Strategies to Increase Underrepresented Minority Trainees in the Ophthalmology Pipeline: Perspective From a Large Retina Research Laboratory

The coronavirus disease 2019 (COVID-19) pandemic has highlighted the effects of systemic racism and health disparities that persist in our country—underrepresented minorities (URMs), including any person whose racial or ethnic identity is African American/Black, Hispanic/Latinx, or Native American, have higher rates of hospitalization and mortality due to COVID-19. ¹ Although the COVID-19 pandemic will end, health care disparities will persist and cannot be ignored.

Racial and ethnic disparities in health care are pervasive in the United States, and vision care is no exception. Racial disparities exist in access to glasses among children, ² adherence to glaucoma follow-up, ³ as well as rates of ophthalmic procedures. ⁴ Black people are disproportionately affected by glaucoma yet are less likely to receive glaucoma testing ⁵ or use low-vision devices. ⁶ Similarly, although racial and ethnic minorities are most affected by diabetic retinopathy, they are less likely to be screened compared with White counterparts. ⁷

Why do such racial disparities in eye care exist? One reason—of many—may be that while our country has become increasingly diverse, ophthalmology has not followed suit. Studies have shown that URM ophthalmologists are more likely to practice in medically underserved areas, ⁸ and that racial/ethnic concordance between patients and their physicians is associated with greater patient satisfaction. ⁹ However, URMs account for only 6% of practicing ophthalmologists, 5.7% of ophthalmology faculty, and 7.7% of ophthalmology residents despite comprising 30.7% of the US population, and the proportion of URM ophthalmology residents and faculty actually decreased between 2005 and 2015. ⁸ To better serve and treat our URM communities, we must increase URM representation in ophthalmology. Leaders have been called on to address the gap in URM representation between the ophthalmology workforce and the population it serves. ¹⁰ We echo this call to action and offer targeted, actionable strategies to improve URM representation in the ophthalmology pipeline.

Starting with the most upstream portion of the ophthalmology pipeline, we need to increase exposure to ophthalmology before and during medical school for URM students. URM medical students may choose not to pursue ophthalmology for a variety of reasons, including insufficient interest and exposure, perceptions of the field as too specialized and competitive, or lack of mentorship. ¹¹ In addition, exposure to ophthalmology is declining in US medical school curricula. ¹² Thus, it is imperative that we provide early exposure to ophthalmology during the formative stages of premedical and medical education to increase knowledge of and interest in the field. For high school and college students, mentorship programs targeting high-achieving URM students can pair students with local ophthalmologists who are willing to have students “shadow” them and serve as a resource through the college and medical school admissions processes. Longitudinal programs pairing incoming URM first-year medical students with ophthalmology residents and faculty can provide exposure and mentorship early on in medical training and increase interest in ophthalmology. ¹³

The work does not stop at garnering interest in the field, however. Once URM students are interested in ophthalmology, we need to enable them to succeed by involving them in the highly active ophthalmology research community. We must actively recruit URM undergraduate and medical students as research fellows. As an example, our Harvard Retinal Imaging Laboratory, composed of undergraduate students, medical students, residents, fellows, and postdoctoral researchers from a variety of racial and ethnic backgrounds, strives to achieve a diverse team by actively recruiting URM undergraduate and medical student research fellows. Using a holistic approach, we consider students’ experiences, attributes, and academic performance as selection criteria when choosing applicants. Our laboratory has had success recruiting students from diverse backgrounds by attending undergraduate career fairs, posting descriptions of retina projects in a centralized database available to medical students, and encouraging current laboratory members to share their research experiences with junior classmates through word of mouth and informal channels.

More formal ways to actively recruit URM undergraduate and medical students are to share research opportunities with and attend events hosted by URM-supporting organizations such as the Student National Medical Association, which has medical school chapters across the country. Additionally, ophthalmologists can participate in the American Academy of Ophthalmology’s Minority Ophthalmology Mentorship program, which pairs physician volunteers with URM premedical college seniors and first- and second-year medical students to provide mentorship and research opportunities to help make applicants competitive for ophthalmology residency. ¹⁴

While recruitment of URM students is an important initial step, fostering each individual’s development and success during the laboratory experience is imperative. To this end, our laboratory uses several strategies to provide mentorship and build technical skills that are required for clinical research. For example, URM students are paired with more senior research fellows (eg, residents or postdoctoral fellows) to provide an accessible point person for assistance or advice. When possible, connecting URM students to mentors who also identify as URM can further enhance the onboarding process and laboratory experience. In addition, regular check-in meetings with the mentor and principal investigator ensure that URM students have the tools to drive their project forward. Specific laboratory didactics and virtual meetings are designed to develop key skills that URM students may have less exposure to, with topics ranging from statistical methods to the approaches used to interpret optical coherence tomography images.

Our laboratory’s collaborative, team-based approach to ophthalmic research ensures that each individual, regardless of education level, prior research experience, or knowledge of ophthalmology, can quickly join projects and integrate into the team, which is diverse both ethnically and by training background. Research fellows are encouraged to engage in multiple research projects, each driven by a unique team of research fellows, depending on their schedule and research interests. This structure allows for frequent and invaluable mentorship and interaction among team members, as well as for all research fellows to achieve their goals at their own pace. Early exposure of URM students to ophthalmology through research enables students to gain research skills, build their own areas of interests, and become more competitive applicants for medical school and ophthalmology residency. Students who have research mentors will have somebody not only to vouch for them in letters of recommendation, but also to provide guidance on applying to ophthalmology.

From our experience, an imaging-focused laboratory provides a unique opportunity to create an active community within ophthalmology in which to position early trainees. Today’s youth are inundated with screens and rapidly changing technology, and imaging is an attractive launchpad into a career in ophthalmology even without prior exposure. Broadly, imaging offers a variety of avenues into ophthalmology ranging from acquiring images in the clinic as an imaging technician to designing artificial intelligence and machine-learning algorithms for those with strong technical backgrounds. Advanced imaging began in retina and is now pervasive in all subspecialties, and an imaging laboratory thus provides an entry point to the entire field of ophthalmology.

The contributions that URM research fellows bring to our laboratory cannot be overstated. Having a diverse research team with different perspectives not only strengthens the quality of our work but undoubtedly benefits the entire research team and our patients. The laboratory’s mission to create a diverse team has resulted in increased awareness, discussion, and action to address problems that extend beyond academic research. Some of our current initiatives include increasing URM representation in clinical research studies, ensuring language interpreters are available to help recruit and obtain consent from patients, and encouraging non-URM and URM research fellows alike to mentor URM premedical college students interested in ophthalmology.

Lastly, increased participation from the ophthalmology and retina community is critical to acknowledge the racial and ethnic disparities in our field and amplify the need for greater awareness and action. Compared with other specialties, fewer publications in ophthalmology have centered on ways to promote racial and ethnic diversity in the field, reflecting insufficient awareness and engagement by the ophthalmology community. ¹⁵ Research output is one way to shed light on the issue of URM representation, but less formal and more accessible channels such as blogs and social media can reach a more widespread readership. Ophthalmology, like other medical specialties, has a substantial presence on social media platforms such as Twitter and Instagram. On Twitter, ophthalmologists most often post about research conferences, personal topics, and accomplishments of their colleagues, and we encourage ophthalmology community members to use their social media platform to advocate for greater URM representation.

Too often, URMs shoulder the burden of educating non-URM colleagues and advocating for underserved communities. Required implicit bias and antiracism training in academic institutions is a start to promote cultural humility and provide the motivation and framework for improving racial and ethnic diversity. Physician engagement in public policy and community outreach should be recognized and rewarded by leadership. Furthermore, educational awards and recognition, and even financial incentives, should encourage faculty to diversify their clinical and research teams and invest resources into diversity, equity, and inclusion initiatives and research.

We acknowledge that the strategies outlined here are not comprehensive, and that discussion and awareness alone are necessary but grossly insufficient to address a societal problem rooted in systemic racism and injustice. We stand beside our colleagues who have dedicated time and effort to combat inequity, and we encourage all members of the ophthalmology and retina community to engage in dialogue and affect tangible change.