The graph is skewed to include outliers (values above the 75th percentile +3/2 × the interquartile range and values below the 25th percentile –3/2 × the interquartile range). Median values are indicated by hollow diamonds.
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Reddy AK, Bounds GW, Bakri SJ, et al. Representation of Women With Industry Ties in Ophthalmology. JAMA Ophthalmol. 2016;134(6):636–643. doi:10.1001/jamaophthalmol.2016.0552
Women in ophthalmology are growing in number and have made strides in traditional metrics of professional achievement. Professional ties to industry represent another potential means of career advancement, recognition, and income.
To report the representation of women among ophthalmologists receiving industry remuneration for research, consulting, honoraria, grants, royalties, and faculty/speaker roles.
Design, Setting, and Participants
In this observational, retrospective study, the Centers for Medicare and Medicaid Services Open Payments database for payments to ophthalmologists by biomedical companies was reviewed for representation, median payments, and mean payments by women and men for industry relationships in 2013 and 2014. The analysis was performed from July 2015 to November 2015.
Main Outcomes and Measures
The primary outcome measures were percentage representation of women vs men overall and in industry research, consulting, speaking roles, royalties and licenses, grants, services other than consulting, and honoraria. Secondary outcome measures included mean and median payments from industry to female vs male ophthalmologists.
In 2013, 4164 of 21 380 (19.5%) ophthalmologists were women, and of 1204 ophthalmologists analyzed for industry payments, 176 (4.2%) women had industry ties compared with 1028 (6%) men (P < .001). Mean payments to women were $11 419 compared with $20 957 for men (P = .001), and median payments to women were $3000 compared with $4787 for men (P = .007). In 2013, women were underrepresented among ophthalmologists receiving industry payments for research (49 of 462 [10.6%]), consulting (96 of 610 [15.7%]), honoraria (3 of 47 [6.4%]), industry grants (1 of 7 [14.3%]), royalties and licenses (1 of 13 [7.7%]), and faculty/speaker roles (2 of 48 [4.2%]). In 2014, 4352 of 21 531 (20.2%) of ophthalmologists were women. Of 1518 ophthalmologists analyzed for industry payments, 255 (6%) women had industry ties compared with 1263 (7.4%) men (P < .001). Mean payments to women were $14 848 compared with $30 513 for men (P = .004), and median payments to women were $3750 compared with $5000 for men (P = .005). Women remained underrepresented among ophthalmologists receiving industry payments for research (25 of 241 [10.4%]), consulting (145 of 921 [15.7%]), honoraria (14 of 11 [12.6%]), industry grants (3 of 25 [12.0%]), royalties and licenses (1 of 22 [4.6%]), and faculty/speaker roles (21 of 189 [11.1%]) in 2014.
Conclusions and Relevance
Women make up a minority of ophthalmologists with professional industry relationships, and the average woman partnering with industry earns less than her male colleagues. The reasons for differences are multifactorial and could not be determined by this study.
Inequity in medicine often is attributed to limited numbers of women entering the profession,1 but because women are now equally represented among medical school graduates (7% of graduates in 1965 compared with 49% of graduates in 2009),2 there has been speculation that gaps in physician salary, leadership positions,3,4 and senior faculty positions5 should eventually close. Even so, because women face gender-related biological pressures, implicit biases,6 and societal hurdles,7 they may continue to face greater challenges in career advancement than their male colleagues.
Quiz Ref IDTraditional metrics of professional achievement for both men and women include salary, academic rank, peer-reviewed publications, and federal funding. Industry partnership, while sometimes controversial,8,9 represents another potential source of income, innovation, and collaboration10 for physicians and can range from speaking engagements to advisory roles to sponsored research. An earlier study11 analyzed the differences between men and women physicians and industry payments, but to our knowledge, little has been documented about industry ties in the specialty of ophthalmology because of the paucity of information accessible until recently. In 2010, the Affordable Care Act required the Center for Medicare and Medicaid Services (CMS) to report industry payments to physicians, and this information is publicly available for 2013 and 2014.
The purpose of this article is to describe female vs male open payments received from industry among ophthalmologists in the United States in 2013 and 2014. We specifically sought to determine whether there are differences among men and women in the types of financial relationships with industry including research funding, honoraria, grants, and consulting.
Question How does industry partnership compare between male and female ophthalmologists?
Findings In this observational study, review of the Centers for Medicare and Medicaid Services Open Payments database revealed that women represent a minority of those with industry partnerships and that, on average, women earn less in financial compensation than men.
Meaning These data suggest women in ophthalmology are underrepresented in industry partnerships.
Institutional review board review and informed consent were not required because no patient or protected data were reviewed. The American Academy of Ophthalmology provided the number of female and male ophthalmologists in 2013 and 2014. These values included retirees but not members in training.
Individual-level data on the industry ties of all ophthalmologists practicing in the United States were downloaded from the CMS Open Payments Database12 for 2013 and 2014 on July 11, 2015, and analysis was performed from July 2015 to November 2015. These data were available in general, research, and physician ownership file categories for each year. The nature of payments to ophthalmologists for purposes other than research is classified by CMS as charitable contribution; compensation for serving as faculty or as a speaker; compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program (hereafter referred to as service other than consulting); consulting fee; current or prospective ownership or investment interest; education; entertainment; food and beverages; gift; grant; honorarium; royalty or license; and travel/lodging. Complete definitions of these payment categories are available through the CMS website.
This study focused on the payments received for research, consulting, honoraria, industry grants, spokesmanship, royalties, and services other than consulting. Information within the database included the company making payment, value of the payment, practice location, and description of the professional relationship, project, or gift. Charitable contributions, meals, education, entertainment, gifts, and travel/lodging represented ties of limited relevance and were therefore excluded from our major analyses. Internet searches were used by typing in the names of each individual ophthalmologist to determine if the ophthalmologists reported in the major analyses were women or men.
For each year, χ2 test with Yates correction was used to compare the number of women with at least 1 industry affiliation with the number of men with at least 1 industry affiliation. The mean industry payments for women and men were compared using 2-sample t test. Median payments between women and men were assessed using the Wilcoxon rank-sum testing. Statistical analyses were performed to describe the association between gender and the financial value of industry payments for research, consulting, grants, royalty/licenses, serving as faculty or speaker, and “other” services as classified by CMS. Statistical analyses were conducted using Microsoft Excel (Microsoft Corporation) and Stata 13 (StataCorp LP). Financial data were tested for normality and skew. Levene’s robust test statistic was used to test for equal variances of financial variables between women and men. To meet the distribution criteria revealed by normality and variance tests, the nonparametric Wilcoxon rank-sum test was used to compare whether industry payments between women and men were significantly different from zero. After performing t tests on log-transformed variables, results were compared with the Wilcoxon rank-sum results, and there were no differences in significant values. Median comparisons were performed when sample size was meaningful (greater than 2 women per category of payment). All P values were nominal, and 95% CIs were calculated using t test results.
Quiz Ref IDAs reported by the American Academy of Ophthalmology, in 2013, there were 21 380 ophthalmologists nationwide, of whom 4164 (19.5%) were female (Table 1). A total of 1204 ophthalmologists (176 women [14.6%] and 1028 men [85.4%]) were analyzed for industry payments in the research, consulting, grants, honoraria, royalties and licenses, serving as faculty or speaker, and services other than consulting subcategories (Table 2). Overall, 4.2% of female ophthalmologists and 6.0% of male ophthalmologists had at least 1 industry tie (P < .001). Mean payment to women was $11 419 compared with $20 957 to men, for a difference of $9538 (95% CI, −$14 362.65 to −$4711.95; P < .001). Median payment to women was $3000 and median payment to men was $4787, for a difference of $1787 (P = .007) (Figure 1).
Women represented 10.6% (49 of 462) of ophthalmologists receiving open payments for research. Total payments to female ophthalmologists for research were $1 020 266, representing 6.9% of the $14 756 693 that biomedical companies invested in research. Three women and 43 men (6.5% of the total) were represented among the top 10% of ophthalmologists receiving industry payments for research. Mean payment to women was $20 821.76 compared with $33 260.11 for men, for a difference of $12 438.35 (95% CI, −$30 271.85 to $5395.14; P = .17). Median payment to women was $6533.99 compared with $10 610.62 for men, for a difference of $4076.63 (P = .09).
Women represented 15.7% (96 of 610) of industry consultants. Only 4 women (6.6%) were represented among the top 10% of ophthalmologists receiving industry payments for consulting as opposed to 57 men. Mean payment to women was $7438.15 compared with $9604.11 for men, for a difference of $2165.95 (95% CI, −$5906.68 to $1574.78; P = .26). Median payment to women was $3000 compared with $3200 for men for a difference of $200 (P = .22).
Women represented 6.4% (3 of 47) of ophthalmologists receiving industry honoraria. Only men were represented among the top two-thirds of ophthalmologists with the highest reimbursements in this category. Mean payment to women was $696.28 compared with $3592.57 for men, for a difference of $2896.29 (95% CI, −$10 032.98 to $4240.40; P = .42). Median payment to women was $1000 compared with $2000 for men, for a difference of $1000 (P = .04).
One woman represented 14.3% (1 of 7) of ophthalmologists receiving industry grants with a payment of $30 000. Notably, this was the highest industry grant payment to any ophthalmologist in 2013.
One woman represented 7.7% (1 of 13) of ophthalmologists receiving payment for royalties and licenses with a payment of $14 583. This was higher than the median payment to male ophthalmologists ($12 292) for this purpose.
Women represented 4.2% (2 of 48) of ophthalmologists receiving payments for faculty and speaking positions. Total payments to female ophthalmologists in this category were $2500, representing 2.7% of the $93 255 reported that year. Mean payment to women was $1250 compared with $1972.93 for men, for a difference of $722.93. Median payment to women was $1250 compared with $1500 for men, for a difference of $250.
Women represented 13.4% (52 of 388) of ophthalmologists receiving payments for services other than consulting but received only 10.8% of total payments. Five women (13.2%) were among those who received the highest 10% of payments to ophthalmologists in this category compared with 33 men. Mean payment to women was $4352.04 compared with $5553.01 for men, for a difference of $1200.97 (95% CI, −$3880.44 to $1478.50; P = .38). Median payment to women was $2000 compared with $2500 for men, for a difference of $500 (P = .23).
Quiz Ref IDIn 2014, there were 21 531 ophthalmologists nationwide, of whom 4352 (20.2%) were female (Table 1). A total of 1518 ophthalmologists (255 women [16.8%] and 1263 men [83.2%]) were analyzed for research, consulting, grants, honoraria, royalties and licenses, serving as faculty or speaker, and services other than consulting payments (Table 3). Overall, 6% of female ophthalmologists and 7.4% of male ophthalmologists had at least 1 industry relationship (P < .001). Mean payment to women was $14 848 compared with $30 513 for men, for a difference of $15 665 (95% CI, −$26 386.45 to −$4942.99; P = .004). Median payment to women was $3750 compared with $5000 for men, for a difference of $1250 (P = .005) (Figure 2).
Women represented 10.4% (25 of 241) of ophthalmologists receiving open payments for research. Total payments to female ophthalmologists for research were $783 020, representing 10.4% of the $7 558 236 that biomedical companies invested in research. Three women (12.5%) vs 21 men were represented among the top 10% of ophthalmologists receiving industry payments for research. Mean payment to women was $31 320.81 compared with $31 366.74 for men, for a difference of $45.93 (95% CI, −$20 375.28 to $20 283.43; P = .99). Median payment to women was $21 668.75 compared with $13 721.50 for men, for a difference of $7947.25 (P = .35).
Women represented 15.7% (145 of 921) of industry consultants. Six women (6.5%) vs 86 men were represented among the top 10% of ophthalmologists receiving industry payments for consulting. Mean payment to women was $10 682.17 compared with $17 683.93 for men, for a difference of $7001.76 (95% CI, −$14 230.27 to $226.75; P = .06). Median payment to women was $3500 compared with $4000 for men, for a difference of $500 (P = .02).
Women represented 12.6% (14 of 111) of ophthalmologists receiving industry honoraria. The maximum payment was much higher for the top paid male ophthalmologist ($98 479) than for the top paid female ophthalmologist ($5000). Mean payment to women was $2367.86 compared with $4778.20 for men, for a difference of $2410.35 (95% CI, −$9964.08 to $5143.39; P = .53). Median payment to women was $2300 compared with $1500 for men, for a difference of $800 (P = .48).
Three women represented 12.0% of ophthalmologists receiving industry grants. Mean payment to women was $3444.45 compared with $15 727.10 for men, for a difference of $12 282.65 (95% CI, −$67 973.65 to $43 408.35; P = .65). Median payment to women was $5000, which was the same as that to men (P = .50).
One woman represented 4.6% (1 of 22) of ophthalmologists receiving payment for royalties and licenses with a payment of $175 000. This single payment was higher than the median payments to male ophthalmologists ($43 572); however, the maximum payment to men was much higher ($911 083).
Women represented 11.1% (21 of 189) of ophthalmologists receiving payments for faculty and speaking positions. Total payments to female ophthalmologists represented 9.9% of the $1 201 838 reported. Three women (17.6%) and 14 men were among the top 10% of ophthalmologists receiving industry payments in this category. Mean payment to women was $5661.90 compared with $6446.06 for men, for a difference of $784.16 (95% CI −$5776.27 to $4207.95; P = .76). Median payment to women was $2500 compared with $3750 for men, for a difference of $1250 (P = .20).
Women represented 17.9% (124 of 694) of ophthalmologists receiving payments for services other than consulting, but received 8.1% of total payments. Nine women (13%) and 60 men were represented among the top 10% of ophthalmologists receiving industry payments in this category. Mean payment to women was $9008.21 compared with $22 363.04 for men, for a difference of $21 959.43 (95% CI, −$56 469.94 to $29 760.26; P = .54). Median payment to women was $3037.50 compared with $4000 for men, for a difference of $962.50 (P = .28).
Despite a steady increase in the number of women entering medicine since the 1960s, the percentage of women faculty in US medical schools at the rank of full professor (11.9%) has not changed since 1980,13 and studies continue to identify lack of equity in compensation and disproportionate workload14 as barriers to retention and achievement for women. Even after adjusting for specialty, rank, leadership roles, publications, and research time, male physician researchers continue to receive higher salaries (by $13 999; P = .001) than female physician researchers,15 and some studies suggest that this gap is growing.16,17 A 2008 study reported that while National Institutes of Health general grant success rates were not significantly different between women and men after controlling for academic rank, disparity existed in median annual funding requested ($115 325 for women and $150 000 for men) and median annual funding awarded ($98 094 for women and $125 000 for men).18 Since 2011, men in ophthalmology receiving National Institutes of Health grants have had higher mean National Institutes of Health awards ($418 605) than their female colleagues ($353 170; P = .005) and significantly higher total funding per principal investigator. This difference is most marked among researchers holding a medical degree.19
Many physicians collaborate with industry on projects with a translational or clinical focus, and while sometimes controversial, such relationships are increasingly accepted and even encouraged for career advancement. This has been historically true for academia, but increasingly also in the private sector, especially because many academic institutions have implemented conflict of interest regulations for their faculty that restrict certain forms of interaction with industry. In 2014, researchers at the Cleveland Clinic Department of Bioethics analyzed 2011 data on physicians with industry ties.11 This analysis differed from our study in several ways: (1) data were obtained through a third party (not publicly reported by CMS), (2) all American physicians were included (as opposed to ophthalmologists alone), and (3) the period of analysis was limited to 2011. More than 75% of physicians who received money from biomedical companies were men, and women received fewer total dollars on average (by $3598.63; P < .001) than men.11 One study reviewed industry payments to ophthalmologists20 over a 6-month reporting period in 2013 but excluded research payments, which have higher values than general payments. Unlike our study, this study did not evaluate payments by gender.20
In a 2015 analysis21 of 671 original articles and 89 editorials from the 3 major ophthalmology journals between 2000 and 2010, most articles were written by men, but the percentage of original articles with a woman as first author or last author increased significantly over that decade. Editorial authorship, however, continued to be overwhelmingly male (ie, 87% in 2000 and 90% in 2010), suggesting that while women were increasingly involved in original investigations, they did not achieve the recognition or influence requisite for invited editorial contributions.
Our series suggests that a similar phenomenon21 may be occurring with ties to industry because advisory and research affiliations with biomedical companies are primarily awarded to ophthalmologists who are felt to be influential. Despite growing numbers of female ophthalmologists in clinical practice, women represent a minority of ophthalmologists participating in industry-sponsored activities, and when they do, they are generally reimbursed substantially less their male colleagues, especially for spokesmanship and consulting, although notable outliers do exist. Because only 2 years’ worth of data are available for analysis, it is difficult to draw broad conclusions, especially about industry honoraria and research funding, which was lower for women than men in 2013 but higher for women than men in 2014.
Our analysis also does not allow us to draw conclusions about reasons for the disparity observed. Underrepresentation of women is not simple, but across all professions, a major factor is the necessity of medical leave for childbirth and status as primary caregiver for families.22 Industry relationships often require travel to maintain. Thus, they may be more difficult for female ophthalmologists to cultivate early in their careers, when many have young families. Several academic centers have reported, however, that female productivity rises dramatically (and, in many cases, exceeds that of men) later in their careers.23,24 If this holds true for achievement in ophthalmology, women “in the pipeline” now will achieve greater influence in the future.
Women have only come to represent 20% of ophthalmologists in the past 2 years. Parity in female and male distribution among ophthalmologists with industry ties may lag behind that of representation because influence takes additional time to achieve.21 Publications such as ours illustrate that while inequity may exist, many women can and do achieve influence in other ways through industry partnership, which is important because many female ophthalmology residents are choosing to leave academia.25 Other authors have argued that increased transparency could close the gap in compensation, especially if companies are asked to account for such differences.11
Quiz Ref IDOne limitation of this study is that physicians who do not participate in CMS are not reported in Open Payments and thus are not included in this analysis. However, this would not be expected to exclude most ophthalmologists. Also, physician age, subspecialty focus, and academic appointments were variables (and possible confounders) that ideally would have been included in this study because payments from industry may increase as a function of time and professional reputation. However, these values were not reported by CMS, were not possible to report uniformly for all ophthalmologists, and were therefore not variables addressed in this article. It may be that after adjusting for such factors, the disparity observed would be less. The Open Payments database is dependent on physician and industry reporting. If present, errors of omission or accuracy within the database, such as categorization of payment, would affect our analysis.
The purpose of this article is to complement previous publications on the topic of disparity between women and men in ophthalmology and demonstrate that inequity is not limited to performance-based salary, federal research funding, and peer-reviewed authorship. Industry ties are a significant source of income and professional advancement in both academic and private centers, and they represent another area in which women should strive for recognition on par with male colleagues. Underrepresentation of women is multifactorial26 but will hopefully improve as more women achieve increasing visibility and influence through scholarly endeavors and targeted efforts are made to reduce such disparities in all professional activities.
Corresponding Author: Ashvini K. Reddy, MD, Wilmer Eye Institute, Johns Hopkins University, 600 N Wolfe St, Woods 472, Baltimore, MD 21287 (email@example.com).
Submitted for Publication: December 3, 2015; final revision received February 8, 2016; accepted February 12, 2016.
Published Online: April 21, 2016. doi:10.1001/jamaophthalmol.2016.0552.
Author Contributions: Dr Reddy and Mr Bounds had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Reddy, Bounds, Bakri, Thorne.
Acquisition, analysis, or interpretation of data: Reddy, Bounds, Gordon, Smith, Haller, Thorne.
Drafting of the manuscript: Reddy, Bounds, Bakri.
Critical revision of the manuscript for important intellectual content: Reddy, Bounds, Bakri, Gordon, Smith, Haller, Thorne.
Statistical analysis: Bounds.
Administrative, technical, or material support: Reddy, Bounds, Gordon. Thorne.
Study supervision: Reddy, Bakri, Smith, Haller.
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Funding/Support: Dr Bakri reports funding from Research to Prevent Blindness.
Role of the Funder/Sponsor: The funding source 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.
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