Bias in the Operating Room: Female Fellows Report Fewer Surgeries

MOSCOW, RUSSIA – AUGUST 15, 2019: Ophthalmic surgeons perform an operation at Veterans’ Hospital 2. Alexander Shcherbak/TASS (Photo by Alexander ShcherbakTASS via Getty Images)
Operating room experience is inconsistent between male and female trainees, and who is selected to perform surgery is prone to sex bias, according to the authors of a new study.

Does the sex of an ophthalmology resident or fellow influence how many surgical procedures they have the opportunity to perform during residency? According to new research published in Retina, the answer is yes.1

The authors of the investigation point to clear discrepancies between the number of surgical procedures self-reported by male and female ophthalmology residents in a review of case logs from 133 vitreoretinal fellows. The investigators looked specifically at logs submitted to the American Society of Retina Specialists between July 1, 2018 and June 30, 2019.1 The data show 37 of 57 (65%) first year fellows, and 59 of 76 (78%) second year fellows were male.1 An average of 1120 procedures were self-reported amongst all vitreoretinal fellows.1 In the group of second year fellows at the completion of fellowship, men reported more total procedures (1171 [864-1600] vs. 1005 [719-1257], P =.072).1 These findings were consistent with previous research, according to the authors, and show that male fellows report more surgical procedures than female fellows.1

“A systemic review found that no difference in surgical skills exists between male or female residents in other surgical subspecialties,” the authors said. “It is important to identify these discrepancies to ensure equal training opportunities.”1

It’s suspected that, in general, operating room experience is inconsistent between trainees and who is selected to perform surgery is prone to sex bias, the authors said.1

According to the authors, these inequities allude to a larger issue—a lack of female representation throughout medicine. Women account for only 25% of all ophthalmologists, and in the retina subspecialty, that number is approximately 20%.1

“The percentage of full-time female professors in ophthalmology ranges anywhere between 15% and 20%, though this number is less than expected for the percent of associate professors, suggesting a lack of promotion. Moreover, male primary investigators in ophthalmology were found to receive higher NIH awards and total funding compared to females,” the authors wrote.1

Prior research shows that “only 13% of society presidents were women in 2018 and only one journal (4%) had a female editor-in-chief,” the authors said. “Lastly, there are fewer female presenters at ophthalmology subspecialty conferences, such as refractive surgery and retina/vitreous.”2

Looking more closely at the differences between male and female self-reported surgeries, the researchers found that females are logging fewer specific procedures. Overall, females reported fewer internal limiting membrane (ILM) peel (P =.015), scleral buckle (P =.028), and cryoretinopexy (P =.012) procedures compared with males, the authors found.1 Fewer female first-year fellows reported performing enucleations than their male counterparts (P =.016). Also, second-year females fellows reported fewer endolaser (P =.018), ILM peel (P =.042), and cryoretinopexy (P =.002) procedures compared with male fellows.1 However, females fellows did report a greater number of silicone oil placement procedures (P =.043) and intravitreal injections (P =.035) than males.1

Self-reporting only captures between 50% and 60% of clinical experience, and cases are often not logged, the authors explained.1 They also point out that they did not have data around the role of the surgeon, meaning if they were the primary or assistant surgeon. They speculate that residents and fellows may be more or less inclined to report the surgical procedure based on their role.1 Females reported less autonomy in the operating room compared with male residents and fellows, according to the study. This offers another potential reason why females are logging fewer procedures.1

More research needs to be conducted to put a finer point on exactly what barriers female vitreoretinal surgeons in training face. 


  1. Reyes-Capo D, Yannuzzi N, Chan R, Murray T, Audina M. Berrocal, Jayanth Sridhar. Gender differences in self-reported procedural volume among vitreoretinal fellows. Retina. Published online Aug 7, 2020. Accessed September 18, 2020. doi: doi: 10.1097/IAE.0000000000002942 
  2. Patel S, Truong T, Tsui I, Moon J, Rosenberg J. Gender of presenters at ophthalmology conferences between 2015-2017. Am J Ophthalmol. 2020;213:120-124. doi: 10.1016/j.ajo.2020.01.018