September 2020

NEWS

Discussing diversity in ophthalmology


by Liz Hillman Editorial Co-Director

The public and recorded killing of George Floyd by a police officer in Minneapolis, Minnesota, on May 25 initiated several months of protests regarding police use of force and systemic racism in the U.S. As a result, the impact of racism and diversity are being discussed with renewed fervor and focus in many areas of American life, including within the healthcare system.
As it pertains to eyecare, research has shown several times over that there is a disparity in care among minority groups and patients with lower socioeconomic status compared to white patients and those of higher socioeconomic status.1 Alongside that, some of the most recent research on the makeup of the ophthalmology workforce found that women and minorities are underrepresented in the specialty—22.7% and 6%, respectively.2 According to this research, which examined data from 2005 and 2015 from the Association of American Medical Colleges, the American Medical Association, and U.S. Census, there was an increase in the proportion of women graduating medical schools and entering ophthalmology (23.8% to 27.1%), but the authors found no increase in underrepresented minorities. They also noted a decrease in underrepresented minorities among ophthalmology faculty. A separate study that evaluated racial and ethnic diversity among faculty in clinical academics also saw an increasing trend toward underrepresentation.3
“Medicine cannot reach its full potential without harnessing the talents of all segments of society,” said M. Roy Wilson, MD. Prior to becoming president at Wayne State University, Dr. Wilson was the deputy director for strategic scientific planning and program coordination at the National Institute on Minority Health and Health Disparities of the National Institutes of Health.
“Medicine serves everyone—rich or poor, man or woman, Black or white. When one or more groups are excluded, the profession does not have access to the talents of that group. Also, research has shown that minority physicians tend to serve minority communities and minority communities are relatively underserved,” he said.
Imam Xierali, PhD, and Marc Nivet, EdD, coauthors with Dr. Wilson on the study published a few years ago about the makeup of the ophthalmology workforce, wrote to EyeWorld about several benefits of a diverse workforce. Dr. Nivet was chief diversity officer at the Association of American Medical Colleges when they conducted the study.
“Studies have found that physicians who are from minority groups underrepresented in medicine (URM) are important for the provision of healthcare for underserved populations and underserved locations,” Drs. Xierali and Nivet wrote. “Students from medical schools with more diverse student bodies report feeling more confident managing patients from different cultural backgrounds as well as having learned from individuals from different backgrounds. Patients receiving care from physicians of the same race/ethnicity report greater satisfaction with their treatment and greater communication with their healthcare professionals.”
According to the U.S. Office of Minority Health, there are 41.4 million Black/African Americans in the U.S. The data pulled from the American Medical Association masterfile by Xierali et al.’s study found 2.5% of ophthalmologists (out of 17,904) in 2015 were Black.
“Those are the numbers, and that’s not OK, but no one is talking about it,” said Daniel Laroche, MD.
“This shortage of Black ophthalmologists translates to lack of access to eyecare in Black communities across the country and higher rates of blindness from cataracts, glaucoma, and diabetic retinopathy. You’re not going to be able to offer premium healthcare to the population because people often identify and trust people from their culture and community,” Dr. Laroche said. “Also, when you live in such a diverse country, when you have diversity in leadership, you make better decisions, you make better conclusions, you make better plans because you have less omission that some people might not even think about because you are incorporating everyone’s diverse experience. Diversity is extremely important when addressing solutions to complex health issues and disparities.”
Dr. Laroche said he was among the first wave of Black medical students integrating in medical schools.
“When I went to Cornell Medical College, 10% of the class was African American men. I thought we had overcome the hump and were in the process of diversifying the medical workforce with that. But there’s been a regression that’s taken place over the subsequent time with reverse discrimination claims being made and institutions backing away from affirmative action and a more holistic approach for candidates.”
Dr. Laroche said there has been too much reliance on standardized testing, which he thinks has cultural and societal biases. Dr. Wilson also expressed a similar sentiment, saying that while there are likely many reasons for a lack of diversity in ophthalmology, one is the increasing importance of United States Medical Licensing Examination (USMLE) scores.
“Most residencies use a score cutoff to determine who gets interviewed, and the cutoff is typically very high,” Dr. Wilson said. “A more holistic review of candidates would be preferable. Plans are underway for the USMLE to become pass/fail, and I think this will offer greater opportunities for deserving minorities to be considered.”
The focus on standardized testing, Dr. Laroche thinks, starts in middle schools, with some middle schools around the country feeding into more specialized high schools that are designed to prepare students to become doctors, lawyers, and businesspeople.
“Some states have moved to a more holistic approach where they take the top students from each neighborhood community,” he said. “Those magnet schools become representative overnight, and students can receive the education, guidance, and preparation to be part of the pipeline to be future physicians, lawyers, and business owners.”
There are initiatives to increase diversity in ophthalmology, such as the Dr. David Kearney McDonogh Scholarship in Ophthalmology/ENT, named after the first African American ophthalmologist/ENT, and the Minority Ophthalmology Mentoring program organized by the American Academy of Ophthalmology and the Association of University Professors of Ophthalmology. Dr. Laroche said these are excellent efforts, but he thinks there is still a heavy reliance on board and test scores. “There is no correlation with board scores and how good of an eye surgeon one is,” he said. He thinks if a student does have a deficit, they should be given a year to put in extra time to overcome it to allow them the opportunity to come into the profession.
“[We have to] create opportunities to expose the profession of ophthalmology, mentorships, scholarships, and research opportunities, and acknowledge that we have a desperate need for this. We have to create scholarships at the high school level and college level and demand that our educational system creates students who are ready to be our new doctors. … We have to fund those opportunities and further open the doors of ophthalmology.”

About the sources

Daniel Laroche, MD
Clinical assistant professor of ophthalmology
Department of Ophthalmology
Icahn School of Medicine
at Mount Sinai
New York, New York

Marc Nivet, EdD
Executive vice president for institutional advancement
University of Texas
Southwestern Medical Center
Dallas, Texas

M. Roy Wilson, MD
President
Wayne State University
Detroit, Michigan

Imam Xierali, PhD
Associate professor
Department of Family and Community Medicine
University of Texas
Southwestern Medical Center
Dallas, Texas

References

1. Zhang X, et al. Vision health disparities in the United States by race/ethnicity, education, and economic status: findings from two nationally representative surveys. Am J Ophthalmol. 2012;154:S53­–62.e1.
2. Xierali IM, et al. Current and future status of diversity in ophthalmologist workforce. JAMA Ophthalmol. 2016;134:1016–1023.
3. Lett LA, et al. Declining racial and ethnic representation in clinical academic medicine: A longitudinal study of 16 US medical specialties. PLoS One. 2018;13:e0207274.

Relevant disclosures

Laroche
: None
Nivet: None
Wilson: None
Xierali: None

Contact

Laroche: dlarochemd@aol.com
Nivet: Marc.Nivet@UTSouthwestern.edu
Wilson: president@wayne.edu
Xierali: Imam.Xierali@UTSouthwestern.edu

Ocular trauma from ‘less-lethal’ weapons

Law enforcement, in some cases amid 2020 Black Lives Matter protests, have turned toward use of rubber bullets, tear gas, and other “less-lethal” crowd control measures, but injuries resulting from these tactics have some calling for their ban.
In mid-July, the Washington Post published an article reporting that eight people lost vision in one eye and 12 others were partially blinded after being hit with police projectiles within the first week of protests that began after the death of George Floyd in May.1 A recent case report of a “less-lethal” weapon injury published in Ophthalmology and Therapy described a patient who presented with no light perception, periorbital ecchymosis, and “devastating globe trauma.”2
The American Academy of Ophthalmology and several other organizations released a statement in early June that read, in part:
While classified as non-lethal, [rubber bullets] are not non-blinding. These life-altering eye injuries are a common result of urban warfare, rioting and crowd dispersion. We have seen it around the world, and we now see it in the United States.  
Following numerous serious injuries in the past two weeks, the American Academy of Ophthalmology calls on domestic law enforcement officials to immediately end the use of rubber bullets to control or disperse crowds of protesters. The Academy asks physicians, public health officials and the public to condemn this practice. 
Americans have the right to speak and congregate publicly and should be able to exercise that right without the fear of blindness. You shouldn’t have to choose between your vision and your voice.
Over the years, there have been dozens of case reports and papers published on injuries caused by less-lethal weapons, including papers that describe instances of lethality.3 A paper published in 2003 in the journal Eye described ocular and orbital rubber bullet injuries in 42 consecutive patients in a 3-month period.4 Lid or skin lacerations were observed in 54% of the patients, 40% had hyphema, 38% ruptured globe, 33% orbital fracture, and 36% retinal damage. More than 50% of patients saw less than 6/60. This paper concluded that “rubber bullet” is a misleading term that often refers to projectiles made from a range of different materials. “Orbital fractures are common” with these projectiles, the study authors stated.
In addition to calling for a ban on rubber bullets, the American Academy of Ophthalmology and the Department of Ophthalmology at the University of California, San Francisco created a registry of eye injuries occurring from participation in protests.

References

1. Kelly M, et al. Partially Blinded by Police. Washington Post. July 14, 2020. Accessed July 19, 2020.
2. Ifantides C, et al. Less-lethal weapons resulting in ophthalmic injuries: A review and recent example of eye trauma. Ophthalmol Ther. 2020;9:1–7.
3. Kobayashi M, Mellen P. Rubber bullet injury: case report with autopsy observation and literature review. Am J Forensic Med Pathol. 2009;30:262–267.
4. Lavy T, Abu Asleh S. Ocular rubber bullet injuries. Eye. 2003;17:821–824.

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