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Differences in Ophthalmology Residents’ Medical Knowledge Ratings Could Indicate Gender Disparities


Although major gender bias on the national level was not found, differences in medical knowledge (MK) ratings could be an indicator of gender bias in ophthalmology education.

Medical knowledge (MK) ratings within the Accreditation Council for Graduate Medical Education (ACGME) Milestone assessments for ophthalmology residents demonstrated some differences between men and women at the midyear mark, which could indicate gender biases, according to a study published in JAMA Ophthalmology.

Eye scanning. Concept image | Image Credit: Sergey Nivens - stock.adobe.com

Eye scanning. Concept image | Image Credit: Sergey Nivens - stock.adobe.com

Women remain underrepresented in the ophthalmology field, with major gender differences in salary, compensation, cataract surgery volume, publication rates in academia, and the amount of funding received. These gender disparities start to occur early in ophthalmology training. For the ACGME Milestones, clinical competency committees rate resident performances in 6 core competencies, with patient care and procedural skills (PC) and MK among them. This study aimed to assess gender differences in ACGME Milestone scores in a sample of residents in postgraduate year 4 (PGY4).

This study focused on the scores for MK and PC in ophthalmology residents. The American Board of Ophthalmology Written Qualifying Examination (WQE), an examination consisting of 250 multiple choice questions given to ophthalmology residency graduates, was included as a benchmark measure. Gender information provided by the programs was used; race and ethnicity were not included.

PGY-4 year-end and midyear ACGME Milestones ratings were matched with the WGE scaled score. There were 6 competencies split into 24 subcompetencies that were in the ophthalmology Milestones reporting form, of which 8 were for PC and 2 were for MK. All subcompetencies were rated on a 5-point scale.

There were 452 trainees with a median (IQR) age of 30.0 (29.0-32.0) years who were matched to WGE scores; 177 (39%) women were included. Bivariate correlations found that mid-year (Pearson r, 0.29) and year-end (Pearson r, 0.31) Milestone reporting periods had the strongest correlation between MK ratings and WQE performance. PC ratings had the second strongest correlation with WQE performance (Pearson r, 0.12 and 0.10 for midyear and year-end assessment, respectively).

The PC domain average found no difference between women and men at midyear (–0.07; 95% CI, –0.11 to 0) and year-end (–0.04; 95% CI, –0.07 to 0.03). Women were rated lower in MK (mean [SD], 3.76 [0.50]) compared with men (3.88 [0.47]) and had an overall difference in mean of –0.12 (95% CI, –0.18 to –0.03). The mean (SD) MK ratings were not different in women (4.10 [0.47]) compared with men (4.18 [0.47]) for the year-end assessment.

Differences in WQE scores were not found between women (786.39 [57.10]) and men (793.59 [59.39]). A main-effects model found that residents with a higher MK or PC domain average rating scored higher on the WQE, with the association found in both genders.

There were some limitations to this study. Other core competencies could not be assessed for potential biases due to other competencies being more subjective. The composition of clinical competency committees was not studied and therefore no data on unconscious bias training were included. The national scale of the study didn’t allow for evaluation of biases in specific programs. The potential of gender bias in the WQE cannot be excluded. Gender data could have reflected the resident’s own declaration or been assessed by the program director. Race and ethnicity also were not able to be assessed in this analysis.

Major gender bias was not found in 2 general competencies of the ACGME ophthalmology Milestones. However, the midyear mark showed differences in MK ratings between men and women. The researchers concluded that it is vital to consider all contributors to gender disparities and support gender equity in the ophthalmologic space.


Huh DD, Yamazaki K, Holmboe E, et al. Gender bias and ophthalmology accreditation council for graduate medical education milestones evaluations. JAMA Ophthalmol. Published online September 14, 2023. doi:10.1001/jamaophthalmol.2023.4138

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