Over 10 years, female ophthalmology residents performed significantly fewer procedures compared with male residents.

A national retrospective cohort study has revealed persistent disparities in surgical case volume among U.S. ophthalmology residents based on gender and underrepresented in medicine (URiM) status. All graduates of Accreditation Council for Graduate Medical Education (ACGME)-accredited ophthalmology programs from 2014 to 2023 were included in the analysis. In their findings, investigators highlighted measurable differences in cataract and total surgical procedures logged during residency.

The investigators analyzed surgical case log data from 4,811 ophthalmology resident graduates. Among them, 41.6% were women and 7.1% identified as URiM. URiM status was defined by the Association of American Medical Colleges and included trainees who self-identified as Black, Hispanic/Latino, American Indian or Alaska Native, or Native Hawaiian or Other Pacific Islander. The main outcome was the difference in average surgical case volume by gender and URiM status.

Lead study author Susan M. Culican, MD, PhD, of the University of Minnesota Medical School, and colleagues wrote: “Our goal with the present study was to determine whether the finding in this sample could be explained by selection bias or whether the finding was representative across all resident trainees in ACGME–accredited programs.”

They found that female residents averaged 184.4 cataract cases compared with 192.7 for male residents—a mean difference of 8.3 cases, or −4.4% (95% confidence interval [CI] = −6.4% to −2.4%, P < .001). Female residents also logged an average of 561.9 total procedures vs 605.4 among male residents—a mean difference of 43.4 cases, or −7.4% (95% CI = −9.7% to −5.1%, P < .001).

Disparities were also evident throughout surgical categories:

• Keratorefractive surgery: −25.2% among female residents compared with male residents (P < .001)

• Panretinal photocoagulation: −15.8% (P < .001)

• YAG capsulotomy: −17.4% (P < .001)

• Retina/vitreous procedures: −10.7% (P < .001)

• Intravitreal injections: −10% (P = .001)

• Globe trauma, oculoplastics, and orbit surgeries: All showed statistically significant lower volumes among female residents.

All resident groups exceeded ACGME surgical minimum requirements despite these disparities, and there was no evidence that clinical outcomes were adversely affected. In fact, the investigators noted, previous studies have shown that female residents have equivalent skill levels and patient outcomes, as well as reduced rates of being sued.

Notably, the study authors explained: “[T]he retina subspecialty is heavily male dominated (19% female) and keratorefractive subspecialty is heavily male dominated (14% female), [but] pediatric ophthalmology (55%) and the traditionally nonsurgical subspecialties of neuro-ophthalmology (56%), uveitis (51%), and medical retina (47%) have a disproportionately high representation of [female residents].”

While they showed no statistically significant difference in cataract surgery volume, URiM residents performed fewer total surgical procedures overall: non-URiM residents had 589.6 total surgical cases, whereas URiM residents had 558.1 — a difference of 31.5 cases, or −5.3% (95% CI = −9.8% to −0.9%, P = .02).

In subspecialty categories, URiM residents logged significantly fewer procedures in:

• Keratorefractive surgery: −17.2% (P = .03)

• Panretinal photocoagulation: −21.6% (P = .003)

• Oculoplastic and orbit procedures: −7.8% (P = .01)

• Strabismus surgery: −10.9% (P = .002).

Interestingly, URiM trainees performed more cases in pterygium/conjunctival procedures (+ 10%, P = .02) and retina/vitreous procedures (+ 7.8%, P = .04).

While the proportion of female residents remained stable at around 41.6% over the study period, URiM representation increased fourfold—from 2.8% in 2014 to 11.3% in 2023. The proportion of female URiM trainees fluctuated significantly and averaged 53.9% over the 10-year span.

“In this cohort, consisting of a limited number of programs in the [United States], the surgical gap increased over time, and the difference could not be explained by parental leaves, which are more commonly taken by [female residents], thus potentially reducing clinical contact time,” the study authors wrote. “Gender disparity in surgical volume not explained by parental leave has also been described in gastroenterology, general surgery, and otolaryngology training programs,” they added.

They continued: “If surgical outcomes are unaffected by lower volume, why is it important to address gender disparity?”

In short, the specialty must address the pay differential, which, they described, has depended historically on procedural volume. An aging population and ophthalmology workforce shortage is another issue that can be addressed with the disparities identified.

The investigators acknowledged limitations, including self-reporting and small sample sizes for URiM trainees.

“These results warrant additional studies exploring the contribution of program-level differences and the intersectional impact of race and gender to test hypotheses about the potential causes and contributing factors to these disparities,” the study authors concluded.

Author disclosures can be found in the published research.

Source: JAMA Ophthalmology