Between 2000 and 2010, there was a significant increase in women ophthalmologists as well as women publishing as first and/or last authors. This increase was not seen in editorial authorship.
Franco-Cardenas V, Rosenberg J, Ramirez A, Lin J, Tsui I. Decadelong Profile of Women in Ophthalmic Publications. JAMA Ophthalmol. 2015;133(3):255-260. doi:10.1001/jamaophthalmol.2014.4447
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In recent decades, there has been an increase in the number of women practicing medicine. We believe this shift may be reaching academic publications in ophthalmology and changing gender trends.
To determine whether there has been an increase in women publishing academic articles and editorials in ophthalmology during the past decade.
Design, Setting, and Participants
In this observational retrospective study, 3 ophthalmology journals were sampled from 2000 and 2010 for at least 100 articles per journal, per year, and all editorials published in both years. Data reviewed included the authors’ gender, number of authors, number of references, subspecialty, and country of origin.
Publication by women authors.
Main Outcomes and Measures
The primary outcome measure was an increase in women publishing in ophthalmology. The hypothesis was formulated before data collection.
Our analysis included 671 original articles (336 from 2000 and 335 from 2010) and 89 editorials. The percentage of original articles with a woman as first author increased from 23.2% in 2000 to 32.5% in 2010, a difference of 9.3% (95% CI, 2.3%-16.4%; P = .009). The percentage of original articles with a woman last author increased from 16.9% in 2000 to 24.4% in 2010, a difference of 7.5% (95% CI, 1.7%-21.2%; P = .02). The percentage of original articles with a woman first author increased in Asia from 9.1% in 2000 to 32.6% in 2010, a difference of 23.5% (95% CI, 5.0%-66.5%; P = .003). The percentage of articles with a woman last author increased in Europe from 11.1% in 2000 to 37.9% in 2010, a difference of 26.8% (95% CI, 10.5%-43.2%; P = .001) and in Asia from 0% in 2000 to 23.3% in 2010, a difference of 23.3% (95% CI, 12.9%-33.9%; P = .001). Editorials were written predominantly by men: 33 of 38 editorials (87%) in 2000 and 46 of 51 (90%) in 2010.
Conclusions and Relevance
Our data suggest an increase in women publishing original investigations in ophthalmic literature, but no increase in editorial authorship.
Historically, all surgical subspecialties, including ophthalmology, have been male-dominated fields.1,2 Potential reasons for this occurrence include lack of opportunity, lack of role models, lack of exposure to surgical fields, and considerations of work-life balance.1,2 During the past decade, there has been an increase in the number of women surgical residents in the United States commensurate with the increase in women graduating from medical schools.3,4
At the same time, it is evident that women in ophthalmology and all fields of academic medicine may not be advancing to senior ranks compared with their male counterparts, even though women are more likely than men to enter academics.3,4 In addition, there is still a gender difference in the salaries of physician researchers.5 Other investigators have validated the use of authors’ gender in academic medical literature as a surrogate marker of gender imbalance.6,7
An important component of academia is publications, as they are the main venue for communicating and encouraging diffusion of scientific innovation. Progress in ophthalmology, or any medical specialty, comes from reporting new investigations and clinical findings. The process of authorship, submission to a journal, peer review, acceptance, and publication are the fundamental steps for the introduction of new knowledge into our practices.8
There are a handful of articles that examine gender trends in the fields of general surgery, otolaryngology, orthopedic surgery, anesthesiology, dermatology, and dentistry, showing that there was often, but not always, an increase in women authors publishing during the past decade.7,9- 15 These studies also found that gender trends in authorship varied between subspecialties. For example, orthopedic surgery did not have the same increase in women authors compared with other fields.16 To our knowledge, there is only 1 article that examines gender trends in ophthalmology authorship.17 The purpose of this study is to further investigate these trends, including original research articles and editorials, in leading ophthalmic journals.
Three journals with high impact factors in ophthalmology18 were included in this study: Ophthalmology: Journal of the American Academy of Ophthalmology (impact factor, 5.56), American Journal of Ophthalmology (impact factor, 4.29), and JAMA Ophthalmology (formerly Archives of Ophthalmology; impact factor, 3.83). Original articles (clinical and laboratory sciences, short series, and meta-analyses) and editorials were reviewed for 2000 and 2010. Single case reports were excluded.
Original articles were reviewed beginning on January 1 until a minimum of 100 articles was reached. When this number was reached, we included the rest of the articles in that month. Editorials from the complete year were included. Data collected for each article consisted of the name and gender of the first and last author, total number of authors, number of references, subspecialty topic of the article, and country in which the research was performed.
An Internet search was conducted to find out the gender of the first and last author. When unclear, an e-mail was sent to inquire about gender. If information about the authors’ gender remained unavailable, the article was excluded from the study. When more than 1 subspecialty was relevant, the article was designated to be of the area of expertise of the last author. When a multicenter study was conducted, the country of origin was chosen according to the affiliation of the last author.
Statistical tests were conducted comparing data from 2000 and 2010 for original articles. The overall authorship gender differences were tested using the proportion test. P values were calculated using the Pearson χ2 test or the Fisher exact test. The same analysis was performed for editorials and authorship by subspecialty. The Wilcoxon rank sum test was applied to determine if women cited more articles than men. Statistical significance was set at P < .05.
A total of 683 articles were reviewed, of which 12 (1.8%) were excluded because either the first or last author’s gender could not be identified, resulting in a total of 671 articles analyzed (336 from 2000 and 335 from 2010). This total represented 43% of all original articles published in those years (Ophthalmology, 35.0%; Am J Ophthalmol, 39.0%; Arch Ophthalmol, 66.0%).
Using a Pearson χ2 test, we found that the proportion of women in this sample who published original articles in ophthalmology, both as first and last authors, increased from 2000 to 2010. The percentage of articles with a woman first author increased from 23.2% (78 articles) in 2000 to 32.5% (109 articles) in 2010, a difference of 9.3% (95% CI, 2.3%-16.4%; P = .009). The percentage of articles with a woman last author increased from 16.9% (55 articles) in 2000 to 24.4% (81 articles) in 2010, a difference of 7.5% (95% CI, 1.7%-21.2%; P = .02) (Figure).
The country of origin was grouped by continent: North America, South America, Europe, Asia, and Australia/New Zealand. Using an exact binomial test, we found that the percentage of articles with women first authors increased in Asia from 9.1% in 2000 to 32.6% in 2010, a difference of 23.5% (95% CI, 5.0%-66.5%; P = .003). There were no significant differences for North America: 24.8% in 2000 to 31.3% in 2010, a difference of 6.5% (95% CI, −3.0% to −15.9%; P = .19); Europe: 28.1% in 2000 to 37.9% in 2010, a difference of 9.8% (95% CI, −8.5% to −28.1%; P = .34); and Australia/New Zealand: 28.6% in 2000 to 44.4% in 2010, a difference of 15.9% (95% CI, −43.5% to −75.2%; P = .90). South America was excluded from this analysis because there were no women first authors in either year. For articles with women last authors, we found that there was an increase in Europe from 11.1% in 2000 to 37.9% in 2010, a difference of 26.8% (95% CI, 10.5%-43.2%; P = .001) and in Asia from 0% in 2000 to 23.3% in 2010, a difference of 23.3% (95% CI, 12.6%-33.9%; P = .001). No increase was seen in North America, South America, or Australia/New Zealand (Table 1).
Subspecialties were grouped into 5 categories: cornea and refractive surgery, cataract surgery, glaucoma, retina, and other (pediatrics and strabismus, oncology, uveitis, neurophthalmology, epidemiology, and education). For articles with women first authors, we found that there was an increase in the cataract surgery group from 13.3% (2 articles) in 2000 to 47.6% (10 articles) in 2010, a difference of 34.3% (95% CI, 1.1%-67.4%; P = .04) (Table 2). No increase was noted in the other subspecialty categories. The increase was also noted for articles with women last authors, in which there was an increase in the retina group from 12.9% (13 articles) in 2000 to 24.8% (25 articles) in 2010, a difference of 11.9% (95% CI, 0.24%-23.5%; P = .047) and in the cataract surgery group from 0% (0 articles) in 2000 to 28.6% (6 articles) in 2010, a difference of 28.6% (95% CI, 3.5%-53.6%; P = .03) (Table 3).
For all 671 articles, the mean (SD) number of authors was 5.4 (2.7) and the mean (SD) number of references was 26.5 (13.8). Grouping all the articles in which the first author was a woman, we found, using the Wilcoxon rank sum test, that there was an increase (P = .03) in the number of references cited by women (mean [SD], 28.6 [14.8]) compared with men (mean [SD], 25.8 [12.8]). No difference was identified in the number of coauthors (mean [SD] for women, 5.6 [2.7] vs men, 5.3 [2.7]; P = .73). Grouping all the articles in which the last author was a woman, we found no difference in the number of references used or in the number of coauthors when compared with articles with a man as a last author.
A total of 89 editorials were published by the 3 journals in 2000 and 2010. Thirty-eight editorials were published in 2000 and 51 in 2010. Thirty-three of 38 editorials in 2000 (87%) and 46 of 51 editorials in 2010 (90%) were written by men (Figure).
This study presents novel findings examining gender trends in ophthalmology authorship. There was an increase in women publishing as first and last authors during the 10-year period, as previously reported.17 Our study differs in that we examined 100 articles per year and found the same result as a prior study, which analyzed an entire year. This finding suggests that our sampling method is accurate and representative. In both studies, articles with women first authors increased by 40%, and articles with women last authors increased by 47%. This increase may be a reflection of the increase in practicing women ophthalmologists. Assuming it takes approximately 2 years for a study to be performed, submitted, and published, we may compare our results with data from the American Medical Association from 1998 and 2008. In this period, there was a 46% increase in practicing women ophthalmologists and a 48% increase in women residents.19,20 Therefore, it seems that the increase in authorship among women is a proportionate reflection of the increase in practicing women ophthalmologists.
Editorials are articles written by an expert in a field by invitation only. In this study, we found that editorials were written predominantly by men. Grouping both years together, there were 6.8 times more editorials written by men than women. This trend was not affected by the 10-year interval. One possible explanation could be that women have more recently entered the workforce and have not reached seniority yet. Averaging American Medical Association data from both years, ophthalmologists aged 55 years or older accounted for 35.2% of the total ophthalmologist population. Ninety-four percent of men ophthalmologists and 6% of women ophthalmologists compose this group.19,20 Another explanation for the lack of increase of women writing editorials could be found in data collected by Mansour and colleagues.17 Editorial boards are composed of 18.8% of women and, until today, none of the journals analyzed in this study has had a woman editor in chief. A longer period will be needed to corroborate if this phenomenon is owing to time bias or a true gender bias.
Subgroup analysis by subspecialty showed an increase in retina and cataract publications only. A study by Kumar et al21 that reviewed more than 12 000 abstracts from 20 ophthalmic journals showed that, from 2005 to 2009, medical retina articles had increased substantially and cataract and refractive surgery articles had the highest forms of study design. The authors postulate that the aging population and recent introduction of anti–vascular endothelial growth factor treatment contributed significantly to the higher proportion of medical retina publications, as did the increasing prevalence of diabetic eye disease.21 Our study adds to this previous work by showing that the increase in retina publications is true for both women and men authors.
The 3 journals examined in this study: Ophthalmology: Journal of the American Academy of Ophthalmology, American Journal of Ophthalmology, and JAMA Ophthalmology (formerly Archives of Ophthalmology), while international in authorship, have a preponderance of US authors, perhaps owing to the language in which they are published, office locations, and medical associations they represent. It is worth noticing that no increase was found in this study in North American women publishing either as first or last authors during the past decade.
Multiple authorship of biomedical articles is now the norm. Less than 5% of published research is written by 1 person.22 In our view, the position of first author is reserved for the person who contributed most to the work and writing of the article. By tradition, many reserve the position of last author for the senior member of the research team, who is assumed to be the driving force, both intellectually and financially.23 However, this practice is unofficial and hence not always followed, meaning that sometimes last authors “mistakenly” benefit when they actually are not principal investigators.24 Several attempts have been made to make author order uniform in multiauthored publications such as sequence determining credit, alphabetical sequence, percentage of contributions indicated, and first and last author emphasis.24 Until now, there is no official norm, and the journals analyzed in this study leave the author order to the investigators’ criteria.
This study shows an increase in women publishing original investigations in ophthalmic literature but still no increase among editorial authorship. It is important to examine and discuss gender trends in authorship to encourage gender equality and motivation. These findings offer interesting insights into authorship gender trends in ophthalmology during the past decade.
Submitted for Publication: June 24, 2014; final revision received September 4, 2014; accepted September 6, 2014.
Correction: This article was corrected online on August 25, 2016, to fix errors in data.
Corresponding Author: Valentina Franco-Cardenas, MD, Retina Department, Association to Prevent Blindness in Mexico, 46 Vicente Garcia Torres, San Lucas, Coyoacan, Mexico City, Mexico 04030 (email@example.com).
Published Online: November 13, 2014. doi:10.1001/jamaophthalmol.2014.4447
Author Contributions: Dr Franco-Cardenas had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Franco-Cardenas.
Acquisition, analysis, or interpretation of the data: All authors.
Drafting of the manuscript: Franco-Cardenas, Ramirez, Lin.
Critical revision of the manuscript for important intellectual content: Franco-Cardenas, Rosenberg, Tsui.
Statistical analysis: Franco-Cardenas, Lin.
Administrative, technical, or material support: Ramirez.
Study supervision: Franco-Cardenas, Rosenberg, Tsui.
Conflict of Interest Disclosures: All authors have completed and submitted the International Committee of Medical Journal Editors Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: The Department of Ophthalmology and Visual Sciences at Montefiore Medical Center is supported by an unrestricted departmental grant from Research to Prevent Blindness.
Role of the Funder/Sponsor: Research to Prevent Blindness had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.