Figure 1. Academic profile of female ophthalmologists, 1969-2009.
Figure 2. Parallel trend between US female physician profile and first author female profile.
Journal Club Slides
Mansour AM, Shields CL, Maalouf FC, et al. Five-decade profile of women in leadership positions at ophthalmic publications. Arch Ophthalmol. 2012;130(11):1441-1446.
Mansour AM, Shields CL, Maalouf FC, Massoud VA, Jurdy L, Mathysen DGP, Jaafar D, Aclimandos W. Five-Decade Profile of Women in Leadership Positions at Ophthalmic Publications. Arch Ophthalmol. 2012;130(11):1441-1446. doi:10.1001/archophthalmol.2012.2300
Author Affiliations: Department of Ophthalmology, American University of Beirut, Rafic Hariri University Hospital, Beirut, Lebanon (Drs Mansour, Maalouf, Massoud, Jurdy, and Jaafar); Ocular Oncology Service, Wills Eye Institute, Thomas Jefferson University, Philadelphia, Pennsylvania (Dr Shields); Department of Ophthalmology, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium (Dr Mathysen); and Department of Ophthalmology, King’s College Hospital, London, England (Dr Aclimandos).
Objective To evaluate the balance between the sexes of published ophthalmic material at the editorial, reviewer, and author levels.
Design Cross-sectional study of 3 journals, American Journal of Ophthalmology, Archives of Ophthalmology, and Ophthalmology, for 1969, 1979, 1989, 1999, and 2009. The data were compared with ophthalmologist-in-training and physician profile in major contributing states from North America and Europe during the same period.
Results Of the 3 major ophthalmology journals, none had a female editor-in-chief. For all journals, the proportion of editorial board members who were women increased from 3.3% in 1969 to 18.8% in 2009. For all journals and all years, women composed a higher proportion of first authors (29.2% in 2009) compared with senior authors (22.9% in 2009), reviewers (18.9% in 2009), or assistant editors (12.5% in 2009). There was an abrupt shift toward women after 1989 in first authorship in Ophthalmology (1969, 4.6%; 1979, 5.4%; 1989, 12.3%; and 1999, 20.2%), Archives of Ophthalmology (1969, 6.6%; 1979, 5.1%; 1989, 15.6%; and 1999, 28.6%), and American Journal of Ophthalmology (1969, 5.6%; 1979, 4.2%; 1989, 9.2%; and 1999, 23.9%). There was also an abrupt increase in female senior authorship for American Journal of Ophthalmology after 1989 (1979, 8.5%; 1989, 8.1%; and 1999, 18.3%). The increase in female first authorship during the 5 decades was parallel with the increase in US female physicians.
Conclusions Women ophthalmologists are authoring publications in increasing numbers that match their prevalence in the academic and overall workforce. However, all editors are men. This discrepancy relates to the relatively younger generation of female ophthalmologists or selection bias, a subject that requires further investigation.
The Russian medical community, including the ophthalmic community, has been largely dominated by women since the Bolshevik revolution.1 Meanwhile, in the developed world, women have lagged behind men in most of the domains of medicine.2- 22 Little has been known about the research productivity of women ophthalmologists.23,24 The aim of the current article is to analyze the role of women in the various processes of publication.6,25- 42 We sought to measure the progress women have made in the last 5 decades in terms of contributing to the knowledge base (authorship) and achieving a reputation as leading contributors or leaders (editors and editorial board members) in the field of ophthalmology. We also explore whether such progress was attributed simply to an increasing number of women in the field.
Three major ophthalmology journals were analyzed for sex research productivity indexes during the past 5 decades. Ophthalmology, Archives of Ophthalmology, and American Journal of Ophthalmology were selected because each ranks high for journal impact factor and readership during the past 50 years. Indexes analyzed included first author, senior author (reprint request author), reviewer, editorial board, assistant to the editor, and editor. Only original articles were included in the current study using the hard-copy version of the journals.
Because the 3 journals under study are international and more than 80% of articles are contributed from North America (nearly half) and Western Europe (nearly one-third)32 (according to a study conducted in 2002), we tried to include data (total physicians, ophthalmologists, and ophthalmologists-in-training) from the countries that have published the most, such as the United States,19,21,31 Germany, France, Australia, Canada, United Kingdom, Japan, Italy, and Sweden.32
Sex was determined by inspection of first name, and for cases in which sex was uncertain, attempts were made to discern the sex through Internet searches using the Google search engine and related sites (genderchecker.com).
We combined the 3 journals' data for each year. Trend analysis was performed using analysis of variance linear regression within the group and Pearson bivariate correlation between groups. Significance was set at the P <.05 level. We used SPSS statistical software, version 19, for statistical calculation (SPSS Inc).
The 3 journals in hard copy had the following entire years screened for original articles: 1969, 1979, 1989, 1999, and 2009. The results are given in Table 1, Table 2, Figure 1, and Figure 2. All categories revealed a significant increase over time (first author, P = .005; senior author, P = .006; reviewer, P = .007; and editorial board, P = .01). Women had low representation in the authorship (first and senior) and reviewer categories for 1969 and 1979 (Figure 1). The rate for lead author almost doubled in 1989 and quadrupled in 1999, and thereafter the increase was modest (Table 1). The rate for reviewer quadrupled in 1989. For example, the journal Ophthalmology revealed 4.6% female first authors in published original reports during 1969, 5.4% in 1979, 12.3% in 1989, 20.2% in 1999, and 26.7% in 2009. In the journal Ophthalmology, women represented 11.3% of all senior authors in 1989, 15.6% in 1999, and 22.8% in 2009. Also in the journal Ophthalmology for 1999 and 2009, women were further less represented in the category of senior author vis-à-vis first author by approximately 4% and in the category of reviewer vis-à-vis first author by approximately 6% to 8%. Most assistant editors (3.4%) and editors (100%) were men.
There was a 10-fold increase between 1969 (3.6%) and 1999 (37.7%) in women enrolled in training in various US ophthalmology programs (Figure 2 and Table 2). In France, the increase was modest from 30.0% in 1979, 40.4% in 1989, 43.1% in 1999, to 43.3% (plateau level) in 2009. There was a similarity in the 2009 proportion of women in the 2 European ophthalmology training programs (43.3% for France and 43.7% for Germany). The ratio of female ophthalmologists to the total number of ophthalmologists increased 4-fold from 1979 to 2009. The proportions of female US physicians paralleled the proportions of first authorship women (Figure 2): 7.6% vs 5.2% in 1969, 16.9% vs 12.7% in 1989, 23.4% vs 23.7% in 1999, and 30.5% vs 29.2% in 2009 with a 4 vs 5.6 times increase during a 50-year period (similar trends existed also for Canadian physicians and PhD degree recipients in the United States).
The number of women in medical fields in the United States has increased during the past 50 years. The reasons for this increase relate to the increased opportunity for education for women, desire for independence and careers, high academic goals, and the slightly reduced drive and focus of young men.6 Besides cultural changes, the women's rights movements and women's health movements, 3 political laws in United States (Civil Rights Act of 1963, Title IX of the Higher Education Act Amendments of 1972, and Public Health Service Act of 1975 banning discrimination on grounds of sex) played a role by increasing the number of women attending US medical schools. During the past 30 years, the proportion of women attending medical schools has steadily risen in the United States and other countries, including the United Kingdom,11,13 Canada,9 and Australia. In 1983, 26.8% of MD degrees in the United States were awarded to women. In 2010, this number increased and women received 8133 (48.3%) of the 16 838 MD degrees awarded in the United States.37 The US medical school enrollment reached almost 50% for women for the academic year 2003-200410 (8528 for women and 8590 for men in their first year of enrollment). Similar trends have been noticed earlier in the UK medical schools, with more female students than male students in 2002-2003.13 It seems that France reached sex parity in ophthalmology residency programs as early as 1989, almost 2 decades earlier than in the United States (Table 2).
This trend partly reflects the increasing success of women applying to medical schools and the general trend in education, with women earning most (50.4%) of the doctoral degrees (PhD) awarded in the United States in 2008-2009 (Table 2) and 60% of master's degrees.38 In 2010, Whitmire35 explored the reasons for the success of women and the downward trend of male interest in academia, particularly at the high school level. This author of Why Boys Fail: Saving Our Sons from an Educational System That's Leaving Them Behind presented in-depth analyses of the finding that 60% of graduating high school students in United States were women, with boys slipping behind girls in math and reading scores. He observed that sex gaps in academic achievement were international and that several countries, including Australia, were ahead of the United States in probing for the causes.
The numbers do not tell the whole story. Most women want the opportunity to have a family, so they require a flexible working schedule, preferably part-time work, and maternity leave.3,4,6,7 Unlike men, women devote a substantial amount of time to families and parenting (“mommy track” as coined by Ann M. Renucci, MD)39 and seek a balance between career and family. Hence, female physicians are more likely than their male colleagues to work part time.12 Fewer women than men choose to work longer hours or hours outside normal times.14 In addition, more women than men convey their plan to retire before 60 years of age, shortening their working life further.13 Compared with men with children, women with children had fewer publications,15 with a resulting gap in female physicians seeking the scientist track.7 In a study of National Institutes of Health grants, sex persisted as an independent significant predictor of R01 award attainment. The reason for the lower rate for women could be either the lower rates of application or lower rates of success in application.30
Women physicians tend to concentrate in a few specialties regarded as “family friendly”16 and tend not to take up specialties, such as general surgery, that could be more time demanding.17 Both issues of pregnancy and childbearing could interfere with the rigid residency programs that include the long hours of surgical training and the highly competitive pyramidal residency systems. In a 2003 study, Blakemore et al33 found that the percentage of all female residents who chose a residency in orthopedics was only 0.6%, a number that has not changed in the past 20 years. Similar trends exist for neurosurgery and thoracic surgery.2,33 According to a survey by Stratton et al,34 many women during their undergraduate surgery rotations had exposure to sex discrimination and sexual harassment, influencing their choice of specialty. Importantly, surgeons with mentors are inclined to publish more, have more career opportunities, and be more confident in their abilities than fellow surgeons without mentors.40 The absence of female mentors in general surgery is an additional factor that perpetuates the low attraction of women to a surgical career.40 In the United States, United Kingdom, Switzerland, and Brazil, women have tended to gravitate to nonsurgical specialties and primary care, such as internal medicine, pediatrics, family practice, and obstetrics-gynecology.3- 6 Women physicians, in growing numbers, are choosing non–primary care specialties, such as pathology, radiology, and anesthesia. In obstetrics-gynecology, the increase of women in the field is significant, from 5% in 1970 to more than 70% 3 decades later.2 A similar increase was seen in ophthalmology, in which there has been a 10-fold increase from 3.6% in 1970 to 32.4% in 2001 in women in training programs.2,31
Several journals have previously reviewed the leadership by sex. Sex was determined for 7249 US authors of original research with MD degrees in 6 major journals,29 including the New England Journal of Medicine, Journal of American Medical Association, Annals of Internal Medicine, Annals of Surgery, Obstetrics & Gynecology, and Journal of Pediatrics for 1970, 1980, 1990, 2000, and 2004. The proportion of first authors who were women increased from 5.9% in 1970 to 29.3% in 2004. The proportion of female senior authors increased from 3.7% to 19.3% during the same period. A similar study performed in the United Kingdom by Sidhu et al25 investigated sex differences in first and senior authorship in 6 peer-reviewed British journals (British Medical Journal, Lancet, British Journal of Surgery, Gut, British Journal of Obstetrics and Gynaecology, and Archives of Diseases in Childhood) for 1970, 1980, 1990, 2000, and 2004, with a total of 6457 articles reviewed. Female first authors increased more than 3-fold from 10.5% in 1970 to 36.5% in 2004, whereas female senior authors only increased by one-third from 12.3% to 16.5%. Within individual journals, the largest increase was in the British Journal of Obstetrics and Gynaecology, with 4.5-fold and 3-fold increases for first and senior authors, respectively.
In the otolaryngology literature, Bhattacharyya and Shapiro26 observed in 4 major journals that the percentage of women who were first authors increased from 3.2% to 11.4% from 1978 to 1998. In educational psychology, Robinson et al41 reported that the female-male ratio of first authors was equalizing and that the increase in the number of female authors and editors in 6 US educational psychology journals from 1976 to 1996 was statistically significant from 23.7% to 48.1% for primary authors and 12.7% to 42.5% for editorial board members. Dickersin et al40 found that women comprised a higher proportion of authors (28.7%) compared with reviewers (26.7%) or editors (12.8%) in 4 US epidemiologic journals between 1982 and 1994, similar to our findings, including first authors more than senior authors, reviewers, editorial board members, or editors.
The lag in promotion of women to higher academic ranks is a complex, multifactorial issue. Demands on our time are plentiful, and the activities that lead to academic advancement (research and publishing) can be difficult to accomplish in the setting of all of our other commitments, both personal and professional.23 From a different perspective, ophthalmic chairs also reflect sex leadership. In terms of the ophthalmology residency program director, 37 (67%) were men, whereas 18 (34%) were women according to a US study.24 In that same study, male department chairs led 53 of 55 (96%) ophthalmology programs.24 Also in the United States, women represented 21% of associate professors, 32% of assistant professors, and 43% of instructors of ophthalmology in 2001.23 Newer information indicates that department chairs at Harvard (Massachusetts Eye and Ear Infirmary), Thomas Jefferson University (Wills Eye Institute), and the University of Pennsylvania (Scheie Eye Institute) are women.
Serving on the editorial board of a leading scientific journal indicates that the individual is recognized as a leading contributor to the discipline. Serving as editor indicates that the individual has achieved an even higher reputation. Wilkes and Kravitz28 conducted a survey that found that 96% of 221 responding editors-in-chief of US and Canadian medical journals were men and that, in 2005, 16% of the editorial board members of the journals studied were women. If the proportion of medical students who are women has only recently reached parity, one cannot expect the senior ranks (from which editorial board members are drawn) to approach an equal sex distribution until substantial time has passed. This has been dubbed the “pipeline phenomenon.” In a review of 16 major biomedical journals during 35 years, overall 7.0% of the editors-in-chief listed were women (0% in 1970 and 12.5% in 2005).29 The reasons for the underrepresentation of women as editors of ophthalmology journals deserves further investigation and may be due to age disparity (women have only recently become more involved as authors and mentors). There may be relatively few female ophthalmologists who could attain the kind of visibility and reputation needed to be appointed as journal editor.
The progress during 5 decades in first authorship in the 3 major ophthalmology journals indicates that women have become more accepted as researchers. Our findings suggest that although women have increased their representation in the field, they have become more involved in publishing research, as both primary and senior authors, and they have become more involved in evaluating the research that is published in 3 major ophthalmology journals as editorial board members. We acknowledge the limitations of the current analysis. Although the publications selected for this study capture 3 of the most respected US journals in ophthalmology, they may not be representative of all journals in which ophthalmologists publish. Today, nearly half of medical school students nationwide are female, and the significant influx of women physicians during the last quarter century has changed both the face and character of medicine. However, women are not entering medicine on equal terms with men. Rather, a dual labor market is being created, with women concentrated in primary care and in low-paid areas of the profession.1 Women migrate toward non–on-call professions to have family time. Women remain underrepresented at the higher levels of academic medicine, but these trends are likely to change. Female graduates' marital status has notably differed from the marital status of male graduates. Reiser et al42 found that more women had never married or were divorced, spent more hours teaching, spent more time with their patients, and had fewer publications compared with men. Yet female ophthalmologists managed to be at the forefront of research with publications commensurate with the current number of women physicians. Ophthalmology in the Western world is steadily reaching equilibrium of near equality between the 2 sexes, unlike the 2 extremes of surgery, which have a male predominance, or obstetrics-gynecology, which has a female predominance.
Correspondence: Ahmad M. Mansour, MD, Department of Ophthalmology, American University of Beirut, PO Box 113-6044, Beirut, 1136044, Lebanon (firstname.lastname@example.org).
Submitted for Publication: November 16, 2011; final revision received May 20, 2012; accepted May 21, 2012.
Conflict of Interest Disclosures: None reported.
Online-Only Material: This article is featured in the Archives Journal Club. Go here to download teaching PowerPoint slides.
Additional Contributions: Mary Tomagan, Jessica Ravetto, and Jill Hartle supplied the information about American Academy of Ophthalmology membership data.