DEI in Clinical Practice

Diversity, equity, and inclusion (DEI) in clinical practice is a two-pronged issue. It affects patients, many of whom are underserved and lack equitable access to care, and providers, particularly those who are underrepresented in medicine (URiM) and may not have equitable access to education and professional opportunities.

Patient-practitioner concordance (ie, shared identity between patient and provider based on a demographic attribute such as race, sex, or age) is important, and research shows a lack of concordance means patients are less likely to have visited an eye care practitioner.¹ This is unsurprising when you consider the persistent lack of diversity among eye care providers. One study showed a decrease in the percentage of American Board of Ophthalmology diplomates who self-identified as URiM (P < .001) between 1992 and 2020.² In addition, investigators found a 2.5% decrease in the percentage of female ophthalmology residents from 2011 to 2019 (P = .02).³ Clearly, there is more work to be done.

This article highlights two programs—one patient-centered, one provider-centered—that aim to promote inclusivity within ophthalmic clinics.

CONNECTING WITH SOCIAL SERVICES

The Bascom Palmer Eye Institute (BPEI) created an ophthalmology-specific social services department to better serve its complex patients. The program offers a wide range of social services that are free of charge to patients (although associated interventions may be billed for), including psychosocial assessments, assistance with health insurance and housing issues, transportation, pre- and postoperative care, vision enhancement services, medication access, and more.

The efforts to create the program began in the 80s, when Myriam Lohr, an employee who worked in patient access at BPEI, noticed a significant population of patients who could not afford to adhere to their doctors’ recommendations. Ms. Lohr worked with these patients and pharmaceutical companies to identify ways to help them access care through patient assistance programs. “The more interest she took in it, the more services she discovered that patients needed,” said Basil K. Williams Jr, MD, in an interview with Retina Today.

The department was formalized when it hired its first licensed social worker, Maria Henao, LCSW, in 2017; today, the department consists of two licensed social workers and three additional staff.

Helping patients access medications is one of the largest functions of the department. “This is especially important for intravitreal injections for patients with diabetic retinopathy (DR), macular degeneration, and other conditions,” Dr. Williams explained. “And for glaucoma, there is an assistance program for patients to obtain their eye drops.” Research shows that certain vision-threatening pathologies, such as DR, requiring regular care and monitoring tend to affect underserved patients disproportionately. One study found that Black and Hispanic patients initiating anti-VEGF therapy presented with worse baseline DR compared with White and non-Hispanic patients (P < .01).⁴ Thus, the department strives to ensure that underserved populations receive care as early as possible to prevent vision loss.

The department also helps uninsured patients acquire health insurance, as lack of insurance and challenges with health literacy are significant barriers to eye care.

Not every ophthalmology department or clinic has the resources to open a fully staffed social services department, but they can identify an employee or two who can work part-time on patient access and assistance programs.

“The goal of medicine in general is to take care of patients to the best of our ability and provide quality care for everyone,” said Dr. Williams. “The psychosocial and emotional aspects of what our social services department offer are powerful and meaningful for a significant proportion of our patients. It’s an opportunity to connect with the community and eliminate or, at the very least, reduce health disparities.”

EYE CAN MENTORSHIP PROGRAM

Harvard University’s Eye Can program is a multitiered approach to offer support for students and faculty at each level of education and professional development.

“The foundation of an inclusive community is an open, welcoming, and affirming environment in which everyone feels they truly belong,” explained Joan W. Miller, MD, during her 2023 AAO Annual Meeting lecture, “Inclusion, Diversity, and Equity: Strategies for Building an Inclusive Community in Your Department, Institution, or Professional Group.”⁵

The program includes several branches geared toward different student populations. The Harvard Retinal Imaging Lab Underrepresented in Medicine Mentorship Program was launched in 2021 to provide clinical exposure, research opportunities, and mentorship to URiM college students at Harvard. The program currently boasts 109 members, including students and mentors.

The Harvard Ophthalmology Research Scholars Program provides URiM medical students with a mentored experience in ophthalmology, including a summer research project with clinical shadowing, weekly mentoring sessions, and authorship on a case report with a resident and faculty member. The program provides ongoing mentorship throughout medical school and support for the scholars to return to the university’s annual alumni meeting.

The Harvard Ophthalmology Faculty Mentoring Program was established in 2014 to support faculty in understanding the complicated promotion process, as well as professional development through societies. The program pairs a junior faculty member with two senior faculty mentors and specifically tracks the URiM faculty to ensure equitable career growth. Currently, 88 mentors are working with 158 junior faculty mentees in the program.

“Whether your organization is an academic institution or a private practice, it’s important to sponsor your junior ophthalmologists in leadership opportunities,” Dr. Miller emphasized in her lecture. Mentorship need not exist in universities alone but can be put into practice wherever more senior ophthalmologists are willing and able to lend support to those who are younger or URiM. Beyond an official mentorship initiative, creating an affirming environment should be a top priority for any practice.

ROLL UP YOUR SLEEVES

The programs highlighted here are doing important work to eliminate disparities among patients and providers, and the key components—mentorship, community engagement, and empathy—are transferable, no matter the size of your department or clinic. Be creative, and use what you have, to make a difference in your community.

1. Ravindranath R, Bernstein IA, Fernandez KS, Ludwig CA, Wang SY. Social determinants of health and perceived barriers to care in diabetic retinopathy screening. JAMA Ophthalmol. 2023;141(12):1161-1171.

2. Bojikian KD, Mekonnen ZK, Adan NM, Rivera-Morales P, Kombo N, Feng S. Primary practice emphasis area and diversity among board-certified ophthalmologists. Am J Ophthalmol. 2023:260:84-90.

3. Aguwa UT, Srikumaran D, Green LK, et al. Analysis of sex diversity trends among ophthalmology match applicants, residents, and clinical faculty. JAMA Ophthalmol. 2021;139(11):1184-1190.

4. Malhotra NA, Greenlee TE, Iyer AI, Conti TF, Chen AX, Singh RP. Ophthalmology. 2021;128(10):1438-1447.

5. Miller J. Inclusion, diversity, and equity: strategies for building an inclusive community in your department, institution, or professional group. Presented at the 2023 AAO Annual Meeting; San Francisco, CA; November 3, 2023.