Progress needed to improve underrepresentation in retina
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Underrepresented populations are not a new phenomenon in ophthalmology, specifically in the retina subspecialty.
According to the most recent U.S. Census Bureau statistics, minority populations made up 38% of the U.S. population in 2014 and are expected to exceed 50% of the population by 2044. Yet, the demographics of the ophthalmology workforce do not reflect this rapidly changing diverse U.S. population.
Source: Carly Croft Kidd
A secondary analysis of medical school faculty demographic data from the 2019 American Association of Medical Colleges Faculty Roster showed ophthalmology faculty are less racially and ethnically diverse compared with graduating medical students and the U.S. population in general. In that study, published in 2021 in Ophthalmology, Fairless and colleagues found that ophthalmology has the third-lowest proportion of underrepresented minority faculty compared with 17 other clinical departments.
“The field of general ophthalmology was third to last in terms of representation in academic faculty. That is not great and is definitely an issue that we need to address,” Jessica D. Randolph, MD, said. “It is a historical issue. Surgical subspecialties in general, especially something as niche as ophthalmology, do not have the exposure like other specialties do. Many of our historically excluded populations are not exposed to the field of ophthalmology.”
There is no doubt that the retina field is lagging in addressing gender and racial equality among physicians, according to Basil K. Williams Jr., MD.
“We don’t have a lot of great data to show this, unfortunately, but when looking at ophthalmology in general, we know that the specialty is among the least diverse fields from a racial and ethnic standpoint and definitely not as diverse as a number of other specialties from a gender standpoint,” Williams said. “Extrapolating that data to retina, which is an even smaller field and historically has been more white male dominated, there is no doubt that this is the case. Over time, from a gender standpoint, we have been making some improvements but there is still a lot more work to be done to create a better balance from a race and ethnicity standpoint. We are making some progress, or at least attempts at progress, but we have not made as much progress as we’d like in the retina field.”
Representation of women
Gender inequality affects many aspects of the ophthalmology field.
In a 2019 study published in JAMA Ophthalmology, Kramer and colleagues found that despite the increasing number of women graduating from ophthalmology residency programs, there is not a corresponding increase in women in leadership positions.
Another study published in 2021 by Fathy and colleagues showed gender disparity among senior authors of published research in ophthalmology. Data indicated that women make up a smaller proportion of first and senior authors of editorial articles in top ophthalmology journals despite growth in recent years.
Female academic ophthalmologists are also paid less than their male counterparts.
A 2022 cross-sectional study by Emami-Naeini and colleagues showed that female ophthalmologists were paid a mean of $50,300 less than their male counterparts. Moreover, women across all medical specialties earned less than men by amounts that ranged from $25,100 in nonsurgical specialties to $104,400 in general surgery. Overall, women’s compensation was between 75% in general surgery and 82% in nonsurgical specialties of men’s compensation.
“There is still discrimination toward women in our field,” Randolph said. “There is this antiquated viewpoint that women are at home taking care of the kids and how will we perform surgeries and handle call schedules. But in modern times, women have again and again proven that this is a complete fallacy and archaic thought pattern that arises from the past. In fact, research has statistically shown that women are better physicians than men, and retina is no exception. Gender discrimination is an issue, and even in my own path and my journey through medicine at all levels, I have been discriminated against in different ways because I am a woman, because I am Black and because I am a Black woman.”
Representation matters
Disparities in representation of Black, Hispanic and Native American physicians have also long plagued the ophthalmology field.
“The retina community and ophthalmology as a whole have lagged far behind in addressing gender and racial equality. However, there have been some advances that have been made with regard to gender differences. Many ophthalmologic societies have dealt with gender issue, and they’ve actually done a great job of addressing it,” Keith A. Warren, MD, said. “The realization should be that we already know that we can address disparity. We also know that diversifying the retina field will make it better for all involved, particularly the trainees and practicing members, but more importantly for our patients. The events of the COVID-19 pandemic, with regards to social investment, have highlighted the need for a closer look at the disparity in health care as it pertains to those underrepresented racial minority groups in medicine.”
In the study by Fairless and colleagues, data showed Black physicians represented 6.7% of graduating medical students but only 2.3% of ophthalmology faculty, followed by Hispanic physicians representing 8.6% of graduating medical students but only 2.3% of ophthalmology faculty, and Native American physicians representing 0.9% of graduating medical students and only 0.03% of ophthalmology faculty.
There is a host of reasons as to why this racial disparity is occurring, Williams said.
“No. 1 is representation. There is the concept that ‘you have to see it to be it.’ I did not have a Black ophthalmologist to look up to when I was young, before I became interested in the ophthalmology field. That inspired me to go into the field. We look up to role models, and having someone who is your same gender, race and ethnicity and speaks your language makes it a lot easier for you to see yourself in that position,” Williams said. “Next is exposure. Ophthalmology is not one of the core rotations in medical school, and retina is a subspecialty of that, so if you go to a medical school that does not have a strong ophthalmology department or an ophthalmology department at all, you may not get exposed to it and therefore may not know or hear about it.”
Implicit bias also plays a key role.
“We know that people from different racial or ethnic groups may have lower acceptance rates to positions in the medical field. This is particularly true for Black applicants,” Williams said. “Part of the thought process is that individuals on admissions committees are looking for people who look like them because they think that they do a good job in their practice, and so identifying people who are like them is good. This is not specifically related to gender, race or ethnicity, but in some ways on an implicit level that does affect gender, race and ethnicity,” Williams said.
People from underrepresented backgrounds are also more likely to work in medical specialties caring for people of underrepresented backgrounds.
“Much of the push in medical school is for underrepresented minorities to take care of the communities of underrepresented minorities from a primary care standpoint. Ophthalmology and retina in particular are not considered primary care fields, and so we definitely have increased numbers going into family medicine, internal medicine and gynecology, but not ophthalmology,” Williams said. “It is important to realize that retina does a lot of primary care. There is so much diabetes and hypertension management that happens in the retina field, which would be good to advertise. Another challenge is that if you don’t have as much exposure to ophthalmology, then your application may not be as strong, and you may not have the opportunities to publish and get as much research done. If our historically Black colleges and universities don’t have a large ophthalmology department, then the applications may not be as strong because they don’t have as much of an opportunity or as easy of an opportunity to get research done.”
OSN Associate Medical Editor Rishi P. Singh, MD, said there is a need to increase representation of ethnic, racial and gender minorities from the grassroots level.
“There have been trends to show increased representation of racial and gender proportions in major meeting participation, which is reassuring to us. However, sometimes trainees think that ophthalmology is not a profession for them because they are not of a specific gender or race,” Singh said. “That is our opportunity in the ophthalmic community to support them and promote them. We need as many diverse views as we possibly can have when deciding on the best care for patients, and having these varied opinions and skill sets is impactful.”
Trickledown effect on patients
A physician workforce that is representative of the patient demographic is imperative across all medical specialties, and the retina field is no exception.
“Based on published research, patient-physician concordance truly helps with better patient outcomes, and this is especially so with Black individuals who have been historically experimented on in medicine,” Randolph said. “There is a long history of prejudice and discrimination in medicine, and Black people do not trust the American health care system. When I see a patient that looks like me, there is this moment between us, especially with older patients, where we kind of lock eyes and they know that they can trust me maybe a little bit more than someone else who doesn’t share the same outward appearance as them. If we want to do better for our patients, then we need to have more physicians who look like them. This is not to say that somebody can’t identify with a patient who doesn’t look like them, but there is something special in knowing and trusting what happens when patients feel seen, and that more often happens with patients who share a common background with their physician.”
Williams agreed.
“The first thing that we need to look at is our patients because they are why we went into this field, to ensure that they have the best outcomes we can give them and that we do the best job for them,” Williams said. “There is a lot of information out there showing that gender, race and ethnicity concordance leads to better outcomes for patients. Many women patients feel more comfortable when their physician is a woman, and many patients from underrepresented backgrounds feel more comfortable with physicians from those underrepresented backgrounds. Working to increase the percentage of physicians who are women and who are from underrepresented backgrounds goes a long way in improving the disparities in the health care system, and it will translate to improved patient care.”
Having a more diverse faculty in ophthalmology could also lead to more diversity of patients in clinical trials.
“During the past 3 years, there have been landmark studies that have helped us better understand the inequities in clinical trials, and what we can do better as clinicians is coming to light now more than it has in the past,” Singh said. “One study in particular looked at clinical trial participants for a diabetes study, which showed that the trials themselves in the past few years have not been reflective of our patient populations with these conditions. A second study that I was the author on looked at racial inequalities with regards to care of diabetic retinopathy and diabetic macular edema and found inequities in the number of injections patients received as well as how they presented to our clinics. Many patients who were Hispanic and Black presented with much worse vision and unfortunately received fewer injections, which led to less improvement in the overall cohorts over time.”
Minority populations with diabetic retinopathy and retinal vascular disease may be better served by someone who looks like them, according to Warren.
“The data suggest that patients are more likely to comply with treatment and experience better outcomes when there is doctor-patient racial or ethnic concordance,” Warren said. “This is why there is a great need to have more underrepresented individuals practicing in retina.”
Looking ahead
There is always room for more growth in all areas of the medical profession, especially in the subspecialty of retina.
“We first have to admit that there is a problem before we can fix a problem,” Randolph said. “We need to be introspective and approach this with an open mind. There are so many inherent bias tests that are free and easily available online. Read books on the subject. Truly take a look at what your institution is doing. How are you hiring and retaining Black, Hispanic and Native American physicians, residents, fellows and staff? If your institution is not taking an active approach, then you are not promoting diversity and inclusion.”
Several organizations within the ophthalmology field are working to overcome this issue.
As previously published on Healio.com/OSN, the American Society of Cataract and Refractive Surgery welcomed more women into leadership roles for 2021-2022, with nine of the 26 current leadership positions being filled by women.
In addition, the Rabb-Venable program supports underrepresented medical students, residents and fellows in ophthalmology.
“The success rate of this program is quite impressive. The program has made a difference and has truly increased the number of Black and Hispanic students that have matched in ophthalmology,” Randolph said. “The American Academy of Ophthalmology also has the Minority Ophthalmology Mentoring program, which is specifically focused on mentoring. Students are paired with a mentor, and there are several time points throughout the year where mentors check in with mentees. They have even started offering a virtual program as well.”
Warren said there is a need for programs that offer opportunities to those underrepresented in medicine and to increase exposure and recognition of the ophthalmology field and its subspecialties.
“For example, the Association of University Professors of Ophthalmology and the American Academy of Ophthalmology have designed a program, dubbed the Minority Ophthalmology Mentoring program, which is designed to provide that exposure and opportunities to those who are underrepresented in medicine, and the program has done quite well,” Warren said. “When looking back at the past 3 years or so, the number of applicants who have matched in a residency program has significantly increased, and when looking at the matching of underrepresented minorities in ophthalmology specifically, that number has increased. However, this still does not address the significant need in retina.”
The American Society of Retina Specialists has developed a Diversity, Equity and Inclusion Committee to specifically look at ways to increase the number of underrepresented minorities practicing retina. Randolph, Williams and Warren are all committee members, Warren said.
The Vit-Buckle Society for vitreoretinal surgeons has the Fostering Careers for Underrepresented Stars (FOCUS) program, Williams said.
“The FOCUS program was recently launched, and the American Society of Retina Specialists is also working on their mentoring program that will hopefully launch at some point this summer. The Retina Society also has a research-based mentoring program that they’re going to be working on to offer to minorities,” Williams said. “There’s a lot of opportunities for increasing exposure and giving underrepresented populations opportunities to improve their curriculum vitae and have good mentorship and good support, so that we can gradually increase these numbers over time.”
In addition, individuals need to feel comfortable in these settings with good inclusion across the board, he said.
“Most of the mentoring programs will not only improve the numbers over time, but also ensure that these individuals feel comfortable and welcomed in the environment and have opportunities to be themselves, to practice well and to ultimately succeed,” Williams said. “We still have a lot of work to do, but these are fantastic steps that are happening so far.”
Randolph agreed.
“This work makes me hopeful, and I am glad that people are talking about it and working on it, but I hope it is not just lip service. My hope is that a lot of this discussion and talk and all of the things that have happened as a result of the George Floyd tragedy and other racially motivated issues in America spur real change,” Randolph said. “Things are better for me now as a young-generation retina specialist than they were for many of the pioneers, such as Maurice F. Rabb Jr., MD, Keith A. Warren, MD, Marcia D. Carney, MD, and Shelby R. Wilkes, MD, MBA, but things are still not perfect. There is still much work to be done.”
- References:
- Emami-Naeini P, et al. JAMA Ophthalmol. 2022;doi:10.1001/jamaophthalmol.2022.0376.
- Fairless EA, et al. Ophthalmology. 2021.doi:10.1016/j.ophtha.2021.01.006.
- Fathy CA, et al. JAMA Ophthalmol. 2021;doi:10.1001/jamaophthalmol.2021.3027.
- Keenan JS. American Society of Cataract and Refractive Surgery introduces more women leaders. https://www.healio.com/news/ophthalmology/20210708/american-society-of-cataract-and-refractive-surgery-introduces-more-women-leaders. Published July 8, 2021.
- Kramer PW, et al. JAMA Ophthalmol. 2019;doi:10.1001/jamaophthalmol.2019.3095.
- For more information:
- Jessica D. Randolph, MD, can be reached at Virginia Commonwealth University, 401 N. 11th St., Suite 439, Richmond, VA 23298; email: jessica.randolph@vcuhealth.org.
- Rishi P. Singh, MD, can be reached at Cleveland Clinic Florida, Martin Health, 200 SE Hospital Ave., Stuart, FL 34994; email: singhr@ccf.org.
- Keith A. Warren, MD, can be reached at Warren Retina Associates, 10100 W. 119th St., Overland Park, KS 66213; email: kwarren@warrenretina.com.
- Basil K. Williams Jr., MD, can be reached at Cincinnati College of Medicine, 3230 Eden Ave., Cincinnati OH 45267; email: basilkwilliams@gmail.com.
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