Lifetime Mentorship Award: A VBS Tradition

As is tradition, the 10th annual Vit-Buckle Society (VBS) meeting didn’t shy away from the tough conversations that are necessary to move the field of retina forward. This year’s Lifetime Mentorship lecture, given by the 2022 Lifetime Mentorship Award honoree, Julia A. Haller, MD, centered on diversity, equity, and inclusion (Figure). Here’s what she had to say.

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Figure. The VBS leadership presented Dr. Haller with the 2022 Lifetime Mentorship Award. Pictured here [left to right]: Back row: Jayanth Sridhar, MD, and Basil K. Williams Jr, MD. Front row: Mrinali Gupta, MD; Yoshihiro Yonekawa, MD; Avni P. Finn, MD, MBA; Dr. Haller, Nika Bagheri, MD; Priya Vakharia, MD; and Charles C. Wykoff, MD, PhD. Image courtesy of Kevin Caldwell.

A LIFETIME OF ADVICE

Dr. Haller began her lecture with a lighthearted story about being a woman in the field retina. She recounted that 30 years ago she was the first female member of the American Society of Retina Specialists and received a certificate commemorating “his role in the advancement of vitreoretinal surgery.” As honored as she was to become a member, she joked that the time had come for her to come out as a female in retina. Amid the many responses to her questioning the certificate’s wording, the one from Jerald A. Bovino, MD, stood out to her. He sarcastically joked that the simplest way to fix the problem was for Dr. Haller to change her sex and go by “Julian” because there was room on the certificate for an “n” and there would be no need to reprint the document.

This was one small personal example of a longstanding lack of and need for sensitivity to equity in the field of retina and elsewhere in medicine, Dr. Haller stated.

To move the needle on diversity, equity, and inclusion, we need more than public demonstrations of support—we must tip the balance through research, evidence, and hard work, she said. The benefits of diversity are well-documented in the clinic, the classroom, and the boardroom. Dr. Haller cited a Wharton School of Business course by Deputy Dean Nancy Rothbard, PhD, during which she emphasized that diversity in the boardroom can be uncomfortable and can take time to implement but is more inclusive of a broader set of stakeholders and yields higher quality decisions.

Perhaps the slight discomfort of being in an unfamiliar group helps with deliberation and decision making, she mused. One key insight that has been borne out in research is that participants come to board meetings better prepared when the board is diverse. Additionally, according to the literature, diverse groups demonstrate more decision-making accuracy, according to Dr. Haller.

RESEARCH ROUNDUP

The quest for gender and racial equity in academic medicine is ongoing, and retina has made some strides, Dr. Haller admitted. She dove into the literature to share examples and demonstrate that the playing field is still far from level. She noted that female residents have fewer cases than male residents, and more female researchers are first or junior authors, but still lag significantly in senior authorship.^1,2 When the last author of a paper is a woman, the first author is far more likely to be a woman than when the last author is a man, she added.² The good news is that, in 2020, women authored more papers and were more frequently the senior author than their representation in the field in general.²

Despite the increased attention to the importance of gender equity over the last few decades and the progress made, there is still significant room for improvement. Women have fewer industry ties and are paid less regardless of the role, whether that’s honoraria, speaking opportunities, or consultancies. In a recent study, women were found to occupy fewer than one in four faculty roles at academic meetings.³ However, when at least one woman was included as a member of the program committee, more female faculty members were invited. Between 2015 and 2019, female editorial authorship increased 68%, but women still represented only 5% of all editorial authors.

Unlike gender diversity, ethnic and socioeconomic diversity has mostly been ignored by academic medicine, Dr. Haller noted. She discussed a study recently published by Soares et al that looked at geographic disparities and access to neovascular AMD trials.⁴ Soares and her team identified 42 trials and 829 unique trial sites and matched them with the surrounding census data. The researchers found that patients in the Midwest and South had longer drives to the clinical trial sites; longer distance travelled was associated with rural populations, lower education levels, and identifying as an ethnic minority. The data suggest that the benefits of medical research—in terms of treatment, education, and engagement—is more readily available to some groups compared with others. It’s no surprise that researchers are working harder to better understand how diverse groups of patients differ with respect to various ophthalmic conditions and treatments.

Dr. Haller then touched on data presented by M. Ali Khan, MD, who reported that Black patients have less visual acuity improvement than White patients when treated with ranibizumab (Lucentis, Genentech/Roche) for diabetic macular edema.⁵ He was unable to analyze the relative efficacy for Asian or Hispanic patients because the trials did not include enough patients from these groups.

Komodo Health looked at larger numbers of patients to assess the relationship between patient care and patient race and ethnicity, Dr. Haller said. Preliminary data from 242,000 patients demonstrated that Black, Hispanic, and Asian patients were all less likely to receive anti-VEGF treatments than their White counterparts. Even among patients who were treated with anti-VEGF therapy, the likelihood that patients received off-label bevacizumab (Avastin, Genentech/Roche) compared with a branded medication was significantly greater among racial and ethnic minorities compared with White patients, Dr. Haller noted.

Unfortunately, an important disconnect remains in academic medicine, according to Dr. Haller. Research is clear that the number one cause of blindness among working-age people is diabetic eye disease, which disproportionately affects racial and ethnic minorities.^6,7 Despite this, racial and ethnic minority enrollment in clinical trials remains unacceptably low, making it challenging, if not impossible, to evaluate differences in response to therapy. In the real-world clinical setting, we know that racial minorities have worse access to care and are treated less frequently and with different drugs, Dr. Haller explained.

WAYS TO MAKE PROGRESS

She concluded by addressing several avenues toward a more diverse and inclusive field. There must be an emphasis on the recruitment of diverse patient populations into large clinical trials, and researchers must identify strategies to circumvent any barriers. Leaders must also emphasis the importance of training health care professionals who are representative of the patient population they serve. Now is the time to harness the outrage and determination unleashed by the events of the last few years to develop treatments and data to help our patients, Dr. Haller said.

To ensure a more equitable future, women and minorities must occupy positions of power—not just on the team, but leaders of the team, Dr. Haller emphasized. Stereotypes matter, she added; words like “bossy” can change the ambitions of girls and women. By their teenage years, many young women are not interested in leadership roles because they don’t want to be labeled as “bossy.” Women must know that it is OK to be ambitious. Dr. Haller suggested a turn-of-phrase to help: “I am not bossy, I am the boss.”

Dr. Haller ended the way she began, with a personal touch. We all need heroes, teammates, and mentors, she said—for her that’s Carol L. Shields, MD, and Marlene R. Moster, MD, among many others. Women and minorities in medicine need networking and mentorship, and the VBS is an inspiring example of that. “The organization has taken the ball and run with it over the past 10 years. Thank you for your hard work and hospitality,” Dr. Haller concluded. “I look forward to continued collaboration.”