The experts: Dr Varo Kirthi

Through the Time to speak series, OT profiles how discrimination in the workplace is affecting eye care professionals.

In this article, OT talks with ophthalmology registrar and research fellow at King’s College London, Dr Varo Kirthi about research exploring racial differences in treatment and his Eye editorial Black eyes matter – do we treat Black patients differently in ophthalmology?

What prompted you to undertake research exploring racial differences in eye care?

Following the death of George Floyd in the US and the Black Lives Matter movement, many people across different industries started looking at their own processes for racial disparities. People were assessing if there was bias within healthcare.

After my third year of training, I took three and a half years out to do a PhD at King’s College London. I completed work on diabetic eye disease and racial differences in treatment as part of my PhD.

I realised that nobody had really looked at this issue within ophthalmology. At King’s College Hospital in London, they have a very diverse population of patients. Around half of the patients in clinic are Black, 20% are Asian and the rest are white. It is a multi-ethnic population. When you go further afield, you tend to deal with mainly caucasian populations. I was curious to see whether there was actually a racial bias against black and asian patients.

Your research revealed that black patients wait longer for hospital eye treatment than white patients. Were you surprised?

We were surprised – we weren’t expecting to find a difference. The nice thing about doing research in diabetes is that there are quite defined outcomes and referral points. Every patient with diabetes in the UK has annual screening. There are very strict criteria on who is referred to the hospital and who stays within the community screening programme.

It was easy for us to access the data sets on who was referred to us in terms of what level of disease they have and when they were referred to the hospital. Once they are in the hospital, because they have an electronic record, it is easy to track their progression: what their diabetic grading is at the point of referral, what treatments we offer and how quickly their disease progresses.

We retrieved a data set of patients who had been referred to King’s from the community screening programme, over a five-year period, and we looked at what happened to them in hospital. What surprised me is that even within a short period of three to four years, we found that actually there were quite significant differences in terms of how long black patients were waiting for treatment compared to their white counterparts.

How much longer on average were black patients waiting for treatment?

There wasn’t a defined time because we were looking at different treatments – for example, VEGF injections and laser. What we did show was that, on average, compared to white patients, black patients did wait considerably longer. The question that it raised is why are they waiting longer? Now we are looking at creating a study to look into that question in more detail.

Is the reason because there is a bias around treating these patients or is it because they are more reluctant to accept treatment compared to their white counterparts? I think the answer is going to be a combination of factors.

What factors do you think might be influencing these differences?

There are many reasons why patients fail to attend hospital and trying to unpack that is not an easy task. Socioeconomic factors may play a more significant role than race per se. For example, if you are in a highly paid job and living on a comfortable salary, you are able to take annual leave whenever you want to, you have social support, there are far fewer barriers to you attending a clinic appointment.

Unconscious bias is the idea that every day we make decisions based on previous experiences and our own deep seated personal assumptions about the world around us

If you are someone who is from a low socioeconomic background and you work on a zero hours contract – if you take time off work, you don’t get paid – it can be harder to attend clinic. We know that black people and people from low socioeconomic backgrounds are more likely to have multiple chronic health problems compared to white people and people from higher socioeconomic backgrounds. Many of these patients have multiple illnesses and they might have competing appointments or hospitalisations preventing timely attendance and treatment.

Part of what we are looking at is what are the underlying health beliefs and biases that patients have. What are their experiences and interactions with healthcare professionals in hospitals? Among ethnic populations studies have shown that myths around diseases and treatments are much higher. There are also higher levels of physician mistrust amongst ethnic minorities.

What role could unconscious bias play in these differences?

Unconscious bias is the idea that every day we make decisions based on previous experiences and our own deep seated personal assumptions about the world around us. Part of that is because our brains are constantly trying to make patterns. When we are sifting through vast amounts of information, having patterns engrained in our heads helps us to react quicker.

It is about tackling those patterns and working out which patterns are helpful and which ones are prejudicing our behaviour to some groups. For example, if a black patient walks into the clinic, do we automatically think they have diabetes, that they are not going to believe what you tell them if you tell them they need injections in their eyes. Do you think they will be less likely to turn up for future appointments?

You always have these patterns of thought in your head. If an elderly white patient walks in, you might assume that they are going to be deaf, that they are going to have macular degeneration and they are going to be OK with any treatment you offer them. Those very factors not only affect us in the hospital eye service, but they also affect optometrists.

We often make assumptions around ‘did not attends’ in secondary care. We might think that people didn’t turn up because they couldn’t be bothered but there might be complex reasons why they can’t come. They could be a carer or on a zero hours contract which means they cannot get out of work. They may have another illness that means they are already in hospital for another reason. The same reasoning applies to optometrist appointments. Thinking a little more deeply about these things helps.

The only way of reducing bias is to talk about it and to raise awareness of it. Think about your own bias and think ‘Did I have an assumption about this person and was that assumption proved wrong?’ When you see biased behaviour and people being treated slightly differently, it is important to challenge that.

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