The United States continues to face racial and ethnic health care disparities for both patient and physician populations. Minority groups underrepresented in medicine (URiM) make up 30% of the US population.¹ As of July 2019, according to the American Association of Medical Colleges, of all practicing physicians in the United States, 5.8% identified as Hispanic, 5% identified as Black/African American, 0.3% as American Indian or Alaska Native, and 0.1% as Native Hawaiian/Pacific Islander.² A recently published paper reported a meager 4% increase in the proportion of Black physicians in the United States from 1900 to 2018.³ The field of ophthalmology faces an extreme diversity challenge, with only 6% of practicing ophthalmologists identifying as minorities.¹ This dearth extends to retina, in which fewer than 100 specialists out of the 2,400 in the United States today identify as URiM.

Ophthalmology faculties follow the same trend in being less racially and ethnically diverse than the US population and other fields of medicine. Research published in 2021 in Ophthalmology identified the specialty as having the third lowest proportion of URiM groups among 17 other clinical departments.⁴

Beyond these basic measures, few data exist. This is in part because providing race and ethnicity information is often optional for those seeking membership in professional organizations or trainees applying to programs. While it is difficult to gauge the level of progress without more robust baseline information, it is safe to say that based on the available evidence as well as anecdotal experience, that the racial gap in both ophthalmology and retina has not changed significantly over the last few decades.

The reasons for this stagnation are numerous and complex. In 2019, 12% of US medical school graduates identified themselves as a URiM.⁵ This shortage of minorities pursuing and entering the field of medicine compared to the general population leads to an even smaller pool of candidates entering ophthalmology and, consequently, even fewer specializing in retina. Xierali et al found that the level of interest in medical students in the field of ophthalmology was less than 3% and even lower among URiMs.¹ The current lack of minority representation in retina, particularly in academic leadership, may dissuade young minority students or residents from envisioning themselves in or even exploring the field, thus perpetuating an unfortunate cycle. Changing the paradigm is critical to the future of retina, of ophthalmology, and indeed medicine as a whole.

THE DIVERSITY ADVANTAGE

Increasing diversity means gaining a greater variety of perspectives, which can improve everything from clinical decision making to practice management, research, and, of course, patient care and outcomes. Any comprehensive solution to the health care disparities faced by communities of color in the United States must include an expansion of diversity among health care providers.

Patients often seek out care givers to whom they feel they can relate.⁶ Indeed, studies have shown that patients may feel an increased level of trust in doctors who are of similar background to their own.⁷ In one study, Black subjects were more likely to talk about their health problems and engage in preventative health services when they saw a Black doctor.⁸ This is especially true for some patient groups who have been alienated or negatively impacted by the health care system in the past and, therefore, have an elevated level of distrust in the medical community in general. Given the prevalence of diabetic eye disease and glaucoma in minority populations and their disproportionately devastating effect in these groups, retina specialists often treat and interact with patients from underserved communities. Additionally, URiM physicians are more likely to care for this population.⁸ Ensuring these patients have access to doctors to whom they feel they can relate not only could improve their level of comfort and trust but also could lead to improved communication and increased compliance.

A more diverse population of health care providers has the potential to improve care on a universal level. The more opportunities health care professionals have to interact with people from different backgrounds, cultures, and socioeconomic circumstances, the greater their ability to empathize with and address the challenges and needs of all patients. Studies have indicated that students who attend medical schools with greater diversity are more comfortable taking care of diverse populations.^9,10 Gaining exposure to people from different backgrounds can also make us better colleagues, helping us recognize bias and inappropriate behavior and increasing our cultural competency.

CATALYSTS FOR CHANGE

Several key drivers can serve as catalysts for making retina a more diverse subspeciality, including increasing opportunities for networking and mentorship. Connecting young minority medical students with fellows and practicing professionals from similar backgrounds creates a community that understands and supports each other, and helps people entering the field visualize themselves pursuing a career in retina. For these students, who may not have family members or other social connections to the field, creating these connections is critical.

As their careers mature, having this network can help young professionals cope with the challenges that URiM physicians often face, such as microaggressions or unconscious bias, from patients or in the workplace. Having a relationship with someone who has had similar experiences and can offer advice for navigating them can benefit them both professionally and personally.

Once a mentee has progressed in the field, we ask them to “pay it forward” by mentoring those entering the field behind them. Having a network of colleagues who understands the challenges of juggling these responsibilities with career demands can help others find balance.

Programs dedicated to creating mentoring and networking opportunities include the Rabb-Venable Excellence in Ophthalmology Research Program and the Minority Ophthalmology Mentoring (MOM) Program from the American Academy of Ophthalmology (AAO) and Association of University Professors in Ophthalmology (AUPO).

Established by the National Medical Association (NMA) — the oldest and largest organization representing African American physicians and healthcare professionals in the United States — the Rabb-Venable Program encourages and fosters interest in ophthalmology among URiM medical students, as well as in those who desire to work in underserved communities. Established in 2000, the Rabb-Venable Program is named in honor of Dr. Maurice Rabb Jr., and Dr. Howard Phillip Venable, 2 outstanding African American ophthalmologists dedicated to patient care, teaching, and research. The program is also supported by the National Institutes of Health National Eye Institute.

Rabb-Venable provides annual travel awards to attend the NMA Ophthalmology Section’s annual meeting, where the participants present their original research, get speaker training and have the opportunity to network with URiM ophthalmologists, among whom are ophthalmology department chairs and residency program directors, academicians and private practitioners. The program also provides mentoring, career development, and volunteer opportunities. Having the chance to present research through this program allows students to connect with experienced attendings in various subspecialties as well as with residents or fellows just a few years ahead.

Young professionals who participate in the Rabb-Venable program often continue on as mentors. Several have even gone on to chair the NMA ophthalmology section — a key access point for recruiting minority medical students into the specialty. Due to COVID, the 2020 and now the 2021 activities are virtual.

Last year, Rabb-Venable offered “fireside chats” for medical students applying in ophthalmology. These virtual meetings featured program directors sharing information about their programs and giving medical students an idea of what they are looking for. This series also created a network among those who were applying that allowed them to connect and share information with each other about the interview process. This level of camaraderie goes a long way toward fostering a more welcoming environment for these prospective students. The Rabb-Venable website was recently updated with support from Aerie Pharmaceuticals and Sam Brown Communications, and is a great resource for more information about the program.

The AAO partnered with the AUPO to create the MOM program. In the MOM program, students have access to mentorship, career guidance, networking opportunities, and educational resources.

In addition to these great programs, the American Academy of Retina Specialist and Retina World Congress have recently created committees to address similar pipeline and mentoring need assessments for residents and fellows with careers in retina.

Diversity in academic institutions and leadership in ophthalmology must increase to further break down the barriers that can impede those who are URiM from entering the field. Those involved in the admissions process may seek, perhaps subconsciously, characteristics of people who are “like them” because they feel these would make the candidate a good “fit” based on the current makeup of the faculty and residency. Without more diverse leadership, it will be harder to achieve greater diversity in ophthalmology programs and retina fellowship programs as well.

HOW EVERYONE CAN MAKE A DIFFERENCE

Increasing diversity is not something that naturally changes over time; it requires a concerted effort, and everyone can help by broadening their perspectives and expanding their personal connections. Reach out to people beyond your usual network. Take a look at your organization for opportunities to make a change. Think outside your usual referral patterns when planning research, publications, and speaking engagements. If you are responsible for a fellowship program, look beyond the biggest name programs or the one where your mentor is.

Retina is an incredibly competitive field, and all retina specialists have earned their accomplishments through their intelligence and hard work. Increasing diversity is about leveling the playing field so that everyone with the same intelligence and work ethic has the same chance to excel, and advance patient care, regardless of their background. RP

REFERENCES

1. Xierali IM, Nivet MA, Wilson MR. Current and Future Status of Diversity in Ophthalmologist Workforce. JAMA Ophthalmol. 2016;134(9):1016-1023. doi:10.1001/jamaophthalmol.2016.2257
2. American Association of Medical Colleges. https diversity in medicine: facts and figures 2019. Accessed June 21, 2021. https://www.aamc.org/data-reports/workforce/report/diversity-medicine-facts-and-figures-2019
3. Ly DP. Historical trends in the representativeness and incomes of black physicians, 1900-2018. J Gen Intern Med. 2021;10.1007/s11606-021-06745-1. doi:10.1007/s11606-021-06745-1
4. Fairless EA, Nwanyanwu KH, Forster SH, Teng CC. Ophthalmology departments remain among the least diverse clinical departments at United States medical schools. Ophthalmology. 2021;S0161-6420(21)00012-9. doi:10.1016/j.ophtha.2021.01.006
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6. Takeshita J, Wang S, Loren AW, et al. Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings. JAMA Netw Open. 2020;3(11):e2024583.
7. Cuevas AG. Exploring Four Barriers Experienced by African Americans in Healthcare: Perceived Discrimination, Medical Mistrust, Race Discordance, and Poor Communication. Dissertation. Portland State University; 2013. https://doi.org/10.15760/etd.615
8. Alsan M, Garrick O, Graziani GC. Does Diversity Matter for Health? Experimental Evidence from Oakland. NBER Working Paper No. 24787. June 2018. Revised September 2018. https://www.nber.org/system/files/working_papers/w24787/revisions/w24787.rev1.pdf
9. Xu G, Fields SK, Laine C, Veloski JJ, Barzansky B, Martini CJ. The relationship between the race/ethnicity of generalist physicians and their care for underserved populations. Am J Public Health. 1997;87(5):817-822. doi:10.2105/ajph.87.5.817
10. Saha S, Guiton G, Wimmers PF, Wilkerson L. Student body racial and ethnic composition and diversity-related outcomes in US medical schools. JAMA. 2008;300(10):1135-1145. doi:10.1001/jama.300.10.1135