The data source is the American Medical Association Physician Masterfile, 2005-2015 (December 31 snapshot), and the data are from ophthalmologists with direct patient care who graduated from US medical schools in 1980 or later. URM indicates underrepresented in medicine.
The data source is GME Track, 2005-2014 (December 31 snapshot). Please note that the 2015 data are not available. URM indicates underrepresented in medicine.
The data source is the Association of American Medical Colleges Faculty Roster, 2005-2015 (December 31 snapshot). URM indicates underrepresented in medicine.
eTable 1. Medical School Graduation Questionnaire (GQ) question on specialty plan in ophthalmology, 2005-2015
eTable 2. Women and URM proportion trends, 2005-2015
eFigure 1. Proportion of women comparison
eFigure 2. Proportion of URM subgroup comparison
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Xierali IM, Nivet MA, Wilson MR. Current and Future Status of Diversity in Ophthalmologist Workforce. JAMA Ophthalmol. 2016;134(9):1016–1023. doi:10.1001/jamaophthalmol.2016.2257
Increasing the level of diversity among ophthalmologists may help reduce disparities in eye care.
To assess the current and future status of diversity among ophthalmologists in the workforce by sex, race, and ethnicity in the context of the available number of medical students in the United States.
Design, Setting, and Participants
Data from the Association of American Medical Colleges, the American Medical Association, and US Census were used to evaluate the differences and trends in diversity among ophthalmologists, all full-time faculty except ophthalmology, ophthalmology faculty, ophthalmology residents, medical school students, and the US population between 2005 and 2015. For 2014, associations of sex, race, and ethnicity with physician practice locations were assessed.
Main Outcomes and Measures
Proportions of ophthalmologists stratified by sex, race, and ethnicity between 2005 and 2015.
Women and minority groups traditionally underrepresented in medicine (URM)—black, Hispanic, American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander—were underrepresented as practicing ophthalmologists (22.7% and 6%, respectively), ophthalmology faculty (35.1% and 5.7%, respectively), and ophthalmology residents (44.3% and 7.7%, respectively), compared with the US population (50.8% and 30.7%, respectively). During the past decade, there had been a modest increase in the proportion of female practicing ophthalmologists who graduated from US medical schools in 1980 or later (from 23.8% to 27.1%; P < .001); however, no increase in URM ophthalmologists was identified (from 7.2% to 7.2%; P = .90). Residents showed a similar pattern, with an increase in the proportion of female residents (from 35.6% to 44.3%; P = .001) and a slight decrease in the proportion of URM residents (from 8.7% to 7.7%; P = .04). The proportion of URM groups among ophthalmology faculty also slightly decreased during the study period (from 6.2% to 5.7%; P = .01). However, a higher proportion of URM ophthalmologists practiced in medically underserved areas (P < .001).
Conclusions and Relevance
Women and URM groups remain underrepresented in the ophthalmologist workforce despite an available pool of medical students. Given the prevalent racial and ethnic disparities in eye care and an increasingly diverse society, future research and training efforts that increase the level of diversity among medical students and residents seems warranted.
There are about 202 million individuals requiring vision correction living in the United States.1 The current supply of practicing ophthalmologists and optometrists appears to be adequate to satisfy the demand for eye care in the United States.2,3 However, significant racial/ethnic disparities persist in eye care delivery and vision health.4-6 It has long been argued that increasing the level of diversity in the physician workforce would have significant positive implications for health care delivery and would reduce racial/ethnic disparities in health care.7 Prior research indicates that physicians who are from minority groups underrepresented in medicine (URM) are important for the provision of health care for underserved populations and underserved locations.8,9 Students from medical schools with more diverse student bodies report feeling more confident managing patients from different cultural backgrounds, as well as having learned from individuals from different backgrounds.10,11 Patients receiving care from physicians of the same race/ethnicity report greater satisfaction with their treatment and greater communication with their health care professionals.12,13 More women have entered the physician workforce, and they are more likely to pursue certain medical specialties than others.14,15 Whether medical care is provided by a man or a woman makes a difference because the professional role of the physician is not sex-neutral.16,17 For example, studies have found that the sex of the physician can influence the provision of both screening and counseling services to patients.18
However, while the racial and ethnic diversity of the US population continues to increase, the physician workforce has been diversifying at a much slower pace.19 Approximately 13.5% of physicians are from URM groups, whereas 31% of people in the United States are from URM groups.20 On the other hand, racial and ethnic disparities in eye care are still prevalent in the United States. A higher proportion of blindness among minorities, an increased prevalence of glaucoma in black individuals and Hispanic individuals, and a decrease in the number of minorities who have undergone surgery21,22 all point to the need to eradicate these disparities. Moreover, a geographic maldistribution of the US physician workforce is common and has important implications for patient access to routine and specialty care. Ophthalmology is one such example of a specialty with a geographic maldistribution of physicians and a lack of diversity by sex, race, and ethnicity.
In a 2014 Association of American Medical Colleges (AAMC) Analysis in Brief report examining the physician workforce, it was recommended that research should be undertaken to evaluate the pursuit of specialties among medical students who are URM.8 However, whether the general patterns observed in the overall physician workforce are also observed in the field of ophthalmology still needs to be reviewed. Furthermore, how the level of diversity in ophthalmology is trending in recent years remains unknown.23 Therefore, the primary objective of this study was to explore the current and future status of diversity in the ophthalmologist workforce stratified by sex, race, and ethnicity. A secondary objective was to determine whether this diversity is associated with physicians practicing in underserved geographic locations.
Question What is the current and future status of diversity among ophthalmologists in the workforce?
Findings This study assesses the current and future status of diversity among ophthalmologists in the workforce by sex and race/ethnicity in the context of the available number of medical students in the United States. A review of sex, race, and ethnicity in the US population and among medical students, medical school faculty, ophthalmology residents, and practicing physicians suggests that while the field of ophthalmology has seen a modest increase in the proportion of women who have entered its ranks, the proportion of minorities underrepresented in medicine remains extremely low.
Meaning An intentional focus on diversity in the field of ophthalmology should be desired to ensure that the future of ophthalmology benefits from all the diverse talent that exists in the United States.
The variables evaluated were sex, race, and ethnicity. A physician’s sex, race, and ethnicity were defined as consistent with the US Census Bureau. Racial and ethnic groups were defined as mutually exclusive groups: (1) Hispanic or Latino (of any race), referred to as Hispanic; (2) non-Hispanic white, referred to as white; (3) non-Hispanic black or African American, referred to as black; (4) non-Hispanic Asian or Asian American, referred to as Asian; (5) non-Hispanic American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander, grouped as one category as Native American; and (6) other, defined in this study as any non-Hispanic person with multiple races, unknown racial and ethnic information, or not classifiable in one of the previous categories. The concept of URM minority groups was first addressed by the AAMC in 1970 and was modified in 2004 to describe minority groups that are underrepresented relative to their numbers in the general population, which currently includes black individuals, Hispanic individuals, and Native American individuals (American Indian, Alaskan Native, Native Hawaiian, and Pacific Islander).24 We also calculated the proportion of ophthalmologists practicing in Primary Care Health Professional Shortage Areas,25 Medically Underserved Areas/Population,26 and rural areas (Rural Urban Commuting Areas, 2010 version)27 for both men and women and for each racial/ethnic group. The American Institutes for Research institutional review board approved this study and granted a waiver of informed consent from study participants.
Data on US medical school students were obtained from the American Medical College Application Service28 and AAMC Student Records System.29 Ophthalmology residency is an advanced residency for applicants and requires 1 year of internship or preliminary residency training before residents can start ophthalmology residency training. Ophthalmology residency applicants must apply through the San Francisco Match for ophthalmology residency positions, and they must also apply for an internship and preliminary residency program, such as in internal medicine, via the Main Residency Match administered by the National Resident Matching Program. While these applicants do use AAMC’s Electronic Residency Application Service to match for preliminary or internship programs via the National Resident Matching Program, we could not differentiate them from other program applicants. Therefore, we did not seek to assess the diversity trends in the residency applicant pool. Instead, we analyzed the responses of medical school graduates who, on the Medical School Graduation Questionnaire (GQ), indicated plans to specialize in ophthalmology. The GQ is administered annually to all graduating US medical students. The response rate in 2015 was 79.9% for the GQ.30 We analyzed the response to the question: “Are you planning to become certified in a specialty? [If yes]: Choice of specialty:” Ophthalmology was one of the specialties listed as a choice.
Data on ophthalmology residents were obtained from the GME Track database. GME Track is jointly run by the American Medical Association (AMA) and the AAMC for following up with postgraduate trainees in all programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). It is an annual “snapshot” of trainees on duty as of December 31 of the corresponding year. The GME Track data are provided by the training programs, and participation is voluntary. Approximately 95% of residency programs submit data each year.31 Data on medical school full-time faculty and department chairs were obtained from the AAMC Faculty Roster through FAMOUS (Faculty Administrative Management Online User System).32 The Faculty Roster includes demographic information on virtually all full-time faculty at US MD-granting medical schools.
We used the 2005-2015 annual AMA Physician Masterfile to study trends in demographic characteristics of ophthalmologists with direct patient care. The physician study cohort is further limited to physicians with direct patient care who graduated from US medical schools in 1980 or later because there was an excessive amount of missing data for race and ethnicity prior to 1980. For a comparative analysis, we determined the trends in the proportions of women and URM minority groups in otolaryngology, other surgical specialties as a group (including colon and rectal surgery, general surgery, neurological surgery, obstetrics and gynecology, orthopedic surgery, plastic surgery, thoracic surgery, and urology), and all other physicians as a group. The 2014 AMA Masterfile was geo-referenced and matched to rural and medically underserved areas. The Masterfile includes data on all current physicians residing in the United States who meet the educational and credentialing requirements to be recognized as physicians.33
Data on the race and ethnicity of physicians come from a variety of AAMC sources but mainly from the self-reported information collected in the American Medical College Application Service, the Electronic Residency Application Service, and the Medical College Admission Test (MCAT). Other sources include self-reported data from the Post-MCAT Questionnaire, the Matriculating Student Questionnaire, the GQ, and the Summer Medical and Dental Education Program, as well as secondary data from the AAMC Student Records System, the GME Track, and the Faculty Roster. Data on race and ethnicity were available for some osteopathic physicians and international medical graduates. Data on the diversity of the US population come from the American Community Survey and US Census Population Estimates.34 Underserved practice locations were identified as rural areas, federally designated Primary Care Health Professional Shortage Areas, and Medically Underserved Areas/Populations.
The t test and the χ2 test were used when appropriate to investigate significant differences in sex, race, and ethnicity among practicing ophthalmologists, ophthalmology faculty, ophthalmology residents, medical students, and the US population. To assess trends in sex, race, and ethnicity between 2005 and 2015, the slope and the associated P values for each group were estimated by using a simple linear regression model, in which year was used as an independent variable. All P values were 2-sided; P < .05 was considered to be statistically significant. Statistical analyses were conducted with SAS version 9.3 (SAS Institute).
There were 17 904 ophthalmologists with direct patient care as identified in the AMA Masterfile at the end of 2015 (Table 1). While census estimates in 2014 show that 50.8% of the US population were women and 30.7% were from URM minority groups, 22.7% of the ophthalmologists with direct patient care were women, and 6% were from URM minority groups (2.5% black, 3.3% Hispanic, and 0.2% Native American). However, when we examine those physicians who graduated from US medical schools in 1980 or later, the proportion of women was higher at 27.1%, and the proportion of URM groups was also higher at 7.2%. The overall proportion of URM groups who were practicing ophthalmologists and who graduated in 1980 or later was static between 2005 and 2015 (P = .90), whereas the proportions of Asian individuals (P < .001) and women (P < .001) had been increasing. In contrast, the proportions of white individuals (P < .001) and men (P < .001) were decreasing (Figure 1).
There were 1341 residents in training in ophthalmology residency programs in 2014. Women comprised 44.3% of residents, which was lower than the proportion of women in the US population but relatively higher than the proportion of female practicing ophthalmologists. The proportion of URM residents was 7.7%, which was lower than the proportion of URM groups in the US population but similar to the proportion of URM practicing ophthalmologists. Also notable was the relatively higher proportion of Asian residents (31.8%), which is about 6 times higher than the proportion of Asian individuals in the US population. The proportion for white residents stood at 55%, which is lower than the proportion of white individuals in the US population (62.1%), as well as white practicing ophthalmologists (72.7%) and white ophthalmology department faculty (61.1%). The proportion of black ophthalmology residents decreased slightly between 2005 and 2014 (P = .01), while the proportions of Hispanic (P = .23) and native (P = .93) ophthalmology residents remained relatively unchanged (Figure 2). During the past decade, the proportion of Asian residents remained stable at around 32.6% (P = .34), whereas the proportion of female residents (P < .001) had been increasing and the proportions of white (P = .002) and male (P < .001) residents had been decreasing.
While the medical school faculty (except ophthalmology) generally lacked diversity by sex (38.9% women) and race/ ethnicity (7.9% URM groups) in 2015, the ophthalmology department faculty had even lower representations of women (35.1%) and URM groups (5.7%). Trend analysis shows that, while the proportions of male and white medical school faculty were decreasing, the proportion of URM faculty was also decreasing (Figure 3). In contrast, the proportions of female and Asian faculty were increasing. The students who enrolled in medical school in the 2015-2016 academic year were much more diverse in terms of sex (46.8% women), the closest representation to the US population. In contrast, the proportion of the URM medical students who enrolled was low at 16.4%. While the overall number of URM medical students stood at 14 241 in the 2015-2016 academic year, there could be room to grow for ophthalmology residents from these groups.
However, the level of interest of medical students in ophthalmology was generally low during the study period. The results of the GQ show that only about 2.5% to 3.1% of medical school graduates indicated a preference to specialize in ophthalmology during the study period (eTable 1 in the Supplement). Even lower proportions of female (2.2%-3.0%) and URM (1.3%-2.4%) graduates were interested in ophthalmology. These proportions remained relatively unchanged during the study period (eTable 2 in the Supplement). In comparison, the proportions were higher for white and Asian medical school graduates. During the study period, the proportions of women who were on the medical school faculty or ophthalmology department faculty, who were department chairs or ophthalmology residents, and in all the physician groups trended upward. However, in general, the proportions of women trended downward from the general population to matriculating students, residents, those interested in ophthalmology, faculty members, and practicing physicians (eFigure 1 in the Supplement). Within the physician groups, ophthalmology had a higher proportion of women than did otolaryngology but a lower proportion than other surgical specialties or other physicians as a group. Similarly, the proportion of women on ophthalmology department faculty were lower than that of all faculty departments (excluding ophthalmology) but higher than that of department chairs.
Results also show that, in general, the proportions of URM individuals trended downward from the general population to matriculating students, residents, those interested in ophthalmology, faculty members, and practicing physicians (eFigure 2 in the Supplement). However, in addition to the lack of interest in specializing in ophthalmology, the proportions of URM faculty members, ophthalmology residents, and practicing ophthalmologists were relatively low and stagnant; the proportion of URM faculty members in ophthalmology departments even trended downward during the study period. The proportion of URM ophthalmologists was slightly higher than that of URM otolaryngologists but lower than that of other surgical specialists or other physicians as a group.
There were significant associations between the diversity of ophthalmologists and their distribution. As of 2015, 22.3% ophthalmologists practice in Primary Care Health Professional Shortage Areas, 26% practice in Medically Underserved Areas/Populations, and 8.1% practice rural areas (Table 2). Overall, geographically, Health Professional Shortage Areas and Medically Underserved Areas had fewer ophthalmologists regardless of the sex or race/ethnicity of the physician.
In this analysis of diversity on the basis of sex, race, and ethnicity in the US ophthalmologist workforce, we found that women and URM groups were significantly underrepresented as ophthalmology residents, academic faculty members, and practicing ophthalmologists compared with the US population. However, the proportions of female ophthalmology residents and female practicing physicians increased. In 2014, this increase in women was most pronounced among ophthalmology residents (44.3% were women) compared with ophthalmologists (22.7% were women). While a higher proportion of URM residents than URM practicing physicians suggests a more diverse workforce in the future, there was no significant increase in representation from individual URM groups during the past decade; on the contrary, the proportion of black residents had decreased slightly, indicating that overall URM representation in the ophthalmologist workforce would not dramatically improve in the near future. Our findings indicate that URM groups decrease in representation when moving from medical school to ophthalmology residency and practice. Efforts such as the holistic review process have been made to increase the level of diversity among matriculating medical students.35 However, these efforts have yet to translate into a commensurate increase in the level of diversity among ophthalmology residents.
The changes in the clinical ophthalmologist workforce were even slower than those among ophthalmology residents, although the changes were generally in the same direction as the resident pool, where we saw a decrease in the proportions of male and white physicians and an increase in the proportions of female and Asian physicians over the study period. The proportion of URM physicians, on the other hand, did not change significantly and remained below 8% for the entire study period. Increasing the level of diversity in the eye care workforce may help reduce disparities in eye care.7 This is important for the eye care workforce in that optometrists, as a group of eye care professionals, were also known to be lacking in diversity with regard to sex (39.8% women) and race/ethnicity (82% white and 13% Asian).36
However, there appears to be a reasonable number of URM medical school students that ophthalmology residency programs can recruit. Our findings suggest that the level of interest in ophthalmology among medical students was relatively low (ie, about 2.5%-3.0% of students were interested in pursuing a career in ophthalmology) and that URM medical students showed even less interest in specializing in ophthalmology. While the lack of interest in ophthalmology among medical students may stem from the fact that there are very few residency positions available in ophthalmology, other factors, such as the requirement of a higher score on the United States Medical Licensing Examination, may have played a role as well.37,38
Potential strategies for addressing these issues in residency programs may include initiating programs to expose preclinical URM minority students (ie, students who have not yet begun rotating on the medical wards) to ophthalmology, highlighting patient contact and health education opportunities, and providing exposure to ophthalmology during third- and fourth-year medical student rotations. Strengthening and expanding ophthalmology curriculum activities in all medical schools may also increase the number of medical students interested in ophthalmology. Curriculum Inventory and Reports (data not shown) suggest that only 61 of 126 medical schools participating in the AAMC program had a robust ophthalmology curriculum in 2015.39 Also, creating opportunities for mentorship and exposure to eye care delivery early in the pipeline in the fields of science, technology, engineering, and mathematics (inclusive of women and minorities) could also improve the appeal of ophthalmology residency programs to potential URM minority medical graduates.
Residency programs may also need to consider reviewing candidates holistically in their admission processes. Finally, there should be some mechanism to periodically evaluate the program’s effectiveness with regard to hiring candidates based on sex, race, and ethnicity to increase the proportions of women and URM groups in these programs. Also, more research is needed to determine and understand the value of diversity in the ophthalmologist workforce. The URM minority physicians tend to practice in medically underserved areas. This points to some opportunity to remedy the overall physician workforce maldistribution.
There are a number of limitations to this study. First, location analysis was limited in that groups were compared across 1 year, with the most recent available data. Second, there were still a lot of missing data on race/ethnicity in the older physician groups. Third, diversity data from the Faculty Roster may not have been self-reported because the data were reported by the medical schools. Although the number of URM faculty members has increased over the years, the proportion of URM faculty members has decreased. Finally, in this analysis, we did not seek to establish “correct” or “sufficient” levels of diversity by sex, race, and ethnicity in the ophthalmologist workforce. Our intent was to assess the current status of diversity and recent trends.
Female, black, Hispanic, and native representations in the ophthalmologist workforce were substantially lower than that of the US population in general and medical students in particular. The ophthalmologist workforce also suffers from a geographic maldistribution. Increasing the level of diversity in the ophthalmologist workforce may have significant implications for developing better ways to alleviate part of the persistent racial/ethnic disparities in eye care. Given the prevalent racial/ethnic disparities in eye care and an increasingly diverse society, future research and training efforts should address the topic of increasing the level of diversity among ophthalmology residents.
Accepted for Publication: May 20, 2016.
Corresponding Author: Imam M. Xierali, PhD, Association of American Medical Colleges, 655 K St NW, Ste 100, Washington, DC 20001-2399 (firstname.lastname@example.org).
Correction: This article was corrected on September 22, 2016, to fix an error in the reference list.
Published Online: July 14, 2016. doi:10.1001/jamaophthalmol.2016.2257
Author Contributions: Dr Xierali had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Xierali, Wilson.
Acquisition, analysis, or interpretation of data: Xierali, Nivet.
Drafting of the manuscript: Xierali.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Xierali.
Administrative, technical, or material support: All authors.
Study supervision: Nivet.
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.