Blurred lines unconscious bias in eye healthcare

Unconscious bias shows up in the split second when we imagine a ‘difficult patient’ or a ‘strong clinician’. It appears when a female doctor or optometrist is mistaken for a nurse or part of the administrative team. It arises when a Māori, Pasifika or First Nations colleague is expected, explicitly or implicitly, to speak for their community. It is present when one trainee is encouraged to attempt a complex case, while another is asked to assist once again.

We do not choose these biases and we rarely notice them. They are not malicious acts; they are acts of familiarity. But they influence how we judge competence, interpret behaviour and allocate opportunity.

The brain science

Unconscious bias exists because our brains are wired for speed. They process vast amounts of information every second and rely on shortcuts to function efficiently. Most of the time, these shortcuts help us. Sometimes, they distort what we see.

Three parts of the brain are central to this:

• The amygdala categorises information, including people, into familiar patterns.
  
  
• The basal ganglia reinforces these patterns, giving us a dopamine ‘reward’ for choosing what feels comfortable.
  
  
• The prefrontal cortex is the reflective, analytical centre that can interrupt bias, but it only engages when we slow down.
  
  

On busy clinical days, when we are rushed or fatigued, the prefrontal cortex steps aside and automatic thinking dominates. Bias lives in this space – not in intention, but in efficiency.

Gaining an understanding of this shifts the conversation away from personal blame and towards human wiring and offers practical ways to interrupt bias in real time.

How bias shows up in micro-moments

Bias rarely appears as a single defining moment. It shows up in the hundreds of micro-decisions that make up a working week.

• In ophthalmology clinics, who is trusted to consent independently? Whose plan is double-checked without a clear reason?
  
  
• In optometry practices, who gets extra chair time and who is hurried? Who is assumed to be price-sensitive, non-compliant, or unlikely to return?
  
  
• In the operating theatre, who gets the lead in the complex cataract case? Who receives detailed technical feedback vs “You’re doing fine”?
  
  
• In teaching, whose tone is labelled ‘confident’ and whose is termed ‘abrasive’? Who is encouraged to present or publish and who is asked to help with the references?
  
  

Each moment is small but, over time, they compound to build confidence or quietly erode it. Bias rarely shapes a career through one decision; it shapes it through a hundred small ones.

Why this matters for eye health care

The eye-health literature across ophthalmology, optometry and vision science is consistent: bias shapes opportunity, perception and patient outcomes.

Surgical opportunity

A 2021 RANZCO study analysing more than a decade of trainee logbooks found that female trainees performed about 40% fewer cataract surgeries than their male peers, even after adjusting for part-time training and parental leave¹. Studies from the US, UK and Canada report similar patterns^2,3. Covid-19 widened this gap further, with female trainees’ surgical volumes falling while male volumes remained stable⁴. Ethnicity data are still developing, but RANZCO’s Te Kitenga: Vision 2030 highlights the under-representation of Māori and Pasifika clinicians and identifies improved measurement as essential to future workforce planning⁵.

Patient outcomes

A landmark BMJ study involving 1.3 million patients found those treated by female surgeons had lower 30-day mortality and complication rates, even after accounting for case complexity⁶. A 2023 follow-up study confirmed these findings across multiple specialties⁷. The message is not that one gender delivers better care – it is that diverse clinical teams consistently deliver safer care. When training opportunity is unequal, patient outcomes can be too.

Clinical decision-making and communication

Bias is not confined to surgery. Across healthcare, evidence shows it operates quietly in everyday communication and assumptions. Female clinicians are more likely to be mistaken for non-clinical staff, judged on warmth rather than competence and given feedback that is vague or personality-focused^8,9,10. Patients also interpret identical behaviours differently depending on a clinician’s gender or ethnicity, perceiving male clinicians as confident, women as reassuring and minority clinicians as less certain, even when the information delivered is the same^11,12. These perception gaps matter. They influence how clinicians are viewed, how recommendations are received and whose authority is recognised in the clinical room.

Structural bias

Not all bias shows up in conversations – some sit quietly in the structures we’ve inherited. Many leadership and committee roles were designed decades ago for a workforce that looked very different. They rely heavily on personal time, unpaid work and goodwill. But goodwill has a cost and that cost isn’t the same for everyone. For some, attending a meeting means stepping away briefly from clinic. For others, particularly those in regional areas, it may mean cancelling clinics or losing an entire day to travel.

Much of the invisible work that sustains professional communities – mentoring, advocacy, cultural leadership and education – tends to fall to the same people repeatedly. These structures are not intentionally exclusionary, but they reflect earlier versions of our professions. When participation depends on who can absorb the extra load, it shapes who leads and whose voices influence decisions.

One of the clearest indicators of unconscious bias is language. Across academic fields, analyses of letters of recommendation show women are more often described using personality traits such as ‘hard-working’ or ‘reliable’, while men are described using ability-based terms like ‘brilliant’, ‘decisive’ or ‘exceptional’^13,14. These differences, although subtle, consistently shape how readers judge competence and potential.

Medicine follows the same trend. A large 2017 Academic Medicine study found women’s recommendation letters contained more cautious phrases and fewer statements of capability, while men’s were longer, more assertive and focused on achievement¹⁵. In ophthalmology, studies show men and women achieve equivalent objective performance scores, yet narrative feedback differs. Men are more often praised for technical skill and leadership, while women are praised for communication and teamwork⁸. These linguistic differences shape perceptions of readiness and potential. Language influences opportunity. Opportunity shapes careers. Careers shape patient care.

Practical steps to remove bias

Bias isn’t reduced by goodwill alone; it shifts when we act with intention.

• Slow the decision. A brief pause allows reflective thinking to engage and that’s where bias can be interrupted.
  
  
• Anchor feedback to behaviour, not personality. Instead of “You are not confident in theatre,” consider: “Let’s look at your hand position during capsulorrhexis - here's what worked well and here’s what could be improved.”
  
  
• Check your adjectives. Would you describe another person the same way?
  
  
• Widen your circle of trust. Notice who you support automatically and who you overlook.
  
  
• Champion, don’t just mentor. Advocacy creates opportunity.
  
  
• Modernise structures where possible. Leadership should not depend on who can afford the cost.
• Don’t assume neutrality. If a workplace structure feels ‘neutral’ or ‘easy’, it may simply be designed around people with similar circumstances to your own.
  
  

A clearer way forward

We are a profession built on clarity, yet bias quietly blurs the view. Unconscious bias is not a failure of values. It is most active when we are busy, fatigued, or under pressure, when fast, automatic thinking takes over and reflective judgement steps back. Modern clinical environments, with their pace and cognitive load, make this risk more likely, not less.

Bias begins early, compounds silently and shapes opportunity and care through hundreds of small decisions rather than a single moment. Awareness is the first correction; creating space to slow down, even briefly, is the second. If we want a profession that reflects our communities and supports future leaders, the shift does not begin with blame or intent, it begins with us – one pause, one decision, one clearer lens at a time.

References

1. Gill HK, Niederer RL, Danesh-Meyer HV. Gender differences in surgical case volume among ophthalmology trainees. Clin Exp Ophthalmol. 2021 Sep;49(7):664-671. doi: 10.1111/ceo.13969. Epub 2021 Jul 24. PMID: 34218497
2. Gong D, Winn BJ, Beal CJ, et al. Gender Differences in Case Volume Among Ophthalmology Residents. JAMA Ophthalmol. 2019 Sep 1;137(9):1015-1020. doi: 10.1001/jamaophthalmol.2019.2427. PMID: 31318390; PMCID: PMC6646997.
3. Culican SM, Syed MF, Park YS, Hogan SO. Gender Differences in Case Volume Among Ophthalmology Resident Graduates, 2014-2023. JAMA Ophthalmol. 2025 Jun 1;143(6):490-497. doi: 10.1001/jamaophthalmol.2025.0935. PMID: 40310612; PMCID: PMC12046517.
4. Katovich H, Singh V, Michael E, McKelvie J. Gender disparity and the impact of COVID-19 on surgical training in New Zealand ophthalmology. N Z Med J. 2025 Sep 19;138(1622):56-65. doi: 10.26635/6965.7003. PMID: 40966699.
5. RANZCO. Te Kitenga: Vision 2030 — Equity & Workforce Strategy. RANZCO; 2023.
6. Wallis CJD, Jerath A, Coburn N, et al. Association of Surgeon-Patient Sex Concordance with Postoperative Outcomes. JAMA Surg. 2022 Feb 1;157(2):146-156. doi: 10.1001/jamasurg.2021.6339. PMID: 34878511; PMCID: PMC8655669.
7. Wallis CJD, Jerath A, Aminoltejari K, et al. Surgeon Sex and Long-Term Postoperative Outcomes Among Patients Undergoing Common Surgeries. JAMA Surg. 2023 Nov 1;158(11):1185-1194. doi: 10.1001/jamasurg.2023.3744. PMID: 37647075; PMCID: PMC10469289.
8. Huh DD, Yamazaki K, Holmboe E et al. Gender Bias and Ophthalmology Accreditation Council for Graduate Medical Education Milestones Evaluations. JAMA Ophthalmol. 2023 Oct 1;141(10):982-988. doi: 10.1001/jamaophthalmol.2023.4138. PMID: 37707837; PMCID: PMC10502694.
9. Pittman M, Sacks T. ‘I’m Not the Doctor’: Gendered Misrecognition in Health Care. Social Science & Medicine. 2021;270;113601
10. Klein R, Kennedy K, et al. Gender Bias in Resident Assessment: A Systematic review. J Gen Intern Med. 2022;37:2037-2045
11. Schmid MM, Kadjii KK. How Gender and Ethnicity Shape Patient-Physician Communication. Patient Education and Counseling. 2018;101(12):2118-2123
12. Haider AH. Et al. Association of Racial and Gender Bias with Patient Assessment of Emergency Department Proviers. JAMA Network Open. 2019;2(11):e1914443
13. Trix F, Psenka C. Exploring the color of glass: Letters of recommendation for female and male medical faculty. Discourse & Society. 2003;14(2):191–220. doi:10.1177/0957926503014002277.
14. Madera JM, Hebl MR, Martin RC. Gender and letters of recommendation for academia: agentic and communal differences. J Appl Psychol. 2009 Nov;94(6):1591-9. doi: 10.1037/a0016539. PMID: 19916666.
15. Tifferet S, Barshtein G, Basson R, Jaffe A. Gender differences in medical recommendation letters. Academic Medicine. 2017;92(8):999–1005.
    
    

Dr Liz Insull is an ophthalmologist and oculoplastic surgeon at Eye Institute, working in private practice across Hawke’s Bay and Wellington with a focus on eyelid, lacrimal and periocular care. She is the current RANZCO NZ chair and a Heather Mack Women in Leadership Scholarship recipient. Liz is passionate about collaboration, leadership and strengthening regional eye care.