Diversity, Equity & Inclusion

Bringing Racial Bias Into Focus in Ophthalmology Case Studies

(from the UW Medicine Huddle)

In 2020, a UW School of Medicine professor in the Department of Ophthalmology presented a case study about glaucoma. The details of the case seemed routine — the kind read in textbooks or taught in ophthalmology classrooms across the country. The case included the use of race as a diagnostic criterion when describing the patient, for example, a fifty-year-old Chinese woman.

Students listening to the presentation raised the question: Why was race — a social construct — a criterion for diagnosis? The professor was uncertain how to respond; race was commonly cited in case studies.

The students’ questions led the Department on a multi-year reflection and subsequent redirection of the use of race in case studies.

Asking the right questions

At the time, the ophthalmology students took their concerns to Edwin Lindo, JD, associate dean, Social and Health Justice in the Office of Healthcare Equity.

He recalls conversations with the students. “I counseled them to dig into the research influencing the case study,” says Lindo. “When we ask critical questions of science, we get better science.”

The students discovered that the research informing the case study was attributed to two British ophthalmologists who studied populations in Mongolia and Singapore and extrapolated that Chinese women over forty have the highest rates of closed angle glaucoma.

“They didn’t study women in China,” says Lindo. “How did they draw that conclusion?”

Lindo notes another concern that students expressed about the case studies: The studies pathologized races not in the racial majority. For example, “Black race” was listed as a leading risk factor for glaucoma, while “white race” was not listed in describing age-related macular degeneration. This omission not only centered whiteness as the default race but also reinforced a false equivalence of race and genetics.

A department’s evolution

A year after the students first questioned the case studies, the Department of Ophthalmology organized a faculty retreat and the department’s Equity, Diversity and Inclusion (EDI) committee suggested inviting the students.

A member of the EDI committee, Michelle Cabrera, MD, professor of Ophthalmology, reflects on the retreat: “The students taught us. It was quite impactful. It not only made people think differently, it led us to carry the conversation into our spheres of influence in the world of ophthalmology.”

In Cabrera’s case, she co-authored an article about glaucoma and race in an effort to challenge assumptions.

“Racial categories represent mixed and variable ethnic origins,” writes Cabrera. “Although ancestry or genetics may play a role in biologic determinants of disease, the associations of race and disease have been shown to derive primarily from social factors, such as racism and social determinants of health.”

Cabrera reflects on how she and many of her peers had to rethink their medical education foundations.

“Race was emphasized in our education; it’s always been taught as if it were a predetermining factor of disease,” she says. “We’ve had to unlearn.”

Engaging the Office of Healthcare Equity

In 2022, Karine Duarte Bojikian, MD, PhD, assistant professor, was appointed to lead of the department’s Equity, Diversity and Inclusion committee and contacted the Office of Healthcare Equity to set up trainings for the ophthalmology faculty. Lindo taught the History of Race and Racism in Science and Medicine, which explores how medicine and science have been used to further racism, how racial categories and hierarchy are still used in modern medicine today and why race is not biological or genetic.

“To be clear,” says Lindo, “I’m not saying race isn’t a real thing. Just that we should not be using it as a biological marker and indicator.”

Lindo, to emphasize this point, shares other examples beyond glaucoma: Why was there a racial variable in the equation to measure kidney function? What does one’s race have to do with whether they should have a C-section? Why do some still use a race-based equation for the spirometer?

Bojikian said the attendees of Lindo’s training were particularly influenced by a sickle cell anemia example. Sickle cell anemia has a racialized association as a disease afflicting Black people. Yet, the disease is a genetic mutation that exists where there is a high prevalence of malaria, from sub-Saharan Africa to Southern India. In both places, there are people who have high rates of sickle cell.

“With that example,” says Bojikian, “we understood how often race is improperly used as a surrogate for genetics.”

The impact

The students, who have since graduated, went on to publish a paper in “The Journal of Academic Medicine,” in which they made the following recommendations to address the impact of using race in medicine:

• Emphasize the need for incoming students to be familiar with how the use of race in case studies can influence health outcomes.
• Provide opportunities to hold open conversations about race in medicine among medical school faculty, students and staff.
• Craft and implement protocols that address and correct the inappropriate use of race in medical school classes and course materials.
• Encourage a large cultural shift within the field of medicine.

Cabrera and Bojikian reflect on the impact of the multi-year discussion, which began in discomfort. Now, in addition to removing race from case studies, multiple faculty members have authored articles about the use of race in ophthalmology cases.

“We’ve made tremendous progress on this humbling journey,” says Cabrera. “I am grateful for the impact of activism within the School of Medicine. It and the Office of Healthcare Equity are making a difference.”

Bojikian agrees.

“We’d been taught things a certain way,” says Bojikian, “and sometimes change takes time and sometimes change takes a shock. The students challenging the case study was a shock, but it put us on this path, and we’ve come so far as a department.”

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Our DEI Mission

Provide equitable eye care to all through an inclusive and diverse team of faculty, residents, and staff

Our DEI Vision

Become a leader in:

• Inclusive and respectful patient care

• Diverse environment and equitable career opportunities for physicians and trainees

Our Values

• Committed and accountable

• Inclusive and respectful

• Open to new ideas and perspectives

Our Initiatives

• Faculty Task Force on Healthcare Equity (4 West)

• UW Office of Healthcare Equity training

• DEI movie night for trainees and faculty: Black Men in White Coats

• Importance of diversifying the medical workforce

 

Diversity Visiting Student Clerkship Program

The UW Department of Ophthalmology is excited to participate in the Diversity Visiting Student Clerkship Program, a funded program designed to give 4th-year medical students from backgrounds historically underrepresented in medicine the opportunity to experience the exceptional education in ophthalmology offered by the University of Washington. Students will spend two or four weeks at one or more of the UW ophthalmology services, including Harborview Medical Center, Seattle Children’s, and/or VA Puget Sound Health Care System, and care for a variety of patients in our tertiary care centers. Students will also be expected to attend all scheduled medical student and resident teaching sessions, conferences and present at least one case presentation to the other students on the rotation.

Eligibility

The program is open to applicants who are currently enrolled in a U.S. medical school, demonstrate academic excellence, and belong to groups that are recognized as historically underrepresented in the health and science professions, including Black or African American, Hispanic or Latino, and Native American (American Indian/Alaska Native/Native Hawaiian). Applicants should be strongly motivated to pursue a career in Ophthalmology.

Application
The funded Visiting Clerkship position will be available during June, July, August, or September. Funding includes a stipend of up to $1,500 to cover housing and travel costs for either 2 or 4 weeks.

Students must also apply through VSLO and submit a personal statement separately to ophthclerk@uw.edu. 

2024 Diversity Visiting Clerkship recipient, Chris Wallace- Carrete, University of Utah School of Medicine

My journey into medicine has been driven by a desire to make a meaningful impact in the lives of underserved communities and to champion diversity in the field of healthcare. This passion, rooted in my own experiences as someone from an underserved background, has propelled me to pursue opportunities where I can contribute to advancing healthcare equity and excellence. Participating in an elective within the Department of Ophthalmology at the University of Washington aligns perfectly with my aspirations to not only further my clinical skills but also to engage with the program’s mission of promoting diversity, inclusion, and health equity in patient care, research, and education. Moreover, I see this rotation as an invaluable opportunity to immerse myself in the vibrant culture of UW, to connect with its esteemed faculty, residents, and staff, and to gain firsthand insight into the program's ethos and values. As someone who harbors a strong desire to pursue ophthalmology residency at the University of Washington, I am eager to showcase my dedication and commitment to the field while also deepening my understanding of its clinical and academic landscape. 

My focus in medical school has been marked by a dedication to addressing the needs of underserved and marginalized communities. Upon entering medical school, I sought opportunities to extend a helping hand to those most in need. In the field of ophthalmology, I found a calling that resonated deeply with my desire to make a meaningful difference in the lives of others. As an active member of the ophthalmology outreach community, I have dedicated my time outside of school to volunteer at free community eye clinics in Salt Lake City. These clinics serve as a lifeline for underserved, uninsured, and homeless individuals, offering vital eye care services that they may otherwise go without. One experience that stands out to me as a positive result of these clinics is a patient I met on my pediatrics rotation. She was a young patient admitted to the hospital for pneumonia. Although her immediate care was focused on her respiratory infection, it was clear through my interactions with her during rounds that she needed glasses. After talking about this with her parents, it became evident that the patient, her parents, and her younger brother were all struggling with poor eyesight. They came from an underserved area within the community and didn’t have the resources to afford appropriate eye care. Through our community eye clinic, we provided the patient and her family with the necessary treatment and prescription glasses, allowing them to see clearly for the first time in years. Witnessing the immediate impact of our work on this family was incredibly rewarding and solidified my commitment to serving those in need.

In addition to my volunteer efforts in the ophthalmology community, my passion for mentorship led me to accept a role as a Mentorship Fellow with the Office of Health Equity, Diversity, and Inclusion at the University of Utah School of Medicine. In this capacity, I serve as a mentor to underserved and underrepresented pre-medical students, offering guidance, support, and mentorship to help them achieve their aspirations of gaining acceptance to medical school. Having benefited from the guidance of mentors who saw my potential and encouraged me to pursue my passions, I am committed to paying it forward and empowering future generations of diverse healthcare professionals