One in Ten Million

Little ophthalmology is taught in medical school, and so, when my three months of dedicated ophthalmology clinic came around, I threw myself into it. One morning, I was practicing applanation tonometry and my patient happened to be a Black male. Given his race, he was six times more likely to have glaucoma, and I – being a Black male in ophthalmology – was statistically much less likely to receive him. Appreciating the rare moment, my patient confided that I was “the first Black ophthalmology resident [he] had seen in 20 years.” It was the second time I had heard that phrase that morning.

Up until residency, I had only thought about residency in the context of a hospital – not a city. Slowly, however, it dawned on me that I was the only Black ophthalmology resident for the whole 10 million residents of LA county. In this city of millions, how could I be the only Black anything? I texted my family to process this reality and then fired off a quick tweet, not knowing what would come next (1).

My tweet went viral and sparked a conversation across multiple social media platforms around race and medicine. Some congratulated me and others, who understood my predicament, encouraged me to remain strong. Rather than meaning to boast about my own exceptionality, my tweet was meant to highlight the sense of loneliness I felt in what was supposedly the most innovative field – and purportedly in the most progressive state. It is important to note that I am not trying to be a stand bearer or trailblazer. Although I am proud of my work so far, I am aware of my privilege. There have been many Black residents that have trained in LA before me that simply are not given the recognition they deserve.

LA was formally the home of the KING-DREW-UCLA Ophthalmology Residency Program; the same program that appointed famed Black inventor and ophthalmologist, Patricia Bath, as chair in 1983. In this position, Bath became the first female ophthalmology residency program director in the US, and in the Martin Luther King Jr. Community Hospital (MLK) in Compton, no less. At a time when so many Black residents were systematically excluded, LA and Howard University in Washington DC provided a hopeful future for young, aspiring Black ophthalmologists.

As the first female member of the Jules Stein Eye Institute, the challenges of intersectional identity no doubt impacted Bath’s career, resulting in her decision to take leave in Europe so that she could continue her work in a more progressive environment. Despite her pioneering efforts, Bath’s legacy no longer lives on in the residency she helped establish. Around the turn of the century the King/Drew-UCLA ophthalmology program lost accreditation and, as a result, no longer offers residency programmes. A legacy effaced – but why?

Systemic racism and a lack of viable support are to blame. With only 6.3 percent of resident ophthalmologists identifying as underrepresented in medicine (URiM), ophthalmology is now the least diverse specialty amongst all residency specialties (2). Disappointingly, this rate is below the 7.2 percent of practicing ophthalmologists who identify as URiM.

Implicitly, one wonders if Black people are able to grasp the complexity that underlies the scientific and technological innovations that have defined our field. Many assume that the composition of a residency class is meritocratic and so, rather than being an issue of discrimination, many believe that the lack of Black residents merely reflects an inability to perform and innovate. Alongside being completely false, this assumption enables the continuation of discrimination in the field. Irrespective of how the meritocracy has cultivated advancement and progress, it is now imperative that we challenge it, ensuring that Black residents are afforded the same opportunities as their White counterparts.

It has become all too familiar for Black trainees and faculty members to experience suspicious eyes and silent pauses on introductions. We adapt the way we speak, focus on communicating as clearly as possible, and constantly calculate the risk–reward ratio of asking for help, knowing that the perception of our competency will be penalized. It comes as no surprise that an investigation by STAT found that “Black residents either leave or are terminated from training programs at far higher rates than white residents (3).”

We need to move beyond seeing diversity, equity, and inclusion as merely the cost of doing business. We are more than just insurance against public outrage or charity cases – there is real importance in the work we produce. Alongside improved clinical outcomes and increased diversity in clinical trials that can more accurately reflect the diversity of the American population, patients feel more seen with patient–physician racial concordance, further highlighting the importance of increased diversity in ophthalmology (4).

Although Black people have been presidents of the AAO and chairs of well established ophthalmology departments, representation is more than just who sits at the top and who is left at the bottom. Representation covers all levels and ultimately shapes the priorities of our profession reflected in patient care, research, and community engagement. Although programs like the Minority Ophthalmology Mentoring program have done their part, it is now time for residency selection committees to chip in, lifting their gates higher to embrace a holistic review (5).

In the spring of 2023, there will be major considerations regarding diversity with a ruling pending against Harvard University and race-based admissions (6). Such a decision threatens affirmative action at colleges and universities around the nation, decreasing the representation of Black and Latino students, while bolstering the number of White and Asian ones. Justice Samuel A. Alito Jr. implied that preferentially considering one applicant, no matter how disadvantaged, will come at the cost of another. This age-old idea harkens back to the difference between equity and equality. Although equality seeks to treat everyone the same, it ignores where one starts. Equity, on the other hand, accounts for one’s starting point and has the end goal of equality.

It is now more important than ever that institutions zoom out and see their role in shaping society. As shown during the tumultuous spring of 2020, an inequitable society is fundamentally unstable. Diversity shouldn’t have to rely on reactionary efforts to mitigate the fallout from visceral displays of racism in the media. Let’s instead invest in the longevity of our communities and begin to see diversity, equity, and inclusion as key areas in which ophthalmology can innovate.

I can gladly write that on the first day of Black history month, I woke up to the news that I was no longer the only Black ophthalmology resident in LA. There are now two.