By Rebecca Salowe
Scheie Vision Annual Report 2021
Eydie Miller-Ellis, MD, Vice Chair for Faculty Affairs and Vice Chair for Diversity, Equity, and Inclusion (DEI) at the Scheie Eye Institute, was recently featured in an in-depth article about healthcare disparities in the American Academy of Ophthalmology’s EyeNet magazine. In this article, Dr. Miller discusses how racial disparities play out in the care of glaucoma patients and provides insight into how to overcome these barriers.
A Silent Disease
Glaucoma is a blinding eye disease that disproportionately affects individuals of African descent. African ancestry individuals are five to six times more likely to be affected by primary open-angle glaucoma (POAG), the most common form of the disease, and up to 15 times more likely to experience vision loss from the disease than European Americans. Furthermore, glaucoma is a familial disease, so vision loss early in life can affect multiple family members, possibly leading to adverse economic and health outcomes in these individuals.
Dr. Miller became interested in pursuing glaucoma as a specialty almost three decades ago. Not only does glaucoma run in her family, but she also noticed repeatedly that certain glaucoma patients were falling through the cracks of the healthcare system. Early care is critical for glaucoma patients, as vision loss from the disease cannot be reversed with current treatments.
“Glaucoma is the number one cause of preventable blindness, disproportionately affecting individuals of African descent—and glaucoma runs in my family,” said Dr. Miller. “I thought glaucoma was where I could make the biggest difference.”
Thirty years later, glaucoma treatments have improved, but many disparities persist or have even worsened, both in glaucoma and in other diseases.
Why Certain Disparities Persist
Many health disparities can be traced back to difficulties with access to care and the reality that many medical facilities in low-income neighborhoods are under-resourced. Additionally, for glaucoma patients, treatment compliance is essential to slowing vision loss. However, individuals who are economically disadvantaged typically have a hierarchy of concerns, including securing food and shelter. A visit to the ophthalmologist, or a purchase of eye drops, may be difficult to prioritize given other concerns.
Dr. Miller emphasizes the importance of patient health literacy and education when discussing treatment options with patients. For example, she has found that most patients are visual learners, so she often writes down treatment directions for patients as a reference. She also takes into account all possible factors when determining a treatment plan. For example, early intervention with a laser or surgery can help to mitigate the long-term challenges associated with eye drops.
Diversity of the physician workforce is another important factor to consider. As of 2015, only 2.5% of ophthalmologists were Black. Racially concordant medical interactions have been shown to improve relationships, health information exchange, and treatment planning. Better pipelines for under-represented minorities to enter ophthalmology (and other medical specialties) are essential; they also provide role models for younger students of color.
Dr. Miller co-directs a program for under-represented students, residents, and fellows called the Rabb-Venable Excellence in Ophthalmology Research Program, with the National Medical Association. The goal of this program is to increase the number of under-represented minorities in ophthalmology residencies and in academic medicine. The Department contacts graduating fellows from this program about open faculty positions.
Research Is Not Immune
Disparities in glaucoma stretch beyond clinical care and into the realm of research. Despite African ancestry individuals being overaffected by glaucoma, the majority of glaucoma studies to date have focused on individuals of European or Asian descent. Many of these findings have little or unknown implications in African ancestry individuals.
This is a global problem across all of medicine: as of 2019, only 2% of participants in genome-wide association studies were of African descent. Polygenic risk scores, as another example, have primarily been tested in European Americans, as the studies used to generate the scores were conducted in European Americans. This cyclical problem ultimately affects those least studied, as it impedes the translation of genetic results into clinical care, limiting diagnostic and therapeutic applications.
However, there has been some positive momentum in glaucoma research in recent years. Several large studies are now examining this disease in individuals of African descent, including the Genetics of Glaucoma in People of African Descent Consortium and International Glaucoma Genetics Consortium. The Primary Open-Angle African American Glaucoma Genetics (POAAGG) study, conducted here at the Scheie Eye Institute, has recruited more than 10,200 African ancestry individuals to its cohort. These studies will help to elucidate the genetics of glaucoma in the most affected individuals.
“Ultimately, we hope to find better ways to diagnose glaucoma at earlier stages, slowing or preventing vision loss,” said Dr. Miller, who is a Co-Investigator on the POAAGG study. “We also aim to develop more targeted treatments for the different subtypes of glaucoma.”
Scheie Eye Institute’s Commitment
Glaucoma is just one disease that exemplifies the disparities that persist in healthcare. The Scheie Eye Institute is fully committed to tangible action to eradicate these disparities, both in glaucoma and more broadly. In her role as Vice Chair of Faculty Affairs and Vice Chair for DEI, Dr. Miller has led conversations and initiatives to take steps towards meeting this commitment. These actions have been consistently guided by the diverse voices of the Scheie community.
The Department supported implicit bias training for all faculty and staff, which is designed to make individuals aware of their implicit biases, provide tools to adjust automatic patterns of thinking, and ultimately help to eliminate any discriminatory behaviors. 100% of employees completed this training.
In 2020, Dr. Miller shared an anonymous survey with the Department, where faculty and staff could discuss any experiences of discrimination and racism in the workplace and in healthcare. The survey also asked for feedback and suggestions on how to open a dialogue.
“Approximately 50% of the Department responded to the survey,” said Dr. Miller. “While it was good to learn that most had not experienced discrimination, there were also reports of microaggressions and communication challenges. To address these issues, the Scheie DEI Committee has been formed.”
A forum was also facilitated by Dr. Miller, Paul Tapino, MD (Scheie Residency Program Director), and Enny Oyeniran, MD (recently graduated Scheie resident) to discuss findings and suggestions from the survey and to encourage further dialogue and feedback.
The Scheie DEI Committee includes representatives from faculty, staff, and administration who can express concerns and perspectives from all areas of the Department.
“Our goal is to improve our work environment by treating each other with respect and compassion, and to encourage an environment that is physically and emotionally safe,” said Dr. Miller. “Social restrictions resulting from COVID have put up barriers that have made it difficult to maintain morale and get to know new employees. Our goal is to break down barriers, encourage collaboration and tolerance, and provide a forum for difficult and important conversations.”
Presentations by experts in DEI, as well as sessions on anti-Asian violence and public safety, were scheduled for eight Grand Rounds in the past year. Examples of topics covered include “Misrepresenting Race: The Role of Medical Schools in Propagating Physician Bias,” “Achieving Health Equity in Ophthalmology,” and “Eradicating Systemic Racism and Microaggressions in Academic Medicine.”
The Department will continue (and expand where possible) other conversations, initiatives, and events that promote diversity. For example, a Black History Month celebration has been hosted by staff members and supported by the Department for almost ten years. This half-day event, which features singers, dancers, and speakers from the Philadelphia community, is open to all faculty, staff, and community members.
For faculty recruitments, the Department will continue to invest in outreach to diverse ophthalmology groups throughout the world, in order to make connections and discover new talent. The Department also seeks to recruit under-represented minorities for work-study positions, summer research internships, writing opportunities, and clinical shadowing experiences. These students are often offered full-time positions after college graduation as scribes, clinical research coordinators, or laboratory scientists, where they can receive mentorship and acquire the publications and experience needed to gain admission into outstanding medical or graduate schools.
The Chairman of the Ophthalmology Department, Joan O’Brien, MD, is fully supportive of these efforts. She is an active member of the CPUP Committee on Anti-Racism.
“While diversity, health disparities, and inclusion have been discussed for years, the events of 2020 have put these issues at the forefront,” said Dr. Miller. “We are finally seeing a real commitment from the government, health providers, and insurers to move these initiatives forward—working on inclusion in bench research and clinical trials while addressing disparities in healthcare. If we as a society can address issues facing the most disadvantaged of people, it will help everyone. Diverse ideas make organizations better. We need to keep moving forward.”