Race and Medicine

Race and Medicine

Source: Healio Interviews
Disclosures: Carter, Fountain, Olivier and Patel report no relevant financial disclosures.
January 22, 2021
10 min read
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Associations provide pathways for underrepresented minorities to succeed

Source: Healio Interviews
Disclosures: Carter, Fountain, Olivier and Patel report no relevant financial disclosures.
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The influence of race and racism in ophthalmology is evident in the numbers.

Of 94,243 students enrolled in U.S. medical schools in 2020-2021, 48.5% are identified as white while 7.6% are identified as Black or African American, according to Association of American Medical Colleges data.

Keith D. Carter, MD
When science-interested students are in late high school or college is the time to get them thinking about medicine, according to Keith D. Carter, MD.

Source: Keith D. Carter, MD

In the ophthalmology community, the diversity quotient is smaller still. Minorities represent about one-third of the U.S. population, but minorities among practicing ophthalmologists are only about 6%, with about half of that number identified as Black or African American. And so, there is a need for more diverse caregivers to serve an already diverse population.

There are programs in place intended to increase diversity in ophthalmology by helping underrepresented minority medical students become successful in the specialty.

The purpose of the Minority Ophthalmology Mentoring (MOM) program, a partnership between the American Academy of Ophthalmology and the Association of University Professors of Ophthalmology (AUPO), is to help such students become competitive ophthalmology resident applicants.

In the MOM program, students considered underrepresented in medicine identify as Black or African American, Hispanic or Latino, and/or Native American (American Indian/Alaska Native/Native Hawaiian).

“This year, of about 125 applicants, we got 50 students into the program. The previous year, we accepted 32 students. We have an ambitious goal next year of 100 students,” program chair Keith D. Carter, MD, said.

Each student is teamed with a volunteer ophthalmologist who is committed to mentoring them through their academic years.

“What we’re trying to do is get people to help these students who don’t have the same pathway to success, especially training in ophthalmology, that the majority students have,” Carter, who served as president of the AAO in 2018 and is current chairman and head of the department of ophthalmology and visual sciences at University of Iowa Health Care, said.

Similarly, the National Medical Association (NMA) Ophthalmology Section sponsors the annual Rabb-Venable Excellence in Ophthalmology Research Program, which “aims to increase our workforce to reflect the population, to increase diversity of ideas in our profession, and to help decrease systemic racism resulting from centuries of unequal treatment.”

Mildred M.G. Olivier, MD, and Eydie G. Miller-Ellis, MD, are co-directors of the program, funded by a grant from the NIH’s National Eye Institute. Both the NMA program and the MOM program provide mentorship, research and training opportunities.

Whereas the MOM program invites first- and second-year medical students to apply, the Rabb-Venable program has a place for latecomers, from first to fourth year medical students.

Mildred M.G. Olivier, MD
Mildred M.G. Olivier

“Almost all of my colleagues would tell you that they didn’t even know that ophthalmology existed until they were third-year students. In the Rabb-Venable program, you could be a fourth year, and we’re not saying it’s too late for you,” Olivier said.

The Rabb-Venable program is about recognizing the qualities one would like to have in their physician, she said.

Mentorship

Both programs have mentorship at their core, which is “absolutely key,” Olivier said. “Sometimes they see things in you that you don’t see, and they put you on a path of ‘you can.’”

In the MOM program, the selected students receive one-on-one mentorship, exposure to educational resources and Step 1 preparation materials, and assistance finding research and shadowing opportunities. At the AAO annual meeting, students are expected to engage with all facets of the specialty, participate in wet labs, learn about different technology and network.

Mentors do not necessarily need to identify as an underrepresented minority, as long as they first jump the hurdle of being willing to give their time and second jump the hurdle of being able to earn a mentee’s trust.

“The first interest is in the program. The second interest is in the individual student,” Carter said.

The student also needs to work at building that relationship of trust with their mentor.

“We tell our students that you have to engage your mentor. You have to realize this is a professional person who has a career and is giving time to help you. You have to take advantage of that generosity,” Carter said.

There is nothing to gain from the program if the student does not trust the recommendations and advice their mentor provides.

Exposure to ophthalmology

There is a wide swath of specialties competing for the small percentage of underrepresented minority medical students. For ophthalmology, getting competitive candidates to even know the specialty exists is a mission in itself. Exposure is vital.

“Part of the problem is that ophthalmology over the years has been seen increasingly by medical school administrators as being less relevant, so an ophthalmology rotation is not required in most medical schools. That is a tremendous problem for us,” AAO president Tamara R. Fountain, MD, said.

Ophthalmology is not unique in recognizing the power of recruiting competitive students.

Tamara R. Fountain, MD
Tamara R. Fountain

“Basically we are competing with orthopedics, with neurosurgery, with radiology, etc, for these small groups of underrepresented medical students. We’re not the only organization with established programs to attract medical students. So, we need to stay on our game to try to get these students into ophthalmology,” Fountain said.

Getting today’s medical students’ attention is different from earlier generations, Carter said. The approach has to meet the need. The MOM program includes a social media subchairman whose purpose is to figure out ways to reach this younger generation.

Purnima S. Patel, MD
Purnima S. Patel

“You have to go out and get them. There are a lot of talented under­represented minorities in medicine, and if you don’t go out and recruit them, they’re going to go somewhere else. Unless we get them early, we’re not going to be able to recruit these students into ophthalmology,” Purnima S. Patel, MD, associate professor of ophthalmology at Emory University, said.

Inspiring a new generation

“There’s a reason why in 30 years there are no more African Americans in ophthalmology than when I started,” Carter said. “If we’re 3% to 4% of ophthalmology but 13% of the population, can we get to 8% or 9%? If we got to 13%, I’d jump up and down, but that’s not realistic because we don’t have that many underrepresented minorities in medical school.”

Exposure again is key to feeding the pipeline of underrepresented minority medical students.

“We as medicine advocates need to be in those educational centers — undergraduate, high schools, maybe even grade schools — to talk about medicine as a career and what you have to do to prepare to be a competitive applicant in medicine,” Carter said. “All the positives of being a physician need to be relayed to these students. The way I look at it, we’re in competition for the talent of the students with all the other professional organizations that are out there in other ways to make a living and give back to society.”

As assistant dean for diversity and learning environment and professor of ophthalmology at Chicago Medical School of Rosalind Franklin University of Medicine and Science and John H. Stroger Jr. Hospital at Cook County, Olivier is reaching out to those young minds, looking at developing interest in all the medical sciences, not just ophthalmology.

“We have to grow the groundswell,” she said. “Let’s say we just graduated 500 Blacks across the country. How many of them can go into ophthalmology given there’s such a need for primary care? And then all the specialties want Black and brown people. So, how many are there that we can keep plucking for ophthalmology?”

An increase in the number of students with an interest in going into medicine in general, not just ophthalmology, is the place to start.

“At the grade school level, we’re really trying to get them into science, but then once they get into late high school and college, then we are trying get the science-interested student to think about medicine,” Carter said.

Olivier is digging deep, negotiating programs that would engage fourth and fifth graders to become interested in science and health care-related pursuits. Exposure at a young age is important, she said.

“We have to motivate underrepresented individuals into the STEM and science programs. If they don’t see people who look like them, they aren’t even thinking about it. Fourth and fifth grade is the age when science is cool, and they can see students of color teaching them. This is where you can start early to build the system,” Olivier said.

Subspecialty care

While there continues to be a paucity of underrepresented in medicine ophthalmologists, some diseases are overrepresented in communities of color.

Patients with glaucoma or diabetic retinopathy, for instance, may be more apt to adhere to their medication regimen or to confide in their ophthalmologist when they are seen to “look like me,” Olivier, who is a glaucoma specialist, said.

The disparities in health care related to socioeconomic status and racial status in the U.S., having been laid bare by COVID-19, cannot be denied, Fountain said.

“We’re going to harness the power of the IRIS Registry and partner with our industry colleagues to mine their data looking at those health care disparities,” Fountain said. “Armed with more granular information, that will be a greater tool for us to use to combat these disparities and to narrow the gap in the health care space as it relates to ophthalmology.”

One premise of the MOM program stated in its 2019 annual report is that “access to care improves when the physician community reflects the population at large.”

That representation engenders trust.

“A growing body of literature in primary care has documented associations between physician-patient racial-ethnic and language concordance (speaking the same language) and increased patient satisfaction and trust in the health care system,” Olivier and colleagues wrote in an editorial in Ophthalmology.

“There is a lot of mistrust in medicine, so if you can find a concordance, you already have that trust,” she said.

For Carter, the buy-in to the MOM program by ophthalmology subspecialty associations makes him proud.

“Many of them volunteer their time to be mentors. To see all the subspecialty areas thinking that recruiting underrepresented minorities in our profession is important, including our American Board of Ophthalmology, that is very powerful. That brings me the most joy because it means we’re starting to gain traction with the majority population,” he said.

George Floyd

Driving the increased awareness of the need for diversity and inclusion is the 2020 killing of George Floyd and the ensuing national unrest.

Medical associations have recognized both the problem of racism in the public they serve and the need to implement changes within their own structures. In a special meeting of its House of Delegates in November 2020, the AMA formally recognized race as a social construct rather than a biological construct while also “encouraging medical education programs to recognize the harmful effects of presenting race as biology in medical education through curriculum changes that explain how racism results in health disparities.”

It is different growing up Black or brown in America, Fountain said in remarks at the AAO’s annual meeting.

“Nearly every mother of a Black or brown child has had some version of ‘the talk’ with her children about how to comport themselves if ever in a law enforcement encounter. That is simply not something my white friends and colleagues have to do,” she said.

Within a week of Floyd’s killing in 2020, the AAO issued a statement condemning the act and committing to change: “The Academy is committed to inclusion, to the richness of a diverse society and to the principles of human dignity and societal equality. ... There is no place for racism.”

The AAO further initiated the #NoMoreRubberBullets #NotOneMoreEye campaign, calling upon law enforcement officials to immediately end the use of rubber bullets for crowd dispersion.

“We came out with that statement about George Floyd that essentially took a stand against the racism underlying his death and pledged to uphold the ideals of diversity and inclusion in our society as well as our organization,” Fountain said. “On the heels of that, during the early protests when we were seeing a relative rash of ocular injuries from kinetic projectiles, otherwise known as rubber bullets, we also felt an obligation as an organization whose sole mission is to empower people’s lives by saving their sight to make a statement about the damage that these kinetic projectiles can cause to the eye.”

Because Floyd’s death was so widely televised, the majority population — individuals, institutions, industries, academia — have awakened to and committed to change.

“Floyd was on TV. You saw the whole event. You saw this guy for the whole time go from talking to dead. And you realized he wasn’t doing anything wrong, not enough to be killed. And that turned the tide,” Carter said.

Next steps

For Patel, working for diversity and inclusion in ophthalmology makes her a better physician.

“I hope it’s personal for everybody. This is the right thing to do to treat and understand the population instead of making inferences,” she said. “The academy has had a nice start, but it can’t just be the academy doing this. The academy started it, AUPO supported it, but now it is magnified because all of these individual institutions are looking at this much more carefully and thinking about more active strategies.”

The beginning was to recognize the disparity and to quantify the problem.

“Next is thinking about how each of us can do a better job educating ourselves and trying to change the statistics. What can we do to serve our patients and bring in this diverse response to caring for patients,” Patel said.

Click here to read John A. Hovanesian, MD, FACS's blog, 'How to become color blind.'