Neuro-Ophthalmology: Creating a Diverse, Equitable, and Inclusive Subspecialty Is the Responsibility of Everyone

Editorial Neuro-Ophthalmology: Creating a Diverse, Equitable, and Inclusive Subspecialty Is the Responsibility of Everyone Peter A. Quiros, MD, Lynn K. Gordon, MD, PhD D iversity is the condition of being composed of differing elements. In a societal context, we define diversity as the inclusion of people from different backgrounds be their socioeconomic, racial, ethnic, cultural, and sexual orientations or gender identities. Academic medicine has many examples of how diversity is critical to the health of our profession and population. As noted in the Association of American Medical Colleges (AAMC) report on diversity in medicine (1): diverse teams are more capable of solving complex problems than homogenous teams (2–4), diverse learner populations improve learner satisfaction with their educational experience (1,3,5), and in research, it has been shown that investigators ask different research questions based on their own unique backgrounds and experiences. Alshebli et al (6) analyzed the role of ethnic diversity in scientific collaboration. They evaluated more than 1 million publications by 1.5 million scientists in 8 scientific fields for diversity of ethnicity, academic age, gender, discipline, and affiliation. Not only did diversity correlate with impact but also the works with the strongest scientific impact came from the most ethnically diverse teams. The implications are that to find solutions to diseases that affect specific populations, a diverse pool of physicians and scientists will be required. Despite the obvious benefits of diversity and the many ways in which it enriches the quality of health care, medicine still has far to go to have a level of diversity that is representative of our population. In this editorial, it is our intention to review the current state of diversity in medicine with a focus on neuro-ophthalmology and the Journal of Neuro-Ophthalmology (JNO). Despite all the varied types of diversities, the focus of this editorial is gender, race, and ethnicity in ophthalmology, neurology, and neuro-ophthalmology, paying attention to the following domains: a. Diversity in residency b. Practicing physicians in ophthalmology and neurology c. Faculty–faculty leadership d. Journal editor and editorial board membership e. Association leadership f. Speakers at meetings g. Grants SETTING THE STAGE According to the US Census Bureau (7), the population of the United States in 2020 is composed of 50.8% female, 36.2% underrepresented minorities (URM), 5.9% Asian, and 60.1% Caucasian. For the purposes of this discussion, we will define URM as individuals who identify as Black or African American, American Indians and Alaskan Natives, Native Hawaiians or other Pacific Islanders, and Hispanic or Latinx. These groups are historically underrepresented in medicine and science (1). According to data from the 2020–2021 academic year, the AAMC (8) published the total US medical school enrollment by gender (51.5% female) and by race and ethnicity, which reveals 14.5% URM and 22.8% Asian, respectively. Doheny Eye Institute (PAQ), and Stein Eye Institute (PAQ, LKG), Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, California. The authors report no conflicts of interest. Address correspondence to Peter A. Quiros, MD, 800 Fairmount Avenue, Suite 215, Pasadena, CA 91105; E-mail: [e-mail]. Quiros and Gordon: J Neuro-Ophthalmol 2021; 41: 279-284 279 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial Much data on diversity is an amalgam of reports because there is no one source easily-identifiable. Therefore, we will present all data in percentages keeping in mind that for a specialty or society to be diverse, it should be reflective of the population which it serves. The data reported in each section are also represented in Table 1 and the aggregate figures for each section. RESIDENCY The 2019 data for neurology residencies from Neurology Today (9) report a composition of 43.1% female, 9.2% URM, and 20.3% Asian. The 2019–2020 data for ophthalmology residencies as listed by the AAMC (10,11) reveal the diversity of ophthalmology residents as 42% female, 8.9% URM, and 32.5% Asian (Fig. 1). Notably, the percentage of women in either neurology or ophthalmology was slightly lower than those in medical school, but there was a larger gap observed in percentage of URMs in the 2 types of residencies and percentage of URMs in medical school. PRACTICING PHYSICIANS The breakdown of diversity among practicing physicians in the United States according to the AAMC (12) in 2018 was 30.3% female, 8.2% URM, and 17% Asian in neurology and 26% female, 6.7% URM, and 17.8% Asian in ophthalmology (Fig. 1). FACULTY The 2019–2020 AAMC (13) data for neurology faculty were 42.1% female, 8.1% URM, and 22.8% Asian. Ophthalmology data revealed 40.3% female, 6.7% URM, and 28.3% Asian (Fig. 1). Notably, there are increased percentages of female faculty and faculty who identify as Asian heritage, as compared with all practicing physicians. Overall, faculty diversity decreased as faculty rank or tenure status increased13. FACULTY LEADERSHIP, EDITORS, AND EDITORIAL BOARDS The available data on academic department leadership is incomplete and what data is available references sex diversity but includes little race or ethnic data. According to TABLE 1 Specialty/Division US population US medical school enrollment Neurology residents Ophthalmology residents Neurology (practicing) Ophthalmology (practicing) Neurology faculty Ophthalmology faculty Neurology chairs Ophthalmology chairs Neurology journal editors Ophthalmology journal editors Neurology journal editorial boards Ophthalmology journal editorial boards JNO editorial board* AAN presidents† Neurology subspecialty society presidents Neurology subspecialty society boards AAO presidents† Ophthalmology subspecialty society presidents Ophthalmology subspecialty society boards NANOS presidents‡ NANOS boards§ Neurology speakers Ophthalmology speakers Grants Female (%) 50.8 51.5 43.1 43 30.3 26 42.1 40.3 12 12 12 4.2 21 26 33.4 12.5 Data not available Data not available 12.5 13.3 27.5 26.3 53.3 25.5 25 Data not analyzed URM (%) 36.2 14.5 9.2 8.9 8.2 6.7 8.1 6.7 Data not Data not Data not Data not Data not Data not 3 Data not Data not Data not Data not Data not Data not 0 6.7 Data not Data not 22 fully available available available available available available available available available available available available available available Asian (%) 5.9 22.8 20.3 32.5 17 17.8 22.8 28.3 Data not Data not Data not Data not Data not Data not 18.2 Data not Data not Data not Data not Data not Data not 5.3 20 Data not Data not Data not fully available available available available available available available available available available available available available available analyzed *JNO board as of January 1, 2020. † During the period of 2000–2015 alone. ‡ Since inception in 1980. § Current board as of May 1, 2021. AAN, American Academy of Neurology; JNO, Journal of Neuro-Ophthalmology; NANOS, North American Neuro-Ophthalmology Society; URM, underrepresented minorities. 280 Quiros and Gordon: J Neuro-Ophthalmol 2021; 41: 279-284 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial FIG. 1. Percent of females, URMs, and Asians in US population vs medical school enrollment, residents, practicing physicians, and faculty in neurology and ophthalmology. URM, underrepresented minorities. Gutierrez et al (14), 94% of neurology chairs were Caucasian and 12% of department chairs were Caucasian women. Tuli (15) documented 12% of female ophthalmology chairs in 2017. A recent publication from Camacci et al (16), using data collected in November 2019, evaluated the editorial board composition of the 20 highest-ranked ophthalmology journals and 15 ophthalmology societies to investigate the composition by gender of their leadership. Race and ethnicity were not analyzed by these authors. Women comprised 26% of editorial board and society leadership board members; however, only 4.2% of journal editors-in-chief were female. North American Neuro-Ophthalmology Society (NANOS) was included as one of the organizations in this analysis, but the JNO was not. Editorial boards averaged 25.6% female with a range of 5.5%–44.9%. For comparison in 2019, the JNO had an editorial board comprising 33.4% female, 3% URM, and 18.2% Asian. Mariotto et al (17) performed a similar analysis for neurology journal editorial boards. They found that of 247 neurology journals, only 12% of editors-in-chief and 21% of editorial board members were female (Fig. 2). Specialty Society Leadership and Board Membership Women represented 13.3% of ophthalmology professional society presidents according to Camacci et al (16). For the board members of the professional societies, the same authors reported an average of 27.5% female with a range of 14.3%–50%. The authors reported that the NANOS board had 37.5% female in the fall of 2019. Currently, the NANOS board has 53.3% female, 6.7% URM, and 20% Asian. Silver et al (18) analyzed the years of society presidential leadership over a period of 10 years for 43 Quiros and Gordon: J Neuro-Ophthalmol 2021; 41: 279-284 specialty societies by gender. Men held the position of presidential leadership for 82.6% of the total years for the selected societies between 2008 and 2017. The years in which there were female presidents for the societies ranged from 0% to 60%; the American Academy of Neurology had 0% female presidential years and the American Academy of Ophthalmology had 20% female presidential years during the study period. In comparison, the review of NANOS data documented 40% female presidential years during the same period. Although race and ethnicity were not included in the publication by Silver et al, it is notable that NANOS had no URM or Asian presidential years within the same period. Subsequently, NANOS has had an Asian president. Jagsi et al (19) examined female society membership, participation on governing boards, and highestranking officer over a period of 16 years. Women were the highest-ranking officers (12.5% between 2000 and 2015) for both the American Academy of Neurology (AAN) and the American Academy of Ophthalmology (AAO). The mean percentage of women in the governing boards of these organizations was 22.1% for AAN and 14.2% for AAO in the period of 2000–2007, increasing over the period of 2008–2015 to 25.3% and 22.6%, respectively. The increase in representation in the AAO outpaced the increase in the AAN. Comparable data for race and ethnicity were not available (Fig. 3). Invited Speakers Larson et al (20) published data regarding female invited speakers at specialty conferences representing 20 medical specialty societies, including the AAN but not the AAO. Invited speakers included plenary speakers, keynote speakers, and other invited and named lectures over a period of 2013–2017. Overall, women represented 25% of the total 281 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial FIG. 2. Percent of females, URMs, and Asians in US population vs faculty leaders, journal editors, and editorial board makeup. JNO, Journal of Neuro-Ophthalmology; URM, underrepresented minorities. speakers, and there was some increased representation of women as invited speakers in 2017, as compared with 2013. Aggregate data for the AAN revealed an insignificant difference between invited speakers and active members. Evaluation of speakers of plenary lectures of the AAN annual meetings reveals disparities between the percentage of female and male speakers. Singhal et al (21) reviewed the plenary speakers at the AAN meetings over a period of 62 years and found that 25.5% of women were nonpresidential plenary speakers but only 14.6% were presidential plenary speakers. Women are also underrepresented among recipients of recognition awards from the AAN (22). Data were analyzed for 20 awards given to 323 physicians over a period of 63 years from 1955 to 2017. Overall, the percentage of female award recipients was 18.3%, and it was increased to 21.9% over the most recent 10 years from 2008 to 2017, which remains well below the percentage of female faculty members in neurology. There were no data presented for race or ethnicity in these evaluations (Fig. 3). Patel et al (23) analyzed the gender of presenters at ophthalmology conferences between 2015 and 2017. During this 3-year period, they reviewed the number of first author paper presenters and nonpaper presenters (moderators, panelists, symposia speakers, and senior course instructors) at 9 major ophthalmology conferences. Of the 14,214 speakers, 30.5% were female. Female first author paper presenters represented 33.1% of speakers, and nonpaper FIG. 3. Percent of females, URMs, and Asians in US population vs society presidents, society boards, speakers, and grant recipients (National Institutes of Health training grants). AAN, American Academy of Neurology; AAO, American Academy of Ophthalmology; NANOS, North American Neuro-Ophthalmology Society; URM, underrepresented minorities. 282 Quiros and Gordon: J Neuro-Ophthalmol 2021; 41: 279-284 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Editorial presenters were 28.5%. Of the 9 conferences, only Association for Research in Vision and Ophthalmology had an increase in the rate of female presenters over the 3-year analysis period. The authors reported 384 speakers at NANOS annual meetings during this period of which 41.5% were female. Once again, no data were available regarding race and ethnicity. GRANTS Data from the National Institutes of Health (NIH) (24) demonstrate that the percentage of URMs on training grants more than doubled from 10% in 2012 to 22% in 2020. In 2020, 15% of K awardees were identified as URMs. When looking at K award recipients, the number of URM recipients more than doubled between 2013 and 2020, whereas the number of Caucasian/Asian recipients increased by 30%. The proportion of NIH R01 recipients identified as 7% URM and 93% Caucasian/Asian; however, the absolute number of URM recipients increased more than 200%, whereas the number of Caucasian/Asian applicants increased by 80%. Since 1985, women have been .50% of graduate school enrollees, yet women receive less than 34% of Research Project Grant Awards (25,26). Furthermore, women receive less NIH dollars for research center grants among others (27). NANOS has provided 2 research grants, the Young Investigator Award initiated in 1997 and the Pilot Research Grant initiated in 2007. Among the 20 recipients of the young investigator award, 40% were female, 20% were Asian, and 5% were URM. Among the 15 grant recipients of the Pilot Research Grant Award, 67% were female, 33% were Asian, and none were URM. Notably, we do not have information about the gender, race, or ethnicity of the applicants for these awards and therefore could not calculate a success rate. DISCUSSION One of the obvious limitations of this editorial is the inability to accurately report race and ethnic diversity because of a scarcity of data from professional organizations. In addition, there are absolutely no data on gender identity, sexual orientation, or disability status. If we are to serve our diverse patient populations, we require a robust data set of the physicians who constitute our profession. As evidenced by the data presented here, great strides have been made in analyzing and addressing gender equity; these efforts will undoubtedly continue. However, without baseline data on the makeup of our societies and those who lead the societies or who are celebrated by them, we can only make assumptions regarding other aspects of diversity and equity (race, ethnicity, disability, gender identity, and sexual orientation). Starting in 2021, NANOS has made a concerted effort to voluntarily collect these data from all members as part of our commitment to becoming a more equitable and diverse society. It is the first step in an Quiros and Gordon: J Neuro-Ophthalmol 2021; 41: 279-284 ongoing process to better our society and its impact. This editorial has made clear that there are many additional analyses that should be performed as part of the process of creating a more diverse and equitable profession. We must focus on intentional efforts that begin with data collection for the purposes of establishing a baseline from which appropriate goals can be created. A striking revelation is apparent when analyzing the first 6 lines of data from Table 1. URMs make up 36.2% of the population yet only 14.5% of medical school enrollees, a 60% reduction. Even more striking is the further reduction in the percentage of URMs in neurology and ophthalmology residencies down to 9.2%–8.9%, respectively. The reasons for these reductions may be varied, complex, and beyond the scope of this editorial, but they underscore the need for intentional multipronged interventions at all levels. In addition to pipeline programs, institutions and organizations must make other commitments to enact change. Diversity efforts often fail because there needs to be both intention and leadership to enact change. Each individual has a shared responsibility to actively learn about our own biases and to take actions to support diversity efforts in hiring processes, reviews of papers and grants, and in planning conferences or educational sessions (28). Medical organizations need to ensure that all members believe that they belong and are valued. There must be diverse representation among the leadership and in committees that select conference speakers (29). Editors of publications also have a responsibility to diversify the editorial board and to intentionally diversify the authors of invited commentaries (30). Change can occur and we can increase equity through a shared and proactive commitment. REFERENCES 1. Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine. Lewis D, Paulson E, eds. Washington, DC: AAMC Press, 2017. 2. 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Quiros and Gordon: J Neuro-Ophthalmol 2021; 41: 279-284 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.