stated that having children had slowed their career progression [2]. Our findings showed that in Austria fewer male consultants worked part-time, but the difference was statistically insignificant. Moreover, it should be noted that the questionnaire did not specify the reasons for part-time work (e.g., private practice, research, personal preference, or family obligations). However, according to data from the Austrian Medical Chamber, male ophthalmologists working in (private) practice alongside their hospital career were far more common than female ophthalmologists, suggesting that male ophthalmologists are more likely to spend their time away from the hospital working rather than on other activities (e.g., family commitments).

Despite an increase in numbers during recent years, female ophthalmologists have been shown to publish fewer papers than their male colleagues and to hold less prestigious authorship roles [18]. Scientific publications are known to be important drivers of promotion in medicine [13] and although this study did not evaluate the scientific output of single persons, it indicates that in Austria fewer women have a habilitation degree (not significant) and a PhD degree (significant). At the annual meeting of the Austrian Ophthalmologic Society, the majority of the speakers were male throughout the last decade. This can certainly explain why more honorees were male, however, as it has been shown that there is a gender-related difference in scientific funding [19, 20]. We showed that in 2023, for the first time in over ten years, more female chairs were registered, likely because of the efforts of the female president at the time. The impact of female program committee members on gender equality has been pointed out in the past [21].

As compared to consultants, departmental heads showed greater surgical versatility (4.4 ± 1.4 vs. 2.4 ± for 1.5) and most of them performed cataract surgery, vitreoretinal surgery (83%), and glaucoma surgery. Nearly 60% of the ophthalmologists undertook unsupervised surgery, of whom nearly 50% were female. Although surgical diversity was comparable between the genders, it was more common for female surgeons to carry out oculoplastic and strabismus surgery. Conversely, significantly more male surgeons were involved in refractive, cataract, glaucoma, and vitreoretinal surgery. We see these findings as matching the results from past studies, which have previously demonstrated an imbalance towards more male surgeons in surgical retina and refractive/cornea/anterior segment specialties, whereas strabismus surgery is traditionally dominated by female ophthalmologists [1, 16, 22, 23]. One explanation may be that women choose their specialization based on factors such as convenience and family life compatibility [16].

Our results show that among female heads of department, there were significantly more female glaucoma and vitreoretinal surgeons. In addition, more female oculoplastic and cataract surgeons were counted, although the end figure did not reach the statistical significance level. This cannot be explained solely by the idea that female department heads provide female surgeons with increased support, but instead also by the fact that female leaders function as role models [8]. The importance of mentorship has been demonstrated in the past with studies showing that senior authors were more likely to publish with a female first author and that female program directors were more common in departments with female heads [24, 25].

Our data indicate that significantly more male residents received training in cataract and glaucoma surgery, whereas in an analysis of all the ophthalmologists receiving surgical training, irrespective of their training status (resident or consultant), there was no significant difference between the genders. This finding indicates that female ophthalmologists receive surgical training later in their careers, especially in cataract surgery, although there might be other explanations. In line with these data, a study has shown that female trainees reported performing fewer surgical procedures in total and cataract surgery specifically [26]. It has thus been concluded that lower surgical opportunities may result in fewer female trainees selecting surgical sub-specializations [13, 27].

Austrian ophthalmologists working in an intramural setting face a marked gender gap in leadership and surgery. The reasons for this situation can only be the subject of hypothesis and probably include cultural factors [25]. Findings from the current study should encourage us to improve surgical education in Austria and provide women with the same opportunities as men. Initial steps have already been taken, as international ophthalmology training programs have defined strategic goals and targets aimed at gender equality [13]. Efforts have been made to establish network organizations and target the number of female speakers at conferences and on expert panels. Furthermore, mentorship programs have been developed [7]. Encouraging gender diversity and equality will ensure that we employ all the available potential within the workforce to provide healthcare of the highest standard for our patients [7, 13, 28].