Our annual Resident Research Day and Graduation Celebration occurred on Friday June 11th. While some COVID restrictions were still necessary, it was an opportunity for our department to gather in person for the first time since the pandemic. Below is the schedule and some photographic highlights.
I hope by having this conversation with you I can share a unique perspective and, ultimately, contribute to improving the match process including for IMGs who can be strong applicants but face a different set of barriers.
The last post, opened up the topic of International Medical Graduates (IMGs) and a personal conversation I had with one that had yet to successfully match into ophthalmology. I’d like to continue that thread today, highlighting some of the obstacles IMGs face in securing a training position.
As before, the italicized excerpts from this conversation are kept anonymous, but published with permission.
Reflecting on my last match experience; out of the 112 programs I applied to last year, I was offered only two interviews. Both from programs where I had connections. I find this surprising, especially after reading other applicants experiences online and comparing my application to theirs, and know how many invites they were offered.
According to NRMP data, only 5.6% of IMGs successfully matched in 2018 (versus 94.3% for US graduates). The odds are deflating, and the process costly – both in terms of time and finances. It takes a IMG an average of three years to enter an ACGME residency program, with the following steps required to becoming an active physician: “confirm eligibility with ECFMG, obtain ECFMG certification (dependent on passing USMLE Step 1 and Step 2 examinations), obtain experience in the US health care system, apply for residency, complete residency, pass USMLE Step 3 examination, apply to state medical board for licensure, and finally receive license to practice medicine.”
Of course, each of these steps have fees. As mentioned previously, it currently costs a IMG $4,500 just to sit for the USMLEs. Additionally, like – and even more than – most other applicants, IMGs feel the need to apply broadly for residency positions:
“As I shopped for programs this match cycle, I ended up applying to almost all programs again. I applied broadly for three main reasons. First, the system incentives you to apply to more. Second, having had only two invites last year, I thought it would be unwise of me to apply for less. Third, I justified this to myself as a long-term investment and I am only losing money (me consoling myself for paying >$3,000 for the third time now just to apply to programs).”
Here are some of the other hurdles IMGs face:
The visa sponsorship barrier – A few programs explicitly state that they don’t sponsor visas. Although I find it surprising that all of these programs have a “Non-discrimination Statement and Policy”, I totally respect the transparency regarding their visa policy.
According to the same 2018 NRMP data, the average USMLE Step 1 and 2 CK scores for matched US IMGs was 222 and 232, while it was 234 and 240 non-US IMGs, respectively. This also suggests a bias over visa status.
Programs prestige and the IMG stigma – I was once told by a program director, who I approached after a panel discussion at the AAO, that he would love to have me for an interview, but went on to say he couldn’t, and this is because they have a unspoken policy against IMGs, as matching an IMG would make them look weak to other applicants.
Internationals are a minority within the applicant pool for Ophthalmology – Unlike other specialties, like medicine for example, ophthalmology programs are not exposed to a large number of applications by IMGs, and therefore may not be used to reviewing it. I once got a rejection from an ophthalmology program I am interested in, and when I reached out, the feedback was they thought I consistently scored below average during my med school, which didn’t make sense. Turned out they read the passing scores on my med school transcript as my actual scores. Also, a GPA of 3.3/4 is not the same across every medical school across the world, and the concept of AOA or Gold Humanism award is not known to my med school, for example. So, comparing all applicants as apples to apples can be tricky.
The total number of IMGs participating in the ophthalmology match last year was 61, representing 9% of the applicant pool. Within the NRMP, the Electronic Residency Application Service (ERAS) provides the option for programs to skip the Medical Student Performance Evaluations (MSPEs) of IMGs.
Flexibility is a double edge sword – Having my immediate family in [a foreign country] makes every state/city in the US equally attractive, and this gives me flexibility that not everyone has. At the same time, it makes it hard for me to make the case that I have strong ties to a specific city or location – which I feel programs value a lot and factor in the selection process. I try to be honest about this when I write a letter of interest to a program, but not sure how well that is perceived.
The residency application process is time consuming, costly and nerve wracking for every applicant. There are very valid reasons for certain groups to feel disenfranchised or particularly vulnerable in the process, such as those with borderline board scores, are from DO programs or lower tier institutions, ethnic and gender related disparities, and many others. These two posts are not an attempt to minimize those issues, but to highlight another group that is often (at least in my limited, personal experience) even further marginalized. I don’t have an immediate remedy for any of this, but I hope that discussing it and providing the perspective of one applicant can raise awareness.
I’ll finish with an update. This conversation and blog post started in the fall of 2019, well before the match cycle ended. I was so thrilled in January to receive an email from this individual stating they had matched into an ophthalmology residency position. Below are some of their parting thoughts:
I am happy, I am elated and I am excited for this new chapter, and the longer the wait the greater the reward. When the chair of the department congratulated me on the match day he said “It took a while but it was worth the wait”. I couldn’t agree more. I think anyone who matched would say the same, so I am not sure how much more I can add to that. I do, however, have something to say about my experience not matching in the previous cycles that is maybe worth sharing with others.
Everyone applying to ophthalmology match or any match in general has challenges to overcome, and in my case being an IMG was one challenge. The challenge may vary but I believe it’s the attitude toward a challenge rather than the challenge itself is what really matters. Working on developing mental toughness and adopting a growth mindset is what helped me shape my attitude not when I matched, but when I didn’t, and kept me motivated to purse my goals. These are a few of the strategies that helped me:
– There is no one-size-fits-all:
I am fortunate to have many friends and mentors who I met along the way and were very generous to support me and share their experiences with me. For them, I am eternally grateful. But what has worked for them isn’t necessarily what has worked for me. For example, the year I matched I wore a blue suit (it looked darker before buying it in the store!) which was against the “match guide” rule of wearing a dark navy or a dark gray suit. However, I still matched. This is not to say that blue suits are a significant factor to match (maybe it was for me!), but this is to say that everyone has a unique story.
– Breaking out of the victim mentality
My father, who is a lawyer in [international country], told me once “I don’t know much about the medical training in the US, or what it takes to match into ophthalmology, but one thing I know is that it’s a country influenced by capitalism. You should bring more to the table than what you expect to take”. His advice opened my eyes and helped me break out of the victim mentality of saying that the system is biased against IMGs (which is at least partially true), and find excitement in adopting an entrepreneurial approach.
– The very basic rule: take care of your body.
Eat healthy, exercise and sleep well. The simplest, yet most effective strategy (whenever I could afford it).
– Surround yourself with those who believe in you.
I can’t stress this enough. Supporters of success are not very common encounters so keep them close. This is not to say that people who constantly remind you how extremely hard matching into ophthalmology is are bad people, in fact they are realist who rely on facts. But it’s important not to let these constant reminders put you down.
– Good things take time
This is not a sprint, but a marathon. After speaking to other inspiring IMGs who matched into ophthalmology before me, one common theme stands out; time. They all spent a couple of years working hard before matching, and that’s the plan I had in mind. Being patient and planning my short- and intermediate-term goals accordingly helped me a lot.
– Time is a luxury
Being able to continue to pursue ophthalmology after not matching is a privilege not everyone can afford. Some people have loans or other circumstances that would make it impossible to pursue something for a long time. That said, I had to make sacrifices myself to be able to afford such luxury. So make sure to know what you want, and rearrange you priorities accordingly. Nonetheless, I acknowledge and feel grateful for the privilege of time.
– It’s about the journey not the destination.
As cheesy as this may sound, it’s very true. Numbers don’t lie; some applicants won’t match. I could have been one myself. What helped me live with this possibility is changing the definition of success by instead of saying I am successful only if I match, I tried to say I am successful as long as I am continuing to improve, learn and have an impact. Roosevelt said it better: “Do what you can, with what you have, where you are”. At the end of the day, life is larger than a residency position. Although this is maybe obvious to others, I found myself too involved and had to remind myself of this from time to time.
– At the end, it’s all about the people.
As my program director told me after the match; beyond the USMLE scores, the letters, the publications and what not, it goes down to connecting as a human. The reason why I chose ophthalmology in the first place, and the reason why I ranked my matched program as my top choice is the people. These are people I look up to and people I enjoy working along with.
This past cycle, 9% of the participants in the Ophthalmology Residency SF Match were International Medical Graduates (IMGs), who matched at a rate of 28% (for comparison, the rate was 85% for US Allopathic Seniors). This is a statistic that I glanced over when the data was released, but admittedly have not given this group much consideration until recently. I would like to share parts of an email conversation I had with one of those 72% of unmatched IMGs that has really opened my eyes. I hope it does the same for you.
The italicized excerpts from this conversation are kept anonymous, but published with permission.
I very much enjoyed reading your blog on UK website, especially your article on how applicants are selected for interviews. I found your article very informative, systematic and transparent. At the same time, I found it thought/questions-provoking as a I reflected on my experience participating in the match cycle, for the 3rd time now. I am writing you this email hoping you would share with me your input on the special case of applicants who are international medical graduates (IMGs).
An International Medical Graduate (IMG) is defined as a physician that graduated from a medical school outside of the United States and Canada, including US citizens and permanent residents who complete medical school outside of the US and foreign nationals that enter the US for residency and fellowship training. As of 2015, IMGs represent ¼ of all trainees and practicing physicians in the US. The numbers in ophthalmology are noticeably lower: 5% of residents and 7% of practicing ophthalmologists.
Let me first briefly share my background; I earned my MD degree from [International University], moved to the US in 2016 and completed a 2-year master’s in clinical research at [Well Known US Academic Medical Center], followed by a prelim year at [Second Well Known US Academic Medical Center], and most recently, joined the [Third Well Known US Academic Medical Center] as an imaging research fellow. My USMLE step scores are: 256, 237 and Pass for step 1, step 2 CK and step 2 CS, respectively. I have letters of recommendations from mentors in the US who I worked closely with for 2+ years. I have 10+ publications/abstracts. I am on F1 student visa.
Prior to entry to the US, IMGs are carefully evaluated by the Educational Commission on Foreign Medical Graduates (ECFMG). IMGs who are not either US citizens or permanent residents almost always complete their training on a J-1 visa, sponsored through the ECFMG at no cost to the training institution. The vetting process sometimes can be delayed for multiple months pending security clearance, which can lead to delays in training and even loss of residency positions. The J1 program requires holders to return to their country of citizenship for at least 2 years after completion of training.
A notable exception to this requirement is local, state and federal programs that allow IMGs to remain in the US if they work in an underserved community. For example, the Conrad 30 federal program offers waivers to up to 35 IMGs per state per year, provided they commit to 3 years working in a medically underserved community. Other programs include the Delta Regional Authority, Appalachian Regional Commission and Department of Veterans Affairs.
For this and other reasons, IMGs disproportionately work in rural and low-income urban communities compared to US medical graduates, serving as the primary source of healthcare access in these areas. Increasing federal immigration restrictions coupled with projected physician workforce shortfalls raise significant concerns about current and future healthcare opportunities in these vulnerable communities.
A final option for IMGs wishing to remain in the US after training is to apply for a hardship and persecution waiver, which requires “evidence that the applicant would be subjected to persecution on account of race, religion, or political opinion, on returning to the home country.” The estimated processing time of this waiver is currently 11-14 months.
So, why do foreign graduates seek training in the US? For many of the same reasons as the rest of us, such as financial opportunities, professional development afforded by our training system, and to improve career options. There are others as well, including personal relationships that necessitate living in the US, or to seek asylum because of war, natural disasters, and persecution. I’ll address some of the barriers these physicians face after arriving in the US in an upcoming post, but want to emphasize that there are refugee and international physicians currently living among us working as janitors, taxi or rideshare drivers, or in the hospitality industry, for example. The under or unemployment of IMGs is all the more underscored by the estimated shortage of 52,000 primary care physicians in the US within the next five years, although the accuracy of all physician workforce data is limited. Unlike other nations such as the United Kingdom, Sweden, and Turkey that have recognized the need for additional healthcare providers and the benefits of assisting IMGs with securing training positions and integrating into the healthcare system, the United States has been very slow to consider changes to its current process.
Immigration is a polarizing and popular topic (always has been), and likely to play an even more prominent role in upcoming elections. It is intimately tied to political and personal conversations and I cannot ignore it is in the background of this one. I will mostly side-step this issue, but do want to end this blog post with a powerful poem and perspective written by the British, Somali poet Warsan Shire:
Post #5: Action – This is our lane
See the prior posts introducing this topic, exploring the scientific myth of race, elaborating why race is still very real, and the role of implicit bias. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
Of all the forms of inequality, injustice in health care is the most shocking and inhumane.Reverend Martin Luther King, Jr., 1965
These words were spoken in Montgomery, Alabama at the end of the march from Selma. Dr. King walked alongside black and white physicians he invited from the Medical Committee for Human Rights. They were there for two primary purposes: to give care to injured marchers and to observe to the abuse suffered.
We, too, must bear witness. For many of us (myself included), this woefully starts with watching, reading, listening, and finally beginning to learn. For instance – ashamedly – I just recently learned after the death of Congressman John Lewis, that Dr. King’s march was in response to one by John Lewis and others where nonviolent protestors were attacked by state troopers with clubs and tear gas; our future Congressman was severely beaten and sustained head injuries. Mr. Lewis’s march was in response to the police shooting of Jimmie Lee Jackson, a 26 year-old church deacon who was attempting to protect his mother from the nightstick of a police officer during a demonstration.
As physicians, though, it does not end with observation. Our education is purposeful – to heal. Unequivocally, both conscious and unconscious racism worsens disease. It leads to inequity in life and death. We cannot heal without combating racism.
In her book “Just Medicine” that I mentioned in the last post, Dayna Bowen Matthew borrows from Thomas Frieden’s Health Impact Pyramid [figure below] to discuss the varying ways public health efforts can impact outcomes. Conceptually, the higher the level of the pyramid, the less public impact. Dr. Matthew uses this figure to implore the need for lower level interventions to truly combat racial inequality in healthcare, and while I encourage reading her book to learn about it, I do not believe I give anything away by stating her plan requires changes in the medicolegal system. Similarly, Ibram X Kendi argues that dismantling racism necessitates policy much more than personal change. Therefore, if we want to truly promote racial healing, as individuals and institutions we need to support broad and encompassing change. We must hold our leaders accountable and elect officials that will enact antiracist policies.
“Racist” and “antiracist” are like peelable name tags that are placed, and replaced based on what someone is doing or not doing, supporting or expressing in each moment. These are not permanent tattoos. No one becomes a racist or antiracist. We can only strive to be one or the other. We can unknowingly strive to be a racist. We can knowingly strive to be an antiracist. Like fighting an addiction, being an antiracist requires persistent self-awareness, constant self-criticism, and regular self-examination.Ibram X Kendi
I started this series with the intent of discussing a few steps I want to take within our program. Admittedly, they are near the apex of the health impact pyramid above. They also are introductory and insufficient. But, they are tangible and accountable: judge our program by these actions and our outcomes.
Education: Social science literature encouragingly indicates that implicit biases are malleable. Even though they are accumulated over a lifetime, we can counteract (although not likely fully eliminate) them with “personal, social, and situational pressures.” With that in mind (see the pun there), I am committed to promoting regular implicit bias education in our didactic curriculum. As a learner rather than an educator on this topic, I will lean heavily on others, and welcome any and all ideas and resources.
The limited data on implicit bias in medical training suggests that early in training physicians are less likely to allow perceptions of race and social class to influence clinical decisions than later on. As Dayna Bowen Matthew explains: “Most medical schools include cultural competency training in their curricula. However, the negative perceptions modeled by seasoned physicians, and possibly other health professionals as well, do not disappear simply because of medical school training in cultural competence … cultural competency training has little impact on the transfer of implicit biases from senior practitioners to their medical students.” Consequently, the behavior modeled by our faculty is passed to our residents, residents to our medical students, and so on. For educational efforts to have an impact, it must encompass our entire department, and we need to be aware the outsized role modeling behavior plays.
Recruitment: According to the most recent census estimate, 14.5% of individuals in Lexington, KY and 13.4% of the entire US population are Black. Our department and residency program do not reflect our population. While we intentionally recruit with racial and gender inclusion in mind, it clearly is insufficient. Last year I wrote on the initial intent compared to the current use of USMLE scores and potential concerns with the void left if (and now when) the scoring system changes. Given this and the disruption to the entire recruitment season as a result of COVID-19, a more holistic review process is needed. I will advocate for systematic advances within our specialty, but also commit to intentional and rigorous changes to our program level application review process. All members of our application review and interview committees will also be required to go through implicit bias training prior to participating.
I hope those that took the time to read these posts found use in them. I hope even more that if you are someone like me, your eyes are similarly starting to open. This is just the beginning for our program, and I will provide updates as they come. The changes we make, and lessons learned will influence many other aspects of our training and clinical environment. Please reach out with any comments, concerns, or suggestions.
The good news is that racist and antiracist are not fixed identities. We can be a racist one minute and an antiracist the next. What we say about race, what we do about race, in each moment, determines what – not who – we are.”Ibram X Kendi
Post #4: Implicit Bias and Personal Reflection
See the prior posts introducing this topic, exploring the scientific myth of race, and elaborating why race is still very real. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“One wishes that Americans – white Americans – would read, for their own sakes, this record and stop defending themselves against it. Only then will they be enabled to change their lives. The fact that they have not yet been able to do this – to face their history to change their lives – hideously menaces this country. Indeed, it menaces the entire world.” James Baldwin, “White Man’s Guilt” in The Price of the Ticket
The last two posts provided examples of egregious racist acts and policies within science and broader society, and how they are intertwined and still very much with us today. A study of medical residents in 2016 demonstrated the racial biases we carry into the hospital, which demonstrates a form of implicit bias: “People – all people – hold some implicit biases. A bias is a negative attitude about one group of people relative to another group of people. However, the distinguishing feature of an implicit bias is the negative association operates unintentionally or unconsciously.”
The quote above is from the book Just Medicine: A Cure for Racial Inequality in American Health Care by Dayna Bowen Matthew. She details the history of racial healthcare laws and policies that formed the framework for much of our inequality today, but also argues the importance of individual implicit bias at the level of the physician-patient encounter and how that influences the overall healthcare system.
If you haven’t, take the Implicit Association Test (IAT): https://implicit.harvard.edu/implicit/. This widely used and validated test has revealed the harm of our implicit biases in many different arenas including prosecuting attorneys in the criminal justice system, the jury selection process, employment hiring and promotion decisions, and school disciplinary actions. Police officers with higher IAT scores (white favored implicit biases) more readily shoot unarmed Blacks than unarmed whites during video game simulations.
Healthcare workers are not exceptional and test no differently than the rest of the population. In her book, Dr. Matthew presents “The Biased Care Model” [figure below] and details six mechanisms by which health care providers’ racial and ethnic biases contribute to disparate health outcomes. Her argument is compelling and well worth the read. If you remain unconvinced on the role of implicit bias in racial inequity, specifically in healthcare and explicitly at the level of the individual provider, then please consider reviewing these or other resources.
“When racist ideas resound, denials that those ideas are racist typically follow. When racist policies resound, denials that those policies are racist also follow. Denial is in the heart of racism, beating across ideologies, races, and nations. It is beating within us.” Ibram X Kendi, “How to be an Antiracist“
Even if it is not explicit, most (if not all) of us carry implicit racist biases. That can be hard to accept, since we believe ourselves to be good and honest people. But what I’ve tried to argue to this point is we are a product of a long history of racist ideas, policies, science, and socialization that is deeply entrenched within ourselves. Denying this truth is harmful, but so is ignoring it. If we believe racial equity is important in our greater profession and in our own office, then it requires constant vigilance against our own biases. As stated by Michelle Alexander in The New Jim Crow: Mass Incarceration in the Age of Colorblindness, “This system of control depends far more on racial indifference (defined as a lack of compassion and caring about race and racial groups) than racial hostility – a feature it actually shares with its predecessors.”
The final post on this topic will explore some actionable items related to all of this, with the intent of creating accountability for our programmatic response.
Post #3: Learning – Race is Real
See the prior posts introducing this topic and exploring the scientific myth of race. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“Although the concept of race invokes seemingly biological based human characteristics (so-called phenotypes), selection of these particular human features for purposes of racial signification is always and necessarily a social and historical process. Indeed, the categories employed to differentiate among human beings along racial lines reveal themselves, upon serious examination, to be at best imprecise, and at worst completely arbitrary. They may be arbitrary, but they are not meaningless. Race is strategic; race does ideological and political work.” Michael Omi and Howard Winant, Racial Formation in the United States
We need to go no further than the current crisis to see this in action. As is now widely acknowledged, current SARS COVID-19 mortality data in the US suggests a disparity based on race and ethnicity, with Black, and to a slightly lesser extent, Latinx patients suffering at much higher rates than whites.
As I limitedly argued in the last post, race is not scientific, so the reason for these disparate outcomes are not – at least not primarily – biologic. Prominent leaders in our country still hold this belief, however, including a physician senator when questioned on the data in his own state. But the truth of the matter is far more complex and damning. As explained recently in JAMA, there are two likely explanations for these data: racial and ethnic minorities have a disproportionate number of underlying comorbidities and risk factors, and minorities, especially in urban areas, live in more crowded neighborhoods and households and more likely to be employed in public-facing jobs; social distancing, safe at home, and other public safety efforts are privileges not extended or available to many in these communities. “As more data emerge, there will likely be evidence of racial/ethnic health disparities due to differential loss of health insurance, poorer quality of care, inequitable distribution of scarce testing and hospital resources, the digital divide, food insecurity, housing insecurity, and work-related exposures.”
These factors are called the social determinants of health, which broadly include all conditions in life that shape health. These are more specifically summarized in six categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (including transportation, housing, security, community self-efficiency), and fairness (in general, sufficient redistribution of wealth and income to ensure social and economic security and equity).
These social conditions help explain why, for example Black individuals at birth have a life expectancy of 3.5 years less than white individuals, 70-80% of which can be explained by socioeconomic factors, and a Black infant born in the US is more than twice as likely to die before their first birthday than a white infant.
Many of these determinants are “far upstream of health care and are deeply rooted in the distribution of money and power, at local and national levels”. These roots are foundational to our country, and a very limited and topical review of some of the branches include:
- Over the past 30 years, the U.S penal population exploded from around 300,000 to more than 2 million, with drug convictions accounting for the majority of the increase. The United States imprisons a larger percentage of its Black population than South Africa did at the height of apartheid.
- These stark racial disparities cannot be explained by rates of drug crime. Studies show that people of all colors use and sell illegal drugs at remarkably similar rates, yet in some states, Black men have been admitted to prison on drug charges at rates twenty to fifty times greater than those of white men.
- More African American adults are under correctional control today – in prison or jail, on probation or parole – than were enslaved in 1850, a decade before the Civil War began. The mass incarceration of people of color is a big part of the reason that a Black child born today is less likely to be raised by both parents than a Black child born during slavery.
- The total population of Black males in Chicago with a felony record (including both current an ex-felons) is equivalent to 55 percent of the Black adult male population and an astonishing 80 percent of the adult Black male workforce in the Chicago area. More than 70 percent of all criminal cases in the Chicago area involves a class D felony drug possession charge, the lowest-level felony charge.
- Black individuals are 3.23 times more likely than white individuals to be killed by a police officer in the United States.
- Black people fatally shot by police are twice as likely as white people to be unarmed.
- Bias in administrative records results in many studies underestimating or discriminately masking racial bias in policing.
- In 1910, Black Americans owned over 14 million acres of land, but today our population of 40 million Black Americans own only 8 million acres.
- Black Americans own less than 1% of rural land in the country. The five largest white landowners own more rural land than all of Black America combined.
- “The Color of Law: A Forgotten History of how our Government Segregated America” provides a detailed history of racial housing policy. Here is a map of redlining in Lexington, KY in 1940.
- The Black poverty rate in 2018 was 22%. It was 9% in whites.
- The Black unemployment rate has been at least twice as high as whites for the past fifty years.
- The median net worth of white households is roughly ten times that of Black households.
- More recently, by April of 2020, among the estimated 36 million jobs lost due to COVID-19, roughly 40% were by persons with an annual household income of less than $40,000. Unemployment rates at that time were 14.2%, 16.7%, and 18.9% among white, Black, and Latinx individuals, respectively.
This is (one reason) why acknowledging race is important, and it is absolutely imperative we do so in medicine. Circling back to COVID-19, the racial disparities were not widely or immediately recognized in the early months of the pandemic because municipalities were not reporting data broken down by race and ethnicity. This color-blind approach clearly can be harmful: “To insist on color blindness is to deny the experience of people of color in a highly racialized society and to absolve oneself of any role in the process.” A recent report of leading ophthalmology journals found that in 2019, 88% of studies reported background information including patient age and sex, but only 43% reported race and/or ethnicity.
To summarize up to this point, race is a sociopolitical construct that serves to create systematic inequity. It harms individuals and communities and directly impacts health. For those reasons and others, it is essential that we report race in the literature and continually raise awareness of these inequities. Simultaneously, it is important that we recognize these are not inherent or biologic traits, but the result of social injustices. The next post will try and make this more personal, including a discussion on the role of implicit bias in healthcare. The final post will focus on ways we can respond, including plans within our program.
Post #2: Learning – Race isn’t Scientific
See the prior post introducing this topic. This discussion is not meant to be comprehensive, nor are the listed resources, but I hope it can shed some light on race, science, and racial medicine. Please contact me with any comments or additional sources.
“White man, hear me! History, as nearly no one seems to know, is not merely something to be read. And it does not refer merely, or even principally, to the past. On the contrary, the great force of history comes from the fact that we carry it within us, are unconsciously controlled by it in many ways, and history is literally present in all that we do. It could scarcely be otherwise, since it is to history that we owe our frames of reference, our identities and our aspirations. And it is with great pains and terror that one begins to realize this.” James Baldwin, “White Man’s Guilt” in The Price of the Ticket
Race is not inherent. It is neither scientific nor biologic. It was created. Consider those statements for a moment. They are radical – they fly in the face of what is taught and understood from grade through medical school. For an excellent review on the history of race, read The History of White People by Nell Irvin Painter or Stamped from the Beginning: The Definitive History of Racist Ideas in America by Ibram X Kendi. If you’d rather listen, the second season of the podcast Scene on Radio entitled Seeing White covers this well.
There are aspects of racial science that seem appalling by today’s standards. A great book that covers the bullets below and much more is Superior: The Return of Race Science by Angela Saini:
- Carl Linnaeus, the father of taxonomy, in his tenth edition of Systema Naturae in 1758 created a human hierarchy within the animal kingdom in the following order: H. sapiens europacus, H. sapiens americanus, H. sapiens asiaticus, and H. sapiens afer. Their corresponding colors of white, red, yellow, and black remain with us today.
- Dr. Samuel Morton, the founder of anthropology in the United States, published Crania Americana in 1839 evaluating his collection of human skulls – the largest in the world – and determined from a detailed analysis of nearly 100 skulls that the Caucasian race has the largest mean internal capacity and therefore the highest intellectual endowment of all races.
- The biologist Francis Galton, cousin of Charles Darwin, coined the term “eugenics” in 1883 from the Greek prefix eu for “well” or good”. His intent was to use social control to improve the health and intelligence of future generations.
- In 1907, the first involuntary sterilization law was passed in the state of Indiana (and not repealed until 1974), with eugenicists endorsing the heredity of criminality, mental health issues, and poverty. An excellent podcast episode on this dark period of US history was produced by “Radiolab”.
- Eugenics reached its logical culmination with the holocaust. Karl Pearson, who is known for his contribution to statistics (he’s the “p” in p-value), was also the successor to in the eugenics movement. He brought the below box to London, representing 30 locks of artificial hair, with the most “desirable” colors and textures in the middle. This device was initially trialed by the Nazis during the first genocide of World War II in Namibia, where ¾ of those deemed to be “non-white” were systematically killed.
- A similar Nazi scientific device utilized eye color to measure race, especially amongst the Jewish people and for similar purposes.
Comparable atrocities are well known to medicine specifically, with these serving as two examples:
- Dr. J Marion Sims, president of the American Medical Association and founder of the American Society of Gynecology in the late 1800s, performed up to 30 procedures each on 11 enslaved, healthy women over 4 years to develop his procedure to treat vesicovaginal fistulas. These women were provided no anesthesia even though it was available, yet used it when performing the procedure on white women a few years later. He claimed – as was widely believed – that Blacks did not feel pain the same way as whites.
- In 1932, the US Public Health Service began its “Study of Syphilis in the Untreated Negro Male” in six hundred syphilis-infected sharecroppers in Tuskegee, Alabama. The investigators secretly withheld treatment and awaited death of the participants to confirm the hypothesis that syphilis more likely influenced the cardiovascular rather than neurologic system of Blacks compared to whites, in part due to the findings of Morton above that buttressed the belief that Blacks had relatively primitive and underdeveloped brains. The study was initially projected to last 6 months, but was not halted until 1972 – forty years later – when it was exposed by the media.
These episodes stand out as historical reminders. We can collectively shudder, yet feel comforted that we have moved on and are more enlightened.
Turns out we’re not. The protests in the streets of our nation today suggest otherwise. Recent scientific literature also suggests otherwise. Both are just harder to see. Harriet A. Washington argues in her book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present these are not isolated events and relying solely on the stories fails “to discern the stubborn and illuminating patterns characterizing the medical abuse of African Americans.”
While the human genome project finished 20 years ago in June 2000 and demonstrated that “human beings, regardless of race, are more than 99.9 percent the same” and there “are greater genetic differences between individuals of the same racial group than between individuals of different groups”, our literature is filled with studies analyzing genetic differences based on race, ancestry, descent, or other analogous terms. These are being published today. And this is despite the fact that the US Census Bureau and National Institutes of Health (NIH) amongst many other governing bodies claim that race is “a social category recognized by the United States and does not attempt to define race biologically, anthropologically, or genetically.”
Race is not scientific. While we may take that statement for granted, the converse remains entrenched in our profession at an institutional and individual level. For example, in 2016 (to repeat, 2016) a study of 121 white resident physicians at the University of Virginia found that over half believed: Blacks’ nerve endings are less sensitive than whites’ (see Marion Sims above), whites’ have larger brains than Blacks’ (see Morton above), and Blacks’ skin is thicker than whites’.
Race is not scientific. But, race absolutely is real. It carries social, economic, and medical significance, and to be “color blind” is perilous as a healthcare provider. The next post covers this in greater detail. What I want to emphasize in conclusion, though, is how important it is to not just learn about these matters, but better understand the implicit biases we carry into the exam room as a result not just of our socialization, but the historical roots of racial science that remain pervasive in ourselves and profession today.
Post #1: Introduction
The recent murders of George Floyd in Minneapolis and Breonna Taylor just up the road in Louisville have raised awareness of systemic racial injustice in our country. I believe it is important to comment on this topic and will use several upcoming posts to do so. I hope this generates some discussion and opportunities for continued learning and growth (starting with myself). First, some qualifiers:
- This is not a political statement. I want to focus on medicine and our programmatic response. However, any reasoned comment on this topic cannot ignore the role of policies in creating and maintaining structural racism.
- This represents my views and perspective. As program director, it also reflects our residency program, but I do not speak on behalf of my residents, faculty, departmental staff, or the broader university.
- Relatedly and most importantly, this represents the views and perspective of a cis gendered white man of high socioeconomic status. I am the beneficiary of race. I have no experiential knowledge of this topic, and while I have vetted these posts with several colleagues and peers, I am certain that parts of this will be insensitive and perhaps inaccurate. I apologize in advance, especially if this somehow adds to the pain of any Black or Brown readers. Please critique these posts harshly and contact me with comments.
Where do we go from here? That’s the biggest question I have for myself and our society, and while I clearly have no answer, there are others with ideas. Research from Movement Netlab, a social movement think tank, frames social movements in cycles: from rising anger, to a trigger moment, heroic phase, disillusionment, learning and reflection, and re-growth (and then repeat).
According to this model, it would appear we are or near the peak, suggesting a contraction is coming. If we want to realize some of the changes the current movement is demanding, it will require sustained efforts to fight through the upcoming waves; on their own, words, institutional statements, and blog posts accomplish very little. With that in mind, I want to orient the remainder of this conversation around three areas within our profession that are necessary for long-term change: learning, reflection, and action.
In 2017, Dr. Ana Bastos de Carvalho and Dr. Eric Higgins founded the Global Ophthalmology (GO) division in our department. The goal of this outreach effort is to develop equity in eye care, not only with global partnerships, but also throughout the Commonwealth of Kentucky. Several of their recent efforts are highlighted here and here.
The program is now starting to focus on education and our trainees, and we are excited to announce the establishment of a global ophthalmology track that we will start offering to an interested matched applicant each year.
Over the past decade, there has been a rise in the number of medical education training programs encouraging careers focusing on global health. These initiatives largely developed as a response to medical school graduates interested in addressing global health inequities. As stated in one editorial: “Global health is not about us; it is about others. The goal of investing in global health career pathways is to improve the health of disadvantaged populations, and it is a tangible investment in social justice, health equity, and the promise of the next generation of caring physicians.”
To help introduce our initiative – and keep this sporadic blog edgy – I’ve done a Q&A type conversation with Dr. Bastos de Carvalho.
What is “UK GO”? What’s your background and interest in global health?
The University of Kentucky Global Ophthalmology (UK GO) program was founded in 2017 by Dr. Ana Bastos de Carvalho and Dr. Eric Higgins, ophthalmologists at the UK Dept. of Ophthalmology & Visual Sciences. Dr. Ramiro Maldonado more recently joined the program as director of Ecuador operations. Their life and work experiences have motivated them to build a program that would help improve eye care equity in Kentucky and internationally. Dr. Bastos de Carvalho has seen firsthand the impact of health inequities growing up in low- and middle-income countries, such as Brazil and Angola. The images she recalls as a child making trips to the hospital with her father, also an ophthalmologist, made an indelible impression that has lasted throughout her life. “I realized at a fairly young age that I wanted to go into medicine and do my part to bridge the gap for people who don’t have access to healthcare,” she says. As for Dr. Higgins, he believes his Appalachian roots and connections are what keep him focused on local underserved populations, while his year-long ophthalmology fellowship in Swaziland taught him the importance of cross-cultural eye care and education. Dr. Maldonado grew up and studied medicine in Ecuador. His strong roots to his homeland steered him towards developing strong relationships with educational and medical institutions in the country, with the goal of expanding ophthalmology education and eye care delivery to the poor in Ecuador.
What are some GO opportunities for residents?
UK GO has established several regional and international partnerships that may provide unique learning experiences to residents interested in Global ophthalmology. Regionally, UK GO directs a large academic-based network that provides diabetic retinopathy screening services to underserved populations and serve as the platform for high-quality implementation science research. Internationally, we have partnered with ophthalmology institutions in India, Ecuador and Haiti to build capacity in eye care in these countries. UK GO can provide our trainees with opportunities to experience global health delivery and research in different cultural and economic environments in all these systems.
What is the GO residency track?
The UK GO residency track is a structured experience that provides well-rounded education in global ophthalmology. To our knowledge we are the first ophthalmology residency in the country to offer this structured opportunity. Applicants selected to participate in the track will participate in and lead GO interventions regionally and internationally, interact with key players in global health, and complete GO scholarly projects. GO Track residents will have their international GO expenses covered and will receive a certificate at completion of the track.
What do you primarily want trainees to learn about global health care?
We hope UK GO can provide trainees with experiences that will allow cultivating a passion for reducing health disparities, cultural humility and awareness, and the tools to develop and sustain high quality symbiotic partnerships with institutions in low-resource settings.
Do you have any other resources or information for anyone interested in learning more?
We’d love to talk to anyone interested in applying to our GO residency track or in engaging in GO experiences during their training at UK. Please email us at firstname.lastname@example.org or email@example.com or firstname.lastname@example.org for more information.
“The psychometric rigor and validity argument for USMLE scores allows for defensible pass/fail decisions related to licensure but does not substantiate use of individual scores in selecting residents.”
In the past two blog posts, I discussed the initial intent, current use, validity and consequences of the USMLE as a residency screening tool. Thankfully, this wasn’t just an exercise; most of my interest and information on this topic came after learning of some very potentially disruptive changes in the near future: moving to a pass-fail scoring system.
As stated in a recent viewpoint on this topic in JAMA: “Changing the USMLE to a pass-fail format would require residency programs to find other, potentially more meaningful, ways of evaluating applicants. Although a more thorough review of applications would be resource intensive, programs might identify outstanding applicants who would have been overlooked based on a numerical cutoff.”
This sounds encouraging, but it would be naïve to think that changing to a pass/fail system would improve much if it occurs in isolation. The authors go on to state:
“Moving to a pass-fail system for USMLE could make it more difficult to counsel students because each residency program would develop independent review standards. Furthermore, the movement over the past decade to pass-fail grading in many medical schools could exacerbate this problem, making it difficult to predict success in the match. Unless the ERAS significantly improves the capacity for programs to screen applicants based on individual characteristics (key words, research area, etc.), program directors may use the variables they have access to such as placing more emphasis on medical school reputation or location. Changing such a complex system must be addressed carefully because it is a crucial factor in determining the specialty training of thousands of medical school graduates.”
Therein lies my biggest concern – if the USMLE is changed to pass/fail without other carefully considered, well implemented, uniform policies from our governing organizations, the process may become even more arbitrary and discriminatory. My hope is our leaders will be proactive in addressing these issues and start trialing and debating potential solutions in the near future.
What could these “more meaningful” evaluation tools look like? A brief literature review provides some insight, although most of these models are rather esoteric to me, and there is very little substantial evidence or use of them for the purpose of residency selection. I’ll briefly (and poorly) describe some of them below.
Holistic Review. Holistic assessment is defined by the American Association of Medical Colleges as ““flexible, individualized way of assessing an applicant’s capabilities by which balanced consideration is given to experiences, attributes, and academic metrics and, when considered in combination, how the individual might contribute value as a medical student and physician.” This involves using programmatic or institutional values to review applications, with all domains of the application measured similarly in regard to the institutional needs. Some of these domains could include “ethics, leadership, cultural competency, diversity, communication, healthcare disparities, patient and family centered care, and innovation.” Such an approach is currently being used in some medical school admissions, and “does not necessarily need to be complex or time intensive.”
Gateway Exercises. These are uniform evaluation opportunities during various checkpoints in medical school training – for example, at the end of required clerkships or beginning/end of the academic year. A common exercise currently implemented by many medical schools are Objective Structured Clinical Examinations (OSCEs).
Simulated Assessments. Simulated encounters and exercises are frequently used in medical training including the OSCE above or other standardized patient evaluations, computer-based cases, written clinical scenarios, mannequins (in bow ties) or a combination thereof.
Competency-Based Assessments. The transition to a competency-based curriculum in medical school (and residency) has been slow but persistent. The evaluation system necessitates assessment across multiple domains, thus creating a more comprehensive portfolio as students progress through training. Along those lines, longitudinal tools or dashboards that provide trajectories over time, as compared to one’s peers, may be a potential tool for comparing residency applicants .
Standardized Video Interview or Letter of Evaluation. Emergency Medicine is on the innovative and “early adapter” end of the curve as it applies to residency application. Not only have they adapted a standardized letter of evaluation at the end of required externships (which is felt to be the most important factor for determining which applicants to interview), but also piloted a standardized video assessment during the 2018 interview cycle. This assessment is an online interview involving questions based on “knowledge of professional behaviors and interpersonal and communication skills”. The interviews are scored by a third-party and both the scores and video are provided to residency programs.
To be honest, I’m not sure I really understand any of what was just stated, especially on a practical level. Some additional (major) limitations to any of these assessment models include: increased cost and complexity, lack of validation for resident selection, difficulty implementing and then comparing across schools, and program director and faculty acceptance.
Lastly, as mentioned in the quote above from the JAMA viewpoint, these measures and application review will likely be more “resource intensive”. I doubt many program directors, coordinators and review committees currently feel capable of devoting additional time and money to this process. To that end, I believe the application and interview process must also change, with several currently debated suggestions highlighted in this prior post. Again, my hope is that our leaders will be proactive rather than reactive with all this, mindful that the party with the most at stake is the applicants.
I hope these posts have been informative and provocative. This is a pivotal aspect of the application process that is likely changing in the near future, so it will be hard to ignore. As always, please let me know any thoughts or perspectives! I have one additional topic to discuss in the near future that has been quite eye opening for me – I imagine it will be much the same for many of you.