Keywords
diversity - underrepresented minorities - medically underserved areas
In 2011, a geographic maldistribution of ophthalmologists was identified, with 61%
of U.S. counties lacking ophthalmologists and 24% of U.S. counties lacking both ophthalmologists
and optometrists.[1] Medically underserved areas (MUAs) contribute to the societal burden of preventable
and treatable eye diseases.[2] Moreover, disparities in eye care tend to disproportionately affect underrepresented
minorities. Recent evidence demonstrates that non-Hispanic (NH) Black/African Americans
suffer from visual impairment due to glaucoma and diabetic retinopathy at 2.35 and
1.34 times the rate of NH White people, respectively.[3]
[4] It is imperative that we address disparate outcomes in eye health in an aging and
increasingly diverse U.S. population.
According to the census data in 2020, the U.S. population was 60.1% NH White, 18.5%
Hispanic/Latino, 13.4% Black/African American, 5.9% Asian, 1.3% Native American, 0.2%
Pacific Islander, and 2.8% multiracial.[5] This unfortunately is not reflected in the ophthalmology workforce. In 2019, the
racial and ethnic composition of ophthalmology faculty members at U.S. medical schools
was 60.3% NH White, 27.6% NH Asian, 2.3% NH Black/African American, 2.3% Hispanic/Latino,
0.03% Native American, and 0.07% Pacific Islander.[6] These demographics were also inconsistent with the demographics of ophthalmology
residency programs from 2011 to 2019, which, despite increasing ethno-racial diversity,
still lag in comparison to other specialties as well as the U.S. population.[7] Research indicates that ophthalmologists from racial and ethnic populations that
are underrepresented in the medical profession relative to their numbers in the general
population groups, abbreviated as underrepresented in medicine (URM), are more likely
to practice in MUAs and bring the clinical benefits that include similar demographics
and language, which improve patient/physician concordance.[8]
[9]
Exploring the intention to practice ophthalmology in underserved areas (IPUA) has
important ramifications for visual health outcomes across the nation. Additional factors
that motivate graduating medical students to practice ophthalmology in MUAs remain
to be investigated. For example, cultural competency, community service, mentorship,
and lower debt burden tend to influence medical students' perceptions of MUAs.[10]
[11] Few studies have implied that underrepresented clusters of the ophthalmology workforce,
including female and osteopathic (DO) ophthalmologists, may have strong intentions
to serve diverse patient populations.[12]
[13]
The primary objective of our study was to examine the characteristics of ophthalmology
intending graduates (OIG) stratified by racial and gender demographics, age at matriculation,
debt burden, elective medical school experiences, and several other factors, such
as degree programs and scholarships awarded. The second objective was to determine
whether these characteristics among students pursuing ophthalmology correlated with
an intention to practice in underserved areas. Finally, we hypothesized that OIG compared
with nonsurgical specialties were less likely to be female or URM. In contrast, we
hypothesized that OIG compared with other surgical specialties were more likely to
be female. In addition, we hypothesized that URM would be more likely to report IPUA.
Methods
The study sample consists of a national cohort of 92,080 U.S. medical students who
matriculated between academic years of 2007–2008 and 2011–2012. Individual deidentified
data were obtained from the Association of American Medical Colleges (AAMC) Student
Record System (SRS) and the AAMC Graduation Questionnaire (GQ). The following data
were obtained for analysis: planned practice area, sex, race/ethnicity, age at matriculation,
total debt at graduation, degree program, parental level of education, intention to
practice in underserved areas, scholarship awarded during medical school, and participation
in electives during medical school. These records were merged across survey years
before analysis. All data were confidential and anonymous. The study has received
approval by the institutional review board.
Students who reported intention for ophthalmology specialty were categorized as OIG.
Students who reported intention for general surgery, colorectal surgery, neurosurgery,
orthopaedic surgery, otolaryngology, plastic surgery, vascular surgery, thoracic surgery,
and urology were categorized as other surgical specialty intending students. Students
who reported intentions for other specialties not forementioned were categorized as
nonsurgical specialty intending students. Age at matriculation was used to create
a binary variable to identify students who were ≥23 years during matriculation. Race/ethnicity
was self-reported by students and categorized into the following eight ethno-racial
groups: NH White, NH Black/African American, NH Asian, Native American/Alaska Native,
Hawaiian Native/Other Pacific Islander, Hispanic, multiracial, and unknown/other.
Students who reported more than one race were categorized as multiracial. Total debt
at matriculation was categorized into four levels: no debt, $1 to $149,000, $150,000
to $249,999, and greater than $250,000. Degree program was categorized into four levels:
MD, BA/BS-MD, MD-PhD, and other dual degrees that included MD-MPH and MD-MBA. Parental
level of education was used to create the binary variable of generation status. First-generation
status was assigned to those who reported “some college” or less for both parents.
Continuing-generation status was assigned to those who reported “college degree” or
higher for either parent. Those with education data for only one parent were categorized
as first-generation if “some college” or less was reported.
All statistical analyses were conducted on STATA 16.1 (StataCorp, College Station,
TX). Descriptive statistics were generated to report frequencies and percentages.
Chi-squared analysis was performed to assess the difference between students with
intention for ophthalmology and those with intention for other surgical and nonsurgical
specialties. Binary logistical regression models were conducted to estimate the adjusted
odds ratio (aOR) for the effect of covariates (e.g., sex, race/ethnicity, total debt
at graduation) on the two primary outcomes: intention for ophthalmology and intention
to practice in underserved areas among students interested in ophthalmology. Statistics
were reported as aOR and the 95% confidence interval (CI).
Results
Of the 92,080 U.S. medical students who matriculated in the academic years 2007–2008
through 2011–2012, 88,059 (95.7%) matriculants graduated by 2017. Of these, 43,820
(49.8%) fully completed the AAMC GQ and were included in the final study sample ([Fig. 1]). In all, 1,177 (2.7%) students were OIG, 7,955 (18.2%) graduates reported intention
for other surgical specialties, and 34,688 (79.2%) graduates reported intentions for
nonsurgical specialties (as shown in [Table 1]. Among OIG, 222 (18.9%) reported intention to practice in underserved areas, compared
with 17.7% of other surgery students and 29.6% of nonsurgery students (p < 0.001). A lower percentage of OIG were NH Black/African American (2.2%) when compared
with other surgery intending (4.1%) and nonsurgery intending (5.4%) students (p < 0.001). A higher proportion of females were OIG than intending for surgical and
nonsurgical specialties (41.4 vs. 31.3 vs. 52.0%; p < 0.001). Students with a total debt at graduation greater than $250,000 were less
likely to intend for ophthalmology than for other surgical and nonsurgical specialties
(13.8 vs. 21.2 vs. 18.8%, p < 0.001). OIG (18.9%) were more likely than other surgical intending students (17.7%)
to report intention to practice in underserved areas but were less likely than nonsurgical
intending students (29.7%) to report intention to practice in underserved areas (p < 0.001).
Fig. 1 Final study sample size flow chart (N = 43,820).
a3,145 missing; 3 unclassified.
bThis includes those who did not respond when asked about (1) elective/volunteer medical
school activities (n = 1); (2) intention to practice in underserved areas (n = 84); (3) scholarships, stipends, or grants (n = 83); or (4) a combination thereof (n = 2,924). Note that the 20,474 records excluded in the previous step were missing
every GQ response, and it is assumed these participants did not take the GQ.
Table 1
Characteristics of graduates who matriculated in academic years 2007–2008 through
2011–2012 by specialty choice at graduation (ophthalmology vs. all other specialties)
|
Characteristics
|
Total, N (%)
|
Nonsurgical specialties, N (%)
|
All other surgical specialties, N (%)
|
Ophthalmology, N (%)
|
p value[a]
|
|
N = 43,820
|
N = 34,688
|
N = 7,955
|
N = 1,177
|
|
Sex
|
|
Male
|
22,799 (52.0%)
|
16,647 (48.0%)
|
5,462 (68.7%)
|
690 (58.6%)
|
<0.001
|
|
Female
|
21,021 (48.0%)
|
18,041 (52.0%)
|
2,493 (31.3%)
|
487 (41.4%)
|
|
Race/ethnicity
|
|
Non-Hispanic White
|
27,665 (63.1%)
|
21,692 (62.5%)
|
5,299 (66.6%)
|
674 (57.3%)
|
<0.001
|
|
Non-Hispanic Asian
|
7,630 (17.4%)
|
6,059 (17.5%)
|
1,254 (15.8%)
|
317 (26.9%)
|
|
Hispanic
|
3,119 (7.1%)
|
2,549 (7.3%)
|
507 (6.4%)
|
63 (5.4%)
|
|
Non-Hispanic Black/African American
|
2,222 (5.1%)
|
1,869 (5.4%)
|
327 (4.1%)
|
26 (2.2%)
|
|
Multiracial
|
1,531 (3.5%)
|
1,208 (3.5%)
|
279 (3.5%)
|
44 (3.7%)
|
|
Native American/Alaska Native
|
83 (0.2%)
|
65 (0.2%)
|
16 (0.2%)
|
2 (0.2%)
|
|
Native Hawaiian/other Pacific Islander
|
56 (0.1%)
|
46 (0.1%)
|
8 (0.1%)
|
2 (0.2%)
|
|
Other/unknown
|
1,514 (3.5%)
|
1,200 (3.5%)
|
265 (3.3%)
|
49 (4.2%)
|
|
Age at matriculation ≥ 23 y
|
24,566 (56.1%)
|
19,570 (56.4%)
|
4,414 (55.5%)
|
582 (49.4%)
|
<0.001
|
|
Generation of college graduate
|
|
Continuing generation
|
38,125 (87.0%)
|
30,057 (86.6%)
|
7,005 (88.1%)
|
1,063 (90.3%)
|
<0.001
|
|
First generation
|
5,695 (13.0%)
|
4,631 (13.4%)
|
950 (11.9%)
|
114 (9.7%)
|
|
Total educational debt at graduation (USD)
|
|
No debt
|
6,891 (15.7%)
|
5,414 (15.6%)
|
1,235 (15.5%)
|
242 (20.6%)
|
<0.001
|
|
$1–149,999
|
12,660 (28.9%)
|
10,051 (29.0%)
|
2,201 (27.7%)
|
408 (34.7%)
|
|
$150,000–249,999
|
15,898 (36.3%)
|
12,703 (36.6%)
|
2,830 (35.6%)
|
365 (31.0%)
|
|
≥$250,000
|
8,371 (19.1%)
|
6,520 (18.8%)
|
1,689 (21.2%)
|
162 (13.8%)
|
|
Received scholarships, stipends, or grants for medical school
|
|
No
|
16,427 (37.5%)
|
13,045 (37.6%)
|
2,967 (37.3%)
|
415 (35.3%)
|
0.240
|
|
Yes
|
27,393 (62.5%)
|
21,643 (62.4%)
|
4,988 (62.7%)
|
762 (64.7%)
|
|
Type of undergraduate institution
|
|
Research universities (very high research activity)
|
27,379 (62.5%)
|
21,518 (62.0%)
|
5,087 (63.9%)
|
774 (65.8%)
|
<0.001
|
|
Doctoral/research universities (high research activity)
|
6,144 (14.0%)
|
4,835 (13.9%)
|
1,142 (14.4%)
|
167 (14.2%)
|
|
Master's colleges and universities
|
4,407 (10.1%)
|
3,612 (10.4%)
|
701 (8.8%)
|
94 (8.0%)
|
|
Baccalaureate colleges (arts & sciences)
|
5,247 (12.0%)
|
4,191 (12.1%)
|
926 (11.6%)
|
130 (11.0%)
|
|
All other undergraduate institutions
|
643 (1.5%)
|
532 (1.5%)
|
99 (1.2%)
|
12 (1.0%)
|
|
Medical degree program
|
|
MD program
|
40,020 (91.3%)
|
31,594 (91.1%)
|
7,373 (92.7%)
|
1,053 (89.5%)
|
<0.001
|
|
Combined BA/MD, BS/MD
|
999 (2.3%)
|
781 (2.3%)
|
175 (2.2%)
|
43 (3.7%)
|
|
Combined MD/PhD
|
1,437 (3.3%)
|
1,212 (3.5%)
|
180 (2.3%)
|
45 (3.8%)
|
|
Other combined advanced-degree programs (e.g., MD/MPH, MD/MBA)
|
1,364 (3.1%)
|
1,101 (3.2%)
|
227 (2.9%)
|
36 (3.1%)
|
|
Intention to practice in underserved areas (IPUA)
|
|
No
|
11,203 (25.6%)
|
8,055 (23.2%)
|
2,812 (35.3%)
|
336 (28.5%)
|
<0.001
|
|
Yes
|
11,925 (27.2%)
|
10,293 (29.7%)
|
1,410 (17.7%)
|
222 (18.9%)
|
|
Undecided
|
20,692 (47.2%)
|
16,340 (47.1%)
|
3,733 (46.9%)
|
619 (52.6%)
|
|
Elective/volunteer medical school activities
|
|
Field experience in providing health education in the community (e.g., adult/child
protective services, family violence program, rape crisis hotline)
|
17,369 (39.6%)
|
13,697 (39.5%)
|
3,193 (40.1%)
|
479 (40.7%)
|
0.420
|
|
Community-based research project
|
12,226 (27.9%)
|
9,757 (28.1%)
|
2,109 (26.5%)
|
360 (30.6%)
|
0.002
|
|
Experience related to cultural awareness and cultural competence
|
30,334 (69.2%)
|
24,141 (69.6%)
|
5,353 (67.3%)
|
840 (71.4%)
|
<0.001
|
|
Educating elementary, high school, or college students about careers in health professions
or biological sciences
|
20,202 (46.1%)
|
15,872 (45.8%)
|
3,792 (47.7%)
|
538 (45.7%)
|
0.008
|
|
Experience with a free clinic for the underserved population
|
32,736 (74.7%)
|
25,946 (74.8%)
|
5,867 (73.8%)
|
923 (78.4%)
|
0.002
|
|
Experience related to health disparities
|
30,345 (69.2%)
|
24,205 (69.8%)
|
5,308 (66.7%)
|
832 (70.7%)
|
<0.001
|
|
Providing health education (e.g., HIV/AIDS education, breast cancer awareness, smoking
cessation, obesity)
|
26,351 (60.1%)
|
21,026 (60.6%)
|
4,606 (57.9%)
|
719 (61.1%)
|
<0.001
|
|
Field experience in home care
|
14,473 (33.0%)
|
11,513 (33.2%)
|
2,570 (32.3%)
|
390 (33.1%)
|
0.320
|
|
Independent study project for credit
|
18,161 (41.4%)
|
13,989 (40.3%)
|
3,588 (45.1%)
|
584 (49.6%)
|
<0.001
|
|
Global health experience
|
13,388 (30.6%)
|
10,793 (31.1%)
|
2,211 (27.8%)
|
384 (32.6%)
|
< 0.001
|
|
Learned the proper use of the interpreter when needed
|
32,696 (74.6%)
|
25,965 (74.9%)
|
5,855 (73.6%)
|
876 (74.4%)
|
0.068
|
|
Learned another language to improve communication with patients
|
10,699 (24.4%)
|
8,558 (24.7%)
|
1,814 (22.8%)
|
327 (27.8%)
|
< 0.001
|
|
Field experience in nursing home care
|
13,857 (31.6%)
|
11,052 (31.9%)
|
2,477 (31.1%)
|
328 (27.9%)
|
0.009
|
|
Research project with faculty member
|
31,459 (71.8%)
|
23,479 (67.7%)
|
6,899 (86.7%)
|
1,081 (91.8%)
|
< 0.001
|
|
Other elective/volunteer medical school activities
|
1,302 (3.0%)
|
1,083 (3.1%)
|
200 (2.5%)
|
19 (1.6%)
|
< 0.001
|
a
p values reported for chi-square tests.
Intention to Practice Ophthalmology
Adjusted logistic regression analysis of ethno-racial groups indicated that NH Black/African
American students were less likely than NH White students to intend for ophthalmology
than for other surgical specialties (0.59 [0.39–0.89]) and nonsurgical specialties
(0.5 [0.33–0.74]) as shown in [Table 2]. When compared with nonsurgical specialties, females were less likely to intend
to practice ophthalmology (0.64 [0.57–0.73]). In addition, OIG were less likely to
be first generation compared with nonsurgical specialties (0.84 [0.69–1.03]). In comparison
to traditional MD students, students in a combined MD/PhD dual degree program were
less likely to intend for ophthalmology than for nonsurgical specialties (0.63 [0.46–0.87]).
Table 2
Graduates who intend to practice ophthalmology versus graduates who intend to practice
nonophthalmology specialties
|
Characteristics
|
Ophthalmology versus nonsurgical specialties
|
p value[a]
|
Ophthalmology versus all other surgical specialties
|
p value[a]
|
|
Adjusted odds ratio (95% confidence interval)
|
Adjusted odds ratio (95% confidence interval)
|
|
N = 35,865
|
N = 9,132
|
|
Sex
|
|
Male
|
(reference)
|
|
(reference)
|
|
|
Female
|
0.64 (0.57–0.73)
|
<.001
|
1.46 (1.28–1.66)
|
0.000
|
|
Race/ethnicity
|
|
Non-Hispanic White
|
(reference)
|
|
(reference)
|
|
|
Non-Hispanic Asian
|
1.40 (1.21–1.62)
|
<.001
|
1.71 (1.46–2.01)
|
0.000
|
|
Hispanic
|
0.80 (0.61–1.04)
|
0.099
|
0.92 (0.70–1.22)
|
0.561
|
|
Non-Hispanic Black/African American
|
0.50 (0.33–0.74)
|
<.001
|
0.59 (0.39–0.89)
|
0.012
|
|
Multiracial
|
1.10 (0.80–1.51)
|
0.552
|
1.10 (0.79–1.54)
|
0.569
|
|
Native American/Pacific Islander
|
1.31 (0.48–3.60)
|
0.601
|
1.23 (0.42–3.60)
|
0.707
|
|
Other/unknown
|
1.12 (0.83–1.51)
|
0.465
|
1.26 (0.91–1.73)
|
0.163
|
|
Age at matriculation ≥ 23 y
|
0.92 (0.89–0.95)
|
<.001
|
0.97 (0.94–1)
|
0.058
|
|
Generation of college graduate
|
|
Continuing generation
|
(reference)
|
|
(reference)
|
|
|
First generation
|
0.84 (0.69–1.03)
|
0.089
|
0.91 (0.73–1.12)
|
0.368
|
|
Total educational debt at graduation (USD)
|
|
No debt
|
(reference)
|
|
(reference)
|
|
|
$1–149,999
|
0.90 (0.76–1.07)
|
0.248
|
0.94 (0.78–1.12)
|
0.488
|
|
$150,000–249,999
|
0.71 (0.59–0.85)
|
<.001
|
0.72 (0.60–0.87)
|
0.001
|
|
≥$250,000
|
0.68 (0.55–0.84)
|
<.001
|
0.55 (0.44–0.69)
|
0.000
|
|
Received scholarships, stipends, or grants for medical school
|
|
No
|
(reference)
|
|
(reference)
|
|
|
Yes
|
1.18 (1.04–1.34)
|
0.011
|
1.10 (0.96–1.26)
|
0.170
|
|
Type of premed institution
|
|
Research universities (very high research activity)
|
(reference)
|
|
(reference)
|
|
|
Doctoral/research universities (high research activity)
|
1.11 (0.93–1.32)
|
0.250
|
1.13 (0.94–1.36)
|
0.202
|
|
Master's colleges and universities
|
0.97 (0.77–1.21)
|
0.767
|
1.10 (0.87–1.39)
|
0.428
|
|
Baccalaureate colleges (arts & sciences)
|
1.03 (0.85–1.25)
|
0.766
|
1.04 (0.85–1.27)
|
0.712
|
|
All other undergraduate institutions
|
0.84 (0.47–1.50)
|
0.547
|
1.18 (0.64–2.19)
|
0.590
|
|
Medical degree program
|
|
MD program
|
(reference)
|
|
(reference)
|
|
|
Combined BA/MD, BS/MD
|
1.15 (0.83–1.59)
|
0.414
|
1.21 (0.84–1.73)
|
0.299
|
|
Combined MD/PhD
|
0.63 (0.46–0.87)
|
0.005
|
1.38 (0.97–1.96)
|
0.070
|
|
Other combined degree programs (e.g., MD/MPH, MD/MBA)
|
0.77 (0.55–1.09)
|
0.139
|
1.00 (0.69–1.44)
|
0.979
|
|
Elective/volunteer medical school activities
|
|
Field experience in providing health education in the community (e.g., adult/child
protective services, family violence program, rape crisis hotline)
|
1.03 (0.90–1.17)
|
0.658
|
0.93 (0.81–1.07)
|
0.327
|
|
Community-based research project
|
1.04 (0.91–1.19)
|
0.570
|
1.18 (1.02–1.36)
|
0.029
|
|
Experience related to cultural awareness and cultural competence
|
1.05 (0.88–1.25)
|
0.599
|
1.11 (0.92–1.34)
|
0.260
|
|
Educating elementary, high school or college students about careers in health professions
or biological sciences
|
1.02 (0.90–1.16)
|
0.748
|
0.85 (0.74–0.97)
|
0.016
|
|
Experience with a free clinic for the underserved population
|
1.21 (1.03–1.41)
|
0.017
|
1.22 (1.03–1.44)
|
0.020
|
|
Experience related to health disparities
|
0.97 (0.81–1.15)
|
0.688
|
1.08 (0.9–1.30)
|
0.404
|
|
Providing health education (e.g., HIV/AIDS education, breast cancer awareness, smoking
cessation, obesity)
|
1.00 (0.87–1.14)
|
0.964
|
1.06 (0.92–1.23)
|
0.412
|
|
Field experience in home care
|
1.04 (0.90–1.20)
|
0.614
|
1.12 (0.96–1.30)
|
0.159
|
|
Independent study project for credit
|
1.21 (1.07–1.36)
|
0.002
|
1.12 (0.98–1.27)
|
0.099
|
|
Global health experience
|
1.08 (0.94–1.23)
|
0.268
|
1.11 (0.97–1.28)
|
0.141
|
|
Learned the proper use of the interpreter when needed
|
0.83 (0.71–0.97)
|
0.019
|
0.84 (0.71–0.99)
|
0.038
|
|
Learned another language to improve communication with patients
|
1.10 (0.96–1.27)
|
0.159
|
1.16 (1.00–1.34)
|
0.052
|
|
Field experience in nursing home care
|
0.78 (0.67–0.90)
|
0.001
|
0.78 (0.67–0.92)
|
0.002
|
|
Research project with faculty member
|
4.78 (3.86–5.92)
|
0.000
|
1.58 (1.26–1.98)
|
0.000
|
|
Other elective/volunteer medical school activities
|
0.55 (0.35–0.87)
|
0.011
|
0.68 (0.42–1.09)
|
0.112
|
a
p values reported for binary logistical regression.
Multivariable analysis revealed elective medical school experiences that were associated
with students' intention to pursue ophthalmology. OIG were more likely than both other
surgical intending students and nonsurgery students to have participated in a research
project with a faculty member (1.58 [1.26–1.98] and 4.78 [3.86–5.92]). Compared with
other surgery intending students, OIG were more likely to have participated in a community-based
research project (1.18 [1.02–1.36]).
Intention to Practice in Underserved Areas
NH Black/African American OIG were more likely than NH White OIG to report intention
to practice in underserved areas (14.29 [1.82–111.88]; [Table 3]). Similarly, multiracial OIG were also more likely than NH White OIG to report intention
to practice in underserved areas (2.5 [1.06–5.92]). Among ophthalmology intending
students, those with experience in community-based research projects (1.45 [1.05–2.02]),
global health experience (1.64 [1.20–2.25]), experience related to health disparities
(1.7 [1.14–2.54]), and providing health education (1.59 [1.17–2.16]) were more likely
to report intention to practice in underserved areas.
Table 3
Intention to practice in underserved areas among ophthalmology intending graduates
|
Characteristics
|
Adjusted odds ratio (95% confidence interval)
|
p value[a]
|
|
|
(N = 1,177)
|
|
|
Sex
|
|
Male
|
(reference)[b]
|
|
|
|
Female
|
1.03 (0.77–1.38)
|
0.830
|
|
|
Race/ethnicity
|
|
Non-Hispanic White
|
(reference)
|
|
|
|
Non-Hispanic Asian
|
1.28 (0.91–1.80)
|
0.150
|
|
|
Hispanic
|
1.54 (0.78–3.02)
|
0.211
|
|
|
Non-Hispanic Black/African American
|
14.29 (1.82–111.88)
|
0.011
|
|
|
Multiracial
|
2.50 (1.06–5.92)
|
0.037
|
|
|
Native American/Pacific Islander
|
1.44 (0.14–14.74)
|
0.756
|
|
|
Other/unknown
|
1.41 (0.72–2.80)
|
0.318
|
|
|
Age at matriculation ≥ 23
|
0.99 (0.92–1.07)
|
0.877
|
|
|
Generation of college graduate
|
|
Continuing generation
|
(reference)
|
|
|
|
First generation
|
1.14 (0.7–1.86)
|
0.590
|
|
|
Total educational debt at graduation (USD)
|
|
No debt
|
(reference)
|
|
|
|
$1–149,999
|
1.06 (0.72–1.55)
|
0.779
|
|
|
$150,000–249,999
|
1.41 (0.94–2.11)
|
0.099
|
|
|
≥$250,000
|
1.14 (0.70–1.85)
|
0.609
|
|
|
Received scholarships, stipends, or grants for medical school
|
|
No
|
(reference)
|
|
|
|
Yes
|
1.12 (0.84–1.49)
|
0.452
|
|
|
Type of premed institution
|
|
Research universities (very high research activity)
|
(reference)
|
|
|
|
Doctoral/research universities (high research activity)
|
0.97 (0.65–1.45)
|
0.891
|
|
|
Master's colleges and universities
|
1.19 (0.71–1.99)
|
0.509
|
|
|
Baccalaureate colleges (arts & sciences)
|
1.62 (1.02–2.58)
|
0.040
|
|
|
All other undergraduate institutions
|
2.08 (0.36–11.88)
|
0.409
|
|
|
Medical degree program
|
|
MD program
|
(reference)
|
|
|
|
Combined BA/MD, BS/MD
|
1.46 (0.66–3.24)
|
0.350
|
|
|
Combined MD/PhD
|
0.39 (0.20–0.77)
|
0.007
|
|
|
Other combined degree programs (e.g., MD/MPH, MD/MBA)
|
1.03 (0.47–2.25)
|
0.940
|
|
|
Elective/volunteer medical school activities
|
|
Field experience in providing health education in the community (e.g., adult/child
protective services, family violence program, rape crisis hotline)
|
1.06 (0.79–1.43)
|
0.698
|
|
|
Community-based research project
|
1.45 (1.05–2.02)
|
0.026
|
|
|
Experience related to cultural awareness and cultural competence
|
0.74 (0.50–1.11)
|
0.151
|
|
|
Educating elementary, high school, or college students about careers in health professions
or biological sciences
|
1.05 (0.79–1.40)
|
0.737
|
|
|
Experience with a free clinic for the underserved population
|
1.07 (0.75–1.52)
|
0.714
|
|
|
Experience related to health disparities
|
1.70 (1.14–2.54)
|
0.009
|
|
|
Providing health education (e.g., HIV/AIDS education, breast cancer awareness, smoking
cessation, obesity)
|
1.59 (1.17–2.16)
|
0.003
|
|
|
Field experience in home care
|
0.80 (0.58–1.12)
|
0.197
|
|
|
Independent study project for credit
|
0.80 (0.60–1.05)
|
0.113
|
|
|
Global health experience
|
1.64 (1.20–2.25)
|
0.002
|
|
|
Learned the proper use of the interpreter when needed
|
0.67 (0.47–0.96)
|
0.031
|
|
|
Learned another language to improve communication with patients
|
1.10 (0.80–1.52)
|
0.555
|
|
|
Field experience in nursing home care
|
1.05 (0.74–1.48)
|
0.777
|
|
|
Research project with faculty member
|
0.77 (0.46–1.30)
|
0.333
|
|
|
Other elective/volunteer medical school activities
|
2.84 (0.78–10.41)
|
0.114
|
|
a
p values reported for binary logistical regression.
b Reference refers to the reference group to which all groups are compared for the
adjusted odds ratio.
Discussion
To our knowledge, this is the first study to characterize graduating medical students
with the intention of ophthalmology and their intent to practice in underserved areas.
Our findings highlight the salient characteristics, contextualize them in the current
literature, and show students intending to practice ophthalmology in underserved areas
are significantly more likely to participate in experiences related to health disparities,
including providing health education, global health, and community-based research
projects.
OIG were more likely to have worked on a research project with a faculty member than
their counterparts interested in other surgical and nonsurgical specialties. Given
how competitive the field is, it may be inferred that research has a significant impact
on matching into ophthalmology, thus leading students to pursue scholarly activity.
However, in evaluating the inequalities in research, we found female physicians have
a lower h-index, a measure of research productivity, compared with their male counterparts,
and URM physicians have significantly fewer peer-reviewed publications than their
white counterparts.[14]
[15] Female and URM students should be encouraged to participate in ophthalmology research
to receive mentorship benefits and increase their h-index, which can affect their
academic promotion.[16] Female and URM students should be encouraged to participate in ophthalmology research
to receive mentorship benefits and increase their h-index, which can affect their
academic promotion.
From 2005 to 2015, the proportion of female ophthalmology residents and faculty members
significantly increased, but women are still underrepresented in the field overall.[8] Our study similarly found females to be less likely than their male counterparts
to intend to match into ophthalmology versus nonsurgical fields, but interestingly
more likely to intend to match into ophthalmology than other surgical fields. According
to the AAMC, women represent 50.5% of all medical students in the country but only
37.9% of active ophthalmology residents and only 26.7% of actively practicing ophthalmologists.[17]
[18]
[19] Female medical students may be less interested in the field compared with nonsurgical
fields than their male counterparts due to “real and perceived gender discrimination”
and fewer female ophthalmologist role models.[20]
[21]
[22]
Studies have shown that racially concordant physician–patient relationships can improve
patient satisfaction and trust because of increased perceived racial similarity between
a provider and a patient.[23] In our study, NH Black/African American students were significantly less likely
to show intention for ophthalmology versus nonsurgical fields and surgical fields
in comparison to their NH White counterparts. In addition, NH Black/African American
and multiracial students intending for ophthalmology were the only two racial/ethnic
groups that were significantly more likely to intend to practice in underserved areas
in comparison to their NH White counterparts. Walker et al similarly found that NH
African American as well as Latin and Pacific Islander physicians were more likely
to practice in primary care and across diverse surgical and nonsurgical specialties
than their NH white counterparts to practice in MUAs in California.[24] Therefore, increasing diversity in the ophthalmology workforce is a substantial
way to reduce inequities in eye care. Encouraging a diversity of students to have
intention for the field is an important means to achieve that diversity.
Lack of exposure represents one of the most significant barriers for URM students'
entry into ophthalmology. In recent decades, ophthalmology's curricular time has decreased
to the point where students are primarily exposed to ophthalmology during their preclinical
years and from extracurricular activities.[22] Because of this, considering ophthalmology as a career costs additional time and
effort when compared with other fields. These differences are even greater if a student's
home institution does not have a program.[25] Data show that URMs face greater financial challenges than other racial/ethnic groups,
as they are more likely to have lower socioeconomic status (SES).[26] Our data show OIG were less likely to graduate with debts greater than $150,000
compared with nonophthalmology specialties, suggesting they are students with adequate
resources to seek exposure to ophthalmology. Higher socioeconomic status is associated
with both financial support and social capital, which translates into an advantage
in finding not only initial exposure to ophthalmology but also other opportunities
including networking, receiving shadowing opportunities, and obtaining letters of
recommendation.
The experiences we found significantly associated with IPUA involved significant interactions
with the underserved population, including global health experience, experience related
to health disparities, and experience completing a community-based research project.
Since these factors were associated with IPUA, increased emphasis should be placed
on them in the residency application process. Further initiatives to advance global
health opportunities in medical school are a potential strategy to expose students
to the field of ophthalmology and raise interest in practicing in underserved areas.
Our findings coincide with Slifko et al's study, which found that medical students
completing a global health elective had a 22% greater prevalence of working with underserved
populations after graduation.[27] Global health experiences would teach students to practice medicine resourcefully
while demonstrating the significance of ophthalmologists within underserved communities.[28] Completing community-based research projects is one of the best ways to understand
health disparities in low-income communities.[29] Awareness of these issues may encourage medical students to tackle those disparities
and therefore demonstrate IPUA, as seen in our study.
Limitations
First, this study explores the intention to pursue ophthalmology and does not look
at actual matriculation rates. IPUA was analyzed to understand which characteristics
and experiences within OIG were associated with ultimately practicing in underserved
areas. While we do not know the correlation between the GQ survey results and the
actual career paths of OIG, roughly half of graduating medical students reporting
IPUA continued to practice in underserved areas 7 to 10 years later, as shown in a
prior study indicating the truthfulness of reported intentions.[30] Next, our data are collected from a self-reported survey, so variations in survey
responses, including the truthfulness of answers, may have affected data collection.
Next, the included ethno-racial groups are aggregates of many ethnic groups with differential
representations and experiences in the medical field that cannot all be accounted
for in this study.
Finally, the last matriculating class in this study would have graduated in 2015,
making these data older. However, the problems addressed in this manuscript are still
prevalent today, namely that women and URM remain underrepresented in ophthalmology
residency nationwide. For example, the 2021 AAMC active resident statistics show a
decrease in active female ophthalmology residents from 2021 compared to 2018 (39.4%
vs 41.2%), which is considerably lower than the proportion of males in 2021 and 2018,
55.8% and 58.8% respectively. These figures include International Medical Graduates
(IMGs), Doctors of Osteopathic Medicine (DOs), and Doctors of Medicine (MDs), down
from 41.2% in 2018, which is much lower than the 55.8% that are males in 58.8% in
2018. Similarly, URM, which includes American Indian or Alaska Native, Black or African
American, Hispanic/Latino, Native Hawaiian, or Other Pacific Islander, in total makes
up 10.6%, which is less than the percent of just Hispanic/Latino individuals and Black/African
American individuals in the United States alone (at 18.5 and 13.5%, respectively).[31]
[32]
Next Steps
The AAMC projected a shortage of ophthalmologists by 2025.[31] Moreover, it is critical that we improve provider coverage in MUAs. We must encourage
diversity within OIG to address these needs.
Mentorship for URM is critical to increase diversity in the field. Recent initiatives,
such as the Minority Ophthalmology Mentoring (MOM) Program and the Diversity, Equity
and Inclusion Initiative by the University of Michigan Kellogg Eye Center, provide
mentorship as well as hands-on experience for first-year medical students who are
URM.[33] The MOM program is new with the inaugural class of students in 2018 but seems promising
given participant feedback and the extent of topics covered in the program.[34] Another initiative is the Rabb-Venable Excellence in Ophthalmology Program, which
was started in 2000. The program provides the opportunity for URM students to present
original work at the National Medical Association Ophthalmology Section meeting. The
program participants also get mentorship in areas ranging from how to create a strong
ophthalmology residency application to interview prep.[35] Targeting first-year students is important to give students the tools they need
to become successful applicants their fourth year. Students should be made aware of
the national programs that they may participate in, and individual medical schools
should foster the development of school-specific programs that may be more easily
accessible for students and perhaps a stepping stone to national organization involvement.
Mentorship for URM at all steps of the educational ladder from medical students to
junior faculty is important to increase diversity in the field as a whole and that
is why programs like the Harvard Ophthalmology Mentoring Program are equally important.
The program is aimed at assisting in the promotion of junior faculty who are URM through
mentorship by senior faculty.[36] Programs like this, whether large or small, should be created at all medical schools
and can have a large influence indirectly and directly on medical students who look
up to URM faculty as resources and role models.
Strategies to encourage female medical students to pursue ophthalmology can help eliminate
gender disparities. National societies, such as Women in Ophthalmology (WIO), represent
a crucial step in the right direction for addressing the disparity and may help account
for our additional finding that females were more likely than their male counterparts
to pursue ophthalmology versus other surgical specialties. However, since females
are still underrepresented compared with nonsurgical specialties, we recommend that
early in their medical student journey they be made aware of groups like the WIO and
its equivalents in other specialties to help encourage female students to pursue surgical
specialties overall.
Community-engaged projects are crucial strategies for addressing health disparities
in ophthalmology. In 2002, Anderson et al demonstrated that using culturally specific
interventions significantly increased follow-up care in patients not receiving adequate
screening and/or treatment for sight-threatening eye problems.[32] We propose creating additional community-engaged projects aimed at practicing the
culturally specific interventions to improve health disparities at home and abroad.
One example is Sight Savers America's collaboration with the government of Nigeria,
which increased cataract surgery coverage from 7.1 to 62%.[37] We also recommend medical students investigate to find projects or programs that
prioritize building trust and relationships through community engagement. Participants
should also continue to interrogate the intentionality of programs and the long-term
impact on the communities they serve.
Scholarships are another important avenue to support students who are unrepresented
in the field, an example of which is the David K. McDonogh, MD Scholarship in Ophthalmology/Otolaryngology
for students who identify as African American, Afro-Latino(a), or Native American.[38] The scholarship can be used by students at their own discretion toward any part
of the application or interview process, additionally empowering them to make the
best decision for their own application journey.[38]
Diversifying our recruitment of medical students to ophthalmology may address ethno-racial,
socioeconomic, and geographic disparities in eye care. The ophthalmology workforce
must be prepared to evolve and meet the needs of an increasingly aging and diverse
U.S. population.
