Trends in Leadership and Award Recognition Among Women in the American Society of Retina Specialists

Abstract

Purpose:

This work evaluates trends in achievement of women in the retina field, through an analysis of gender representation in the American Society of Retina Specialists (ASRS).

Methods:

This retrospective, longitudinal study spans 1983 to 2020. Historical data classified by male or female gender were collected from ASRS's overall membership, board of directors and officers, and recipients of the 4 society awards. The proportion of each benchmark held by women was compared with prior decades since the founding of ASRS using the Fisher’s exact test.

Results:

Women’s representation increased from 11% of ASRS members in 2007 to 19.7% in 2020. From 2010 to 2019, women received a higher proportion of society awards (21.1%) compared with membership prior to the start of that decade. In 2020, women were proportionally well represented in board of director positions (21.9%) and held a significantly higher proportion of board positions than in the period 1983 to 1989 (P = .02). From 1983 to 2020, women held 4.3% (1 of 23) of presidencies.

Conclusions:

Although the number of women in retina is increasing, women remain underrepresented in the leadership of ASRS. Interventions to increase exposure to female mentorship and improve childcare benefits are warranted to engage female ophthalmology trainees in retina and ultimately society leadership.

Introduction

In 2019, women composed almost half (41.2%) of residents pursuing training in ophthalmology. ¹ However, this near parity in training has not yet translated to a similar representation of women in journal productivity nor in senior academic positions. Women compose 36.8% of basic science ophthalmology journal authorship, 33% of academic full-time faculty, 28% of ophthalmology residency program directors, and only 10% of department chairs. ^{2 -5} In addition, women are less likely to be recipients of major grants for research in ophthalmology, with only 25% of grantees of career-development awards (K awards) being women. ⁶ An even smaller proportion of ophthalmologists who receive industry payments for speaking, consulting, and research contributions are women (14.6%). ⁷ With research productivity as a known contributor to career advancement in medicine, ⁸ this pattern in research funding is of particular concern. Among ophthalmology subspecialties, retina attracts the smallest percentage of women. ⁹ Given these trends, we aim to explore the representation of women in overall membership, leadership positions, and award recognition within the American Society of Retina Specialists (ASRS) over the past 4 decades.

In addition, we seek to identify targeted interventions to improve gender parity in the field of retina. To the best of our knowledge, no prior studies have explored differences in patient outcomes or satisfaction for retina specialists who are women vs men. However, patients of women hospitalists have been shown to have statistically significant lower rates of mortality and readmission than those of their male counterparts. ¹⁰ Across multiple specialties, women physicians more frequently use patient-centered communication techniques, spend more time with their patients in an average clinic visit, and exhibit more empathy in patient encounters. ^11,12 With these patterns in other specialties, retina patients would likely benefit from increased representation of women practitioners as well. In fact, female vitreoretinal surgeons have been shown to have a faster learning curve than their male peers in training for retinal detachment surgery. ¹³ Thus, while this work focused on the representation of women in retina society membership, leadership, and achievement, we also want to acknowledge the many potential benefits of an increasing proportion of women in the specialty at large.

Methods

Study Design and Data Sources

This is a longitudinal, retrospective study to assess the representation of women in society membership, board of director and president positions, and award recognition within the retina subspecialty. We used national membership data from ASRS, the largest retina organization in the world. With data spanning 1983 to 2020, these records included both publicly available data on ASRS.org as well as archived data generously provided by ASRS management. Current society membership and trainee data, as well as historical board of directors data, were provided through email communication with Chayal Patel, the member communications manager for ASRS. The proportion of overall membership of women in ASRS for 1984, 2007, and 2018 was found via online review. ¹⁴

The primary outcomes were representation of women on the ASRS board of directors, representation of women in the role of ASRS president, and recognition of women with societal awards. Representation of women on the board was measured across the following decades: 1983 to 1989, 1990 to 1999, 2000 to 2009, 2010 to 2019, and the year 2020. Award recognition was quantified through the 4 major awards presented by ASRS, including the Gertrude B. Pyron Award and the ASRS Founders Award, both of which recognize contribution to knowledge in the retina field; the Early Career Section Crystal Apple Award for outstanding mentorship; and the Presidents’ Young Investigator Award for original research.

Secondary outcomes included the proportional representation of women as award recipients across each decade since an award’s founding, which was determined by comparing women's representation at each individual ASRS award with that of overall membership. In addition, using the program directory listing in the 2020 to 2021 SF Match application portal (https://sfmatch.org), we calculated the proportion of medical and surgical retina fellowship director positions held by women in the United States and Canada. To assess trends in publication, we determined the number of journal articles in PubMed returned from a search of the terms women, representation, and ophthalmology. The percentage increase in publication rate on these topics was quantified for the period from 2011 to 2020 relative to the preceding decade, 2001 to 2010.

Statistical Analysis

Leadership representation of women in retina was assessed by calculating the proportion of board of director positions held by ASRS members who identified as female in each year. In addition to presenting leadership data over individual years, results were averaged over each decade since the society’s founding to convey larger scale trends. The percentage of president positions held by women between 1983 and 2020 was also determined. Given the small sample sizes, the Fisher’s exact test was used to analyze trends in representation for board positions and awards across consecutive decades. A P value of less than .05 was considered statistically significant. Statistical analysis was conducted using RStudio version 1.2.5033 (RStudio, PBC).

Results

Overall Membership

In 2020, membership of women made up 19.8% of the total society (397 of 2009 members who identified their gender) (email communication with ASRS, January 27, 2020). This was an increase from 17% of ASRS members in 2018. ¹⁴ In 2007, women composed 11% of society membership, compared with just 1.5% in 1984 when the first female members joined. ¹⁴

Fellowship Membership

In 2020, women composed 30.5% (94 of 308) of the fellow-in-training membership category, which includes members who are currently training in a 1- or 2-year vitreoretinal fellowship program (2019-2020) (email communication with ASRS, January 27, 2020). This was slightly less than the 33% of fellow-in-training members who identified as women in 2018. ¹⁴ Outside of these few statistics that were presented in Women in Retina (WinR) anniversary articles, historical gender data for fellow-level and traditional membership were not available. Membership lists or induction ceremony programs from prior years were not found in an extensive online search, nor were they available from ASRS administrative staff.

Board of Directors

A woman, Dr Julia Haller, was first elected to the ASRS board of directors to serve for the period of 1997 to 1998, roughly 14 years after the society’s founding. In the years that followed, there has been a consistent increase in representation of female members on the board, with a sharp rise over the past 2 decades (Table 1). Women held no board positions from 1983 to 1989 and 2.0% of board positions from 1990 to 1999 (P > .99). However, the proportion of ASRS board membership held by women significantly increased from 4.7% in 2000 to 2009 compared with 13.3% in 2010 to 2019 (P < .01). In 2020, women represented 21.9% of board positions, continuing the trend of increase in representation (P = .3) relative to the prior decade (Figure 1). Further, women held a significantly larger proportion of board positions in 2020 relative to the period 1983 to 1989 (P = .02).

Table 1.

Female Representation on the American Society of Retina Specialists Board of Directors by Year, 1983 to 2020.

Year	Women on board	Board total	% Female
1983	0	2	0.0
1984	0	1	0.0
1985	0	3	0.0
1986	0	4	0.0
1987-1988	0	6	0.0
1989-1990	0	8	0.0
1991-1992	0	15	0.0
1993-1994	0	16	0.0
1995-1996	0	17	0.0
1997-1998	1	21	4.8
1999-2000	1	22	4.5
2001-2002	1	29	3.4
2003-2004	2	32	6.3
2005-2006	1	30	3.3
2007-2008	1	30	3.3
2009-2010	2	27	7.4
2011-2012	1	24	4.2
2013-2014	3	28	10.7
2015-2016	3	29	10.3
2017	4	31	12.9
2018	6	32	18.8
2019	8	32	25.0
2020	7	32	21.9

Figure 1.

Although the American Society of Retina Specialists (ASRS) was founded in 1982, the first board of directors began its service in 1983.

President and Other High-Ranking Officer Positions

There have been 23 ASRS presidents, the highest level of leadership in the organization, from 1983 to 2020. During this time, only 1 (4.3%) female retina specialist, Dr Haller, has served as president of the ASRS. She led the organization from 2007 to 2008. Between 1983 to 2008, the roles of president, vice president, treasurer, and secretary composed the officer directors. In that time, 3 of the 53 positions (5.6%) were held by a woman—namely, when Dr Haller served as secretary (2001-2002), vice president (2005-2006), and president (2007-2008). In 2009, the position of vice president was discontinued and a new board position, program chair, was created. From 2009 to 2020, 2 of 32 members (6.3%) serving in the role of president, treasurer, secretary, or program chair were women. Specifically, Dr Judy Kim served as secretary in 2018 and treasurer in 2019. Thus, in the history of ASRS, 2 women have occupied high-ranking officer positions.

Recognition With Societal Awards

In the past 3 decades, female members have increasingly been recognized with each of the 4 major ASRS awards (Figure 2). The Gertrude B. Pyron Award was founded in 1995, followed by the Founders Award in 1997, Early Career Section Crystal Apple Award in 1999, and the Presidents' Young Investigator Award more recently in 2014. From 2010 to 2019, women earned 9.1% of Early Career Section Crystal Apple Awards, 16.7% of Presidents’ Young Investigator Awards, 20.0% of Founders Awards, and 36.4% of Gertrude B. Pyron Awards.

Figure 2.

The first American Society of Retina Specialists award was founded in 1995.

Notably, there has been a large increase in women award recipients over the decades since the Gertrude B. Pyron Award (0.0% to 36.4%, P = .2) and Founders Award (0.0% to 20.0%, P > .99) were each founded. Conversely, there was a slight decrease in women award recipients for the Early Career Section Crystal Apple Award from 2010 to 2019 relative to 2000 to 2009 (9.1% from 11.1%, respectively; P > .99). In the 2020 to 2021 application cycle, women made up 18.9% (23 of 122) of medical and surgical retina fellowship program directors in the United States and Canada. While many Crystal Apple Awards have historically recognized retina fellowship directors, women were not as well represented in these award recipients as they were in overall fellowship director positions.

When considering all awards presented since each award’s founding, women have made up a higher proportion of Gertrude B. Pyron Award recipients (18.5%) than Presidents’ Young Investigator Award (16.7%), Founders Award (12.5%), or Early Career Section Crystal Apple Award recipients (9.5%) (P = .8). However, with the small sample sizes, these differences of proportions in women recipients across decades and between awards were not statistically significant. Women earned 21.1% of awards presented by ASRS from 2010 to 2019 and 14.1% of all society awards presented since each award’s founding (Table 2).

Table 2.

Trends in Female Representation in Award Recognition in the American Society of Retina Specialists by Decade, 1995 to 2019.

	Female	Total	% Female
Society awards, all	11	78	14.10
2010-2019	8	38	21.05
2000-2009	3	30	10.00
1995-1999	0	10	0.00
Distribution by award name
Gertrude D. Pyron award, overall	5	27	18.52
2010-2019	4	11	36.36
2000-2009	1	11	9.09
1995-1999	0	5	0.00
Founders award, overall	3	24	12.50
2010-2019	2	10	20.00
2000-2009	1	10	10.00
1997-1999	0	4	0.00
President’s Young Investigator Award, overall	1	6	16.67
2014-2019	1	6	16.67
Early Career Section Crystal Apple Award, overall	2	21	9.52
2010-2019	1	11	9.09
2000-2009	1	9	11.11
1999	0	1	0.00

Conclusions

Historically, women in ophthalmology have experienced less representation in senior academic positions, residency program and department leadership, and receipt of grants for academic research. ^{3 -6} Certain aspects of clinical training, including medical school admissions, ophthalmology residency programs, and some ophthalmology subspecialty fellowships, have achieved or are nearing gender parity. ^9,15,16 This trend has also translated to parity in instructor and assistant professor ranks within ophthalmology. ¹⁷ Although representation of women has improved over time in early levels of training, the gender disparity in senior positions has persisted despite the narrowing gap in representation for trainees and young ophthalmologists.

We undertook this analysis to determine whether women in retina were proportionally at parity with men in society membership, rate of appointment to board positions and the ASRS presidency, and recognition through several ASRS awards. Of the multiple retina societies that exist, we investigated the representation of women within ASRS because it is the largest retina society and has a fellowship membership category for trainees. In addition, general membership, as opposed to membership in the Macula Society or Retina Society, requires only completion of fellowship rather than an application process that considers publications, grants, and other metrics of career advancement previously shown to have elements of gender disparity.

Women have made strides in ASRS between 1983 and 2020. Whereas women made up only 11% of membership in ASRS in 2007, this increased to 19.7% of membership in 2020 (email communication with ASRS, January 27, 2020). ^9,14 ASRS does not have historical data of members' gender identity for years prior to 2020, outside of those years referenced earlier in an anniversary WinR publication. Between 2010 and 2019, women held 13.3% of positions on the board of directors and received 21.1% of ASRS awards. That pattern suggested that award recognition of women approximated or even exceeded membership during the decade. When considering that women represented 21.9% of board of director positions in 2020, it is notable that these women were likely to have completed fellowship and had joined the organization at least a decade prior, when women made up closer to 11% of membership. This suggested women were taking on more board leadership roles than can be explained by an increase in membership alone. A similar trend was present in overall receipt of society awards during that time.

The increasing representation of women in ASRS membership, leadership, and award achievement is likely due to multiple contributing factors. First, there has been a growing awareness of gender disparities in the field, as evidenced by a 950% increase in the publication rate on this topic when comparing the decades 2011 to 2020 vs 2001 to 2010. Second, there is an increasing percentage of women members in ASRS as more women enter the field, translating to greater involvement in leadership positions and award recognition for contributions. Finally, the WinR community provides women a horizontal and vertical support network for career progression, made possible through invested mentorship by men and women retina specialists.

The highest level of leadership in ASRS is the society president. Between 1983 and 2020, only 1 woman, Dr Haller, has served in this position, representing 4.3% of the 23 presidents. A few members of the board of directors (28.1%, or 9 of 32 total positions in 2021) also served on the society executive committee, which oversees business operations for ASRS, holds monthly meetings as opposed to the board’s 2 meetings per year, and has the power to call special meetings of the board. ^{18 -20} In 2021, 1 of these 9 executive committee members (11.1%) is a woman. ²⁰ Although the executive committee holds significant voting and decision-making ability, ASRS does not have historical data on its committee membership. Thus, there are not enough data available to understand parity at the most prestigious levels of the society.

A comparative evaluation of the ophthalmology subspecialties has shown that women are least represented in the retina subspecialty, where women make up 19% of the field, as opposed to 26% of specialists in oculoplastics, 29% in cornea, 34% in glaucoma, and 47% in pediatric ophthalmology. ⁹ Our data illustrate that women have made significant achievements in the retina subspecialty and that our male colleagues continue to support gender equity in leadership and award levels. Dr Charles L. Schepens, for example, trained the first woman retina surgeon, Dr Alice McPherson. ¹⁴

We would like to take this opportunity to recognize a few of the other giants in the field who are women, including Dr Haller, the only ASRS woman president. Dr Haller, along with Drs Nancy Holekamp, Alice Lyon, Pauline Merrill, and Jennifer Lim, founded the WinR organization in 2007. ²¹ WinR provides mentorship to young women retina specialists, financial support for fellow trainees to present at conferences, and community events at national meetings. ²² However, there remains a disproportionately low number of female providers within and entering retina, suggesting an important target for intervention.

There is a paucity of formal research examining what deters women from training in retina. One possible reason for this gender gap is the lack of female practitioners in the subspecialty to mentor the next generation of female trainees. Prior work has illustrated the benefits of mentorship to career success in surgical fields—medical students with access to female role models in surgical fields were more likely to pursue those careers as well. ²³ Lower numbers of female attending retina specialists in academic centers complicate this access to female mentors and necessitate the role of male professionals in mentoring female and male trainees. ²⁴ In addition, women may gain less exposure to retina through disparate resident training experiences within ophthalmology. Data show that female residents complete fewer surgical cases than their male peers in the same training programs. ²⁵ These areas offer continued opportunity for senior male and female retina specialists to engage in mentorship of trainees, with earlier introduction to the subspecialty likely to attract more women to training. ²⁶

Both the ASRS Gertrude D. Pyron Award and Presidents’ Young Investigator Award honor retina specialists for their scientific contributions. However, women have been less represented in receipt of the Early Career Section Crystal Apple Award for teaching and mentorship as well as the Founders Award, a prestigious annual honor recognizing 1 retina specialist for advancement of the field. Women making up the smallest proportion of Early Career Section Crystal Apple Award recipients relative to the other ASRS awards suggests that women are being less recognized for their mentorship efforts. Toward this point, women make up a larger proportion of retina fellowship program directors than of Crystal Apple Award recipients, which is notable because many Crystal Apple Awards honor fellowship directors. Ultimately, mentorship is a key step in and opportunity for increased representation of women in the retina subspecialty.

For women planning to bear children, the constraints of their biological clock and disproportionate responsibility for the time-consuming nature of childcare may shape the decision to pursue retina. Demands specific to the retina subspecialty that can complicate childcare include the challenging call schedule, length of fellowship training, and frequency of emergency surgery. ⁹ However, recent phenomena are improving predictability in the field. For example, surgery for macula-involving retinal detachments is becoming less emergent, and the trend toward large, retina-only practices reduces the frequency of call. ²⁷ In addition, with increased subspecializing in medicine as a whole, ²⁸ the decision to pursue a 2-year fellowship is becoming less of an exception. Continued efforts toward parity should improve parental leave policies and childcare support or benefits for women in retina.

This investigation is not without limitations. The 2020 proportion of female members and annual board of director identities since the society’s founding were shared by direct email communication with the ASRS administrative staff. Gender identity has not been historically recorded with ASRS membership registration. Therefore, membership records do not provide detailed data on representation of women within the society at large. Currently, the gender field on membership registration is optional, which further complicates the understanding of parity. A total of 213 active members did not disclose their gender on registration and were excluded from our 2020 membership calculations for gender representation. Logging membership gender annually and regularly presenting these data in the future would be a helpful metric and intervention for ASRS to better assess parity.

In the case of awards and board of director seats, we, supplemented with biographies and online photographs, have individually assessed and verified the gender of each retina specialist recognized through these honors. However, there was the potential for misclassification of gender for members who have transitioned or are gender nonconforming. In addition, there was an absence of data collected on transgender, nonbinary, and genderqueer ASRS members, award winners, board of director members, and presidents. To better understand the disparities that exist across the gender spectrum, it is critical that gender data be collected in a nonbinary fashion. Finally, we would like to point out that the ASRS application does not distinguish whether a physician is a medical or surgical retina specialist. As these subspecialties have different fellowship lengths and clinical practices, they could see significant differences in representation of women.

Through this research, we have found that women have been increasingly represented in ASRS over the past 4 decades. What is more, female members are earning the society awards and serving on the board of directors at proportions higher than what would be expected based on their representation in membership. Disparity remains at the president level, with only 1 woman serving in this highest leadership position of the society since its founding in 1982. Once women enter the retina field, they make significant contributions. However, a continuing need exists for supporting women to consider and pursue the retina specialty.