Ophthalmology Leaders See Hope for Diversity

Laird Harrison

November 22, 2021

NEW ORLEANS — Leaders of the American Academy of Ophthalmology (AAO) are seeing signs of hope that their profession will become more ethnically and racially diverse despite decades of slow progress.

Dr Tamara Fountain

Subspeciality groups have formed task forces seeking to make ophthalmologists more representative of the population they serve, and the AAO's 5-year-old mentorship program for underrepresented groups has received an infusion of donations in the past year, said AAO President Tamara Fountain, MD.

These efforts may not yet be reflected in the statistics on race and ethnicity — which are among the worst of any US medical specialty — but they are providing crucial encouragement, she told Medscape Medical News.

"It's touched a groundswell of people who have felt marginalized in our workforce, in our training programs, who come to these Academy meetings and realize there's something for them, that we, this behemoth of a medical organization devoted to eye care, is speaking to them and is looking out for them and providing the support that they need," she said.

Fountain was one of 18 panelists who spoke here at a symposium devoted to diversity, equity, and inclusion at the American Academy of Ophthalmology (AAO) 2021 Annual Meeting.

One by one, speakers displayed slides demonstrating the stark underrepresentation of most ethnic groups in ophthalmology.

Together, Black, Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander people made up only 6% of practicing ophthalmologists in 2015, according to a JAMA ophthalmology study cited by Basil Williams, MD, assistant professor of ophthalmology at the University of Cincinnati College of Medicine, Cincinnati, Ohio.

That contrasted not only to the 30.7% share of these groups in the total US population that year but also to their proportion among ophthalmology residents (7.7%) and medical students (16.4%). The study also found that these numbers had barely budged in a decade. Citing an article in Ophthalmology that she co-authored, Kristen Nwanyanwu, MD, MBA, said that university ophthalmology departments are the third least diverse among all US medical specialties.

Dr Angela Elam

"The numbers you have shown are dismal, just dismal," said panelist Terri L. Young, MD, MBA, the chair of the Department of Ophthalmology and Visual Sciences at the University of Wisconsin, Madison. "Folks are getting different compensation schedules. They're given different resources. They're given different leadership opportunities. They're certainly not getting the proper coaching for promotion."

The lack of ophthalmologists from the underrepresented groups has consequences for patient care, said Angela R. Elam, MD, assistant professor of ophthalmology at the University of Michigan, in Ann Arbor.

Racial and ethnic minorities are at greater risk of losing vision from eye disease, she said, citing an article she coauthored in Survey of Ophthalmology. In part, this is due to income, she said. For example, people enrolled in Medicaid receive less glaucoma care than people enrolled in commercial health plans.

But even after controlling for other socioeconomic factors, the disparities between Black and White patients remain. For example, Black patients are more likely than White patients to undergo enucleation or evisceration after eye trauma, Elam said.

Jayanth Sridhar, MD, associate professor of clinical ophthalmology at the Bascom Palmer Eye Institute in Miami, Florida, who has researched diversity in ophthalmology, said several explanations have been proposed for glaucoma's weak track record compared to other medical specialties.

First, many people from underrepresented backgrounds think of primary care as an obvious way to contribute to their communities, he told Medscape Medical News.

Second, many medical schools don't include ophthalmology rotations, so students don't consider it as an option for their residencies. Third, more than in other specialties, ophthalmologists are exposed to the specialty because someone in their family is an ophthalmologist.

Finally, ophthalmology is a competitive specialty, with more students applying relative to the number of residencies than the average specialty, said Sridhar, who was not part of the symposium.

"When it comes to applying and matching in a competitive field, you may not be prepared," he said. "You did not get the sufficient mentorship. You didn't start doing the shadowing and research early on, you didn't go and find out the ophthalmologists at your institution. So you're kind of behind the eight ball."

The AAO is attempting to address the problem in conjunction with the Association of University Professors of Ophthalmology through its program Minority Ophthalmology Mentoring, Fountain said. Founded in 2016, the program matches medical students to ophthalmologists and provides support and training programs to the students. It has grown rapidly in recent years, doubling in size to 50 students from 2019 to 2020. Its budget is $297,459 for 2021.

Keith Warren, MD, who has a private retina specialty practice, said it troubles him that he is the only Black American ophthalmologist in Kansas City, Missouri. A decade ago, he brought up the problem to leadership at the American Society of Retina Specialists (ASRS) but got little response, he told Medscape Medical News.

Then the COVID-19 pandemic made many people more aware of disparities in healthcare, and incidents of police brutality that were publicized in 2020 put a spotlight on racism. So he wrote an article in the ASRS publication Retina Times, calling for new efforts to diversify the subspecialty. This time the leadership asked him to form an ad hoc committee, which is looking for ways to address the problem.

One idea: mentorship "families" in which ophthalmologists at all stages of their careers mentor each other. For example, the younger members in each group can offer advice about new technology to the older ones, while the older ones provide career advice.

Warren draws encouragement from changes at the top of the AAO, as well. Both Fountain and the organization's CEO, Stephen D. McLeod, MD, are Black. Warren is pleased that the US Medical Licensing Examination Step 1 exam will become pass-fail starting January 26, 2022, because some studies have found the test to be biased against people from underrepresented groups.

White ophthalmologists have a role to play as well, Warren said. The first ophthalmologist to encourage him in the career was his mother's doctor, a White man.

And sometimes it's a matter of creating a safe space where people from underrepresented backgrounds can express their views. "Part of safety is listening," he said. "It is compassion. You have to understand that ultimately, it's going to benefit you because you would have employees that can bring things to the table that you might not have heard otherwise. Your patient population could certainly expand if you have a diverse workforce."

As she stepped down from the podium after the symposium, Fountain was greeted by Harry Levine, a medical student from Mexico who is studying at the University of Miami, Florida. "Every time I see something like this it is reassures me that I'm picking the right career," he told her. "People on the top care for minorities and we're valued. It's gratifying to see that."

"That's one example of why I'm optimistic," Fountain said.

American Academy of Ophthalmology (AAO) 2021 Annual Meeting: Abstract SYM39. Presented November 16, 2021.

Laird Harrison writes about science, health, and culture. His work has appeared in magazines, newspapers, on public radio, and on websites. He is at work on a novel about alternate realities in physics. Harrison teaches writing at the Writers Grotto. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.

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