Perspectives on Diversity

“Have we asked the Question?” Religious Inclusion within Glaucoma Pre-Op Counseling

by Kirsten Simmons, BS, MHSc

Kirsten Simmons is a 4th year medical student at Duke University School of Medicine, applying to ophthalmology. She is also completing a Master’s of Theological Studies at Duke University Divinity School as a Theology Medicine and Culture Fellow. Within Duke SOM, some of her greatest joys have included serving as the Co-President of the Student National Medical Association- Duke chapter, where she served as an advocate for underrepresented minority trainees.

 

My training within the humanities thus far has taught me that everyone has a value system which dictates decision making, whether big or small. Through identifying and honoring a patient’s value system (which is often crafted multi-dimensionally over a lifetime), one can become more compassionate and effective at understanding adherence practices, delivering news of a diagnosis and guiding patients through variable contingency plans; all critical components of the ophthalmology specialty. Therefore, I was excited to hear Dr. Leon Herndon pose the following question to our team before beginning surgical cases one day: 

“How might patients of the Islam faith consider the XEN Gel stent for their glaucoma disease?”

It was a simple yet insightful question; one that we would aim to discuss collectively throughout my few weeks on the department’s General Ophthalmology elective.

The XEN Gel stent is classified along the micro invasive glaucoma surgeries (MIGS) for glaucoma treatment. This stent is composed of porcine (pig-derived) gelatin that is cross-linked with glutaraldehyde; a composition that helps it achieve permanent hydrophilic properties within human tissue. 

However, according to Islamic purity law, pork and pork products are impure, and people of Islam faith do not partake in its consumption. Despite most medically used gelatins going through various types of radiation and chemical processing that yield it to be “acellular” of porcine components, many Muslims still forbid usage of such.

Thankfully, I had the privilege to connect with a few Muslims within my social circle to gain insight into their interpretation of this specific purity law and how it might impact their options for this glaucoma surgical procedure. I crafted four questions to inquire about their desire for pre-op counseling, what language of inclusivity should look like within counseling, what factors contribute to their personal decision making, and whether or not they believe they would ultimately accept the XEN Gel stent for glaucoma management.

Question #1: “Would you want information of this device’s material composition (porcine-derived gelatin) made known to you?
Unanimous: information regarding the device’s composition should be acknowledged within pre-op counseling.
 
Question #2: “After receipt of this information, how would you proceed with your medical decision?”
One contributor stated they would be willing to receive this device, as long as the Imam (spiritual leader/prayer leader) stated that this medical decision was permissible. They believed that XEN use may be permissible if solely used for preservation of sight. 
Another contributor stated that they would reject this device, and ask for other options, even if those alternative options had lower success rates.
 
Question #3: “How do you learn about which medications and medical products are permissible for you to use in accordance with your religious beliefs?” 
One contributor stated that their elders and family members give them guidance on what is acceptable and what is not. They additionally seek out information on Google and drug profile pages.
Another contributor stated that they conduct a lot of their own research on the internet. They additionally ask pharmacists and members of their community about medication components. 
 
Questions #4: “How can physicians offer pre-op counseling/ inquire of patients’ religious preferences in an inclusive way?”
Consider the following phrase for pre-op counseling of the XEN Gel stent:
“There are multiple surgical devices that we can insert into the eye, to help reduce its pressure. Based on your presentation, our team believes that the XEN Gel Stent would treat this appropriately for you. (Introduce overview of procedure). Of note, the XEN Gel Stent is made of durable gelatin that is porcine (pig) derived. Some patients may have specific religious beliefs that prevent them from using this device. Would this be a concern of yours?”

In light of the different interpretations and ultimate decisions that patients of the Muslim community may have and make, it is imperative that physicians acknowledge the uniqueness of all patients and their dependency on spiritual leaders to aid them in medical decision making. Some patients may only choose the XEN Gel stent if it is their last resort, whereas others may entertain the option sooner within their treatment plan. Above all, informing all patients that this particular device is porcine derived, provides the greatest transparency of this particular surgical option. As a result, the physician should prepare a surgical contingency plan for patients who may reject the XEN Gel stent in an open-minded manner.

I am grateful for the opportunity to have taken the General Ophthalmology elective.  As a 4th year medical student who chose ophthalmology “late”, I was eager to complete my checklist of learning objectives, much of which centered upon clinical skill observation and demonstration. However, the most impactful component of this elective was engagement in the question of how we can tangibly become more inclusive in our language and practice within the ophthalmology department. This experience (and hopefully further research in this topic!) demonstrated that one must not simply bring diverse perspectives and values to a workplace, but audibly engage with others about them. It is my hope that the latter approach will continually yield genuine patient-physician trust, communication and shared decision making.


Glaucoma Chief Dr. Leon Herndon Discusses Race and Diversity in Ophthalmology on AAO Podcast

By: Nicholas A. Johnson, M.S., Duke Medical Student

Two weeks after the murder of George Floyd, Duke Eye Center Chief of Glaucoma, Leon Herndon Jr., MD, joined a panel to discuss the topic of race and diversity in ophthalmology. The conversation was featured on Episode 240 Straight from the Cutter's Mouth: Race in America and Improving Diversity in Ophthalmology a podcast hosted by Dr. Jayanth Sridhar for the American Academy of Ophthalmology (AAO). Dr. Herndon was joined by two of his colleagues, ophthalmologists Dr. Tamara Fountain and Dr. Basil Williams.

In this episode, the group first discusses their personal reactions to the murder of Floyd and the resultant sociopolitical unrest throughout the country. Dr. Herndon speaks of the conversations he has had with his own family, and the fact that he is heartened by the willingness of young Americans to engage in difficult conversations with peers from various backgrounds.

Special consideration is given to the state of diversity within the field of ophthalmology, in which only 2.5% of physicians are Black. Dr. Herndon highlights the commitment of Duke Eye Center to diversity not only in words, but also in action. He notes that the increased enrollment of African American trainees to the ophthalmology residency program at Duke is a sign that the institution is heading in the right direction.

In his closing remarks, Herndon reemphasizes that the importance of diversity in ophthalmology extends beyond improved patient outcomes. He suggests that diverse groups tend to possess more creativity and offer unique opportunities for innovation and collaboration. A commitment to maintaining a robust pipeline of diverse applicants to ophthalmology therefore sets the stage for the advancement of the field.

Listen the podcast 


My Experience Participating in the Rabb-Venable Excellence in Ophthalmology Program

By Maria Gomez-Caraballo, BS, Duke Medical Student

I am a first generation Afro-Latina medical student, and it was at Duke School of Medicine that I first discovered my passion for ophthalmology. Through Duke Eye Center, I was able to attend the Rabb-Venable Excellence in Ophthalmology Research program hosted by the National Medical Association (NMA) this past summer in Hawaii. This conference was one of the most inspiring events that I have experienced as a Duke medical student.

The NMA was founded in 1895 as the nation’s first medical association representing African American health professionals. To this day, the NMA continues to amplify the voices of African American doctors and works to advance medicine in minority communities through improvements in education, quality of care, and medical disparity reduction. The Rabb-Venable Award for Outstanding Research, begun in 2000, is named after Dr. Maurice F. Rabb, Jr. and Dr. Howard Phillip Venable, two leading African American ophthalmologist who mentored their students in the pursuit of research and academic excellence. Today, the program is led by Dr. Mildred Olivier and Dr. Eydie Miller-Ellis, who are dedicated to furthering the mission of the program. Every year, they select medical students, residents, and fellows to present original research and attend an immersive experience for awardees.

At the conference, Dr. Olivier, Dr. Miller-Ellis, and the some of the diverse Rabb-Venable shared advice on being active participants in our medical school experience and overcoming obstacles during clinical years. The program included lectures and workshops on practical matters that are not often covered in medicine’s core curriculum, such as discussions of NEI available funding, what goes into grant selection, and successful grant writing. My personal favorite workshop was the intensive public speaking training, which gave us time to practice poster and podium presentations and interviewing skills. The program culminated with attendees’ poster and podium sessions and award presentations.

Both the NMA and the Rabb-Venable Excellence Research program are platforms where minority students and physicians can seek out professional development, mentorship, and empowerment. I hope this is only the beginning of a long career as Rabb-Venable alumni. It was amazing to be in rooms full of physicians who shared similar backgrounds with the hopeful medical students in attendance, many of us the first in our families to follow this path. I strongly encourage all medical students interested in ophthalmology, residents, and fellows who identify as Black or African American, Latinx, or Native American to submit their abstracts for consideration to attend the August 2020 conference in Atlanta (www.rabbvenable.org). This year will the conference’s 20th anniversary, and we encourage all past participants to return to be a part of the celebration!


 

Read Previous Perspectives on Diversity Blogs 

Sexual Harassment in Ophthalmology -- #MeToo by Laura Enyedi, MD

Minority Ophthalmology Mentoring Program by Jullia Rosdahl, MD, PhD

Pathways to Physician Diversity by Eleonora Lad, MD, PhD

Reframing our Ways of Thinking about Diversity by Leon Herndon, Jr, MD

InSight into Inclusion by Goldis Malek, PhD

 

More information:

http://cookross.com/about-us/our-team/howard/

https://implicit.harvard.edu/implicit/