A Historical Review of Racial, Ethnic, and Gender Diversity in Plastic Surgery at the University of Michigan

Abstract

In this article, we examine the 60-year history of diversity efforts within the Section of Plastic Surgery at the University of Michigan (UofM) in the context of national trends. We describe the experiences of pioneering Underrepresented in Medicine (URiM) and female graduates of the program. James Norris, MD, and Christine Sullivan, MD, were the first URiM and female graduates from UofM in 1974 and 1989, respectively. Currently, women constitute over one-half the plastic surgery trainees at UofM, but URiM trainee representation remains limited. Dr. Adeyiza Momoh and Dr. Amy Alderman were the first URiM and female faculty members hired in 2011 and 2004, respectively. At present, there are four URiM and seven female faculty members in the Section. With a shared vision, supportive leadership, and motivation to change, faculty diversity has increased substantially. Additional strategies, including ongoing pipeline programs in medicine and science for URiM and women, are needed to further increase workforce diversity in plastic surgery.

Health care disparities and inequities in medicine and surgery negatively impact patient care and outcomes; workforce diversity is one approach to improve health care access and outcomes. Like many subspecialties of medicine, plastic surgery faces challenges with the discrepancy between the growing population of ethnic and racially diverse patients and the proportion of physicians with concordant backgrounds available for care. As a subspecialty that is constantly innovating with a broad range of clinical applications and patient populations, it is imperative that plastic surgery recruit individuals with diverse perspectives and skills. Workforce diversity engenders a higher quality of work, better decision-making, and greater team satisfaction. In this way, gender and cultural differences are transformed into assets for the organization.

Underrepresented in medicine (URiM) is defined as populations that are underrepresented relative to their numbers in the general population. Diversity, equity, and inclusion (DEI) has an important impact on institutional and organizational functioning. Specifically, workforce diversity improves patient-physician communication and has the potential to mitigate health care disparities. ^{1 2} Despite the recognition of the importance of diversity, the proportion of black and Hispanic plastic surgery trainees, faculty, and full professors remains extremely low. ² Blacks comprise 12.3% of the population but just 3.6% of plastic surgeons in the workforce. ² Similarly, Hispanics comprise 14.8% of the population but 5.7% of the plastic surgery workforce. ² In 2019, the American Council of Graduate Medical Education modified the common program requirements to specifically focus on systemic recruitment and retention of a diverse and inclusive workforce of trainees and faculty. ³ Although the modifications are now required, it is unclear to what extent programs adhere to them.

The University of Michigan (UofM) Section of Plastic Surgery in the Department of Surgery was established in 1964 and has been on the cutting edge of medical education, research, and patient care. In this article, we examine the experiences of the first URiM (Dr. James Norris) and one of the earliest female graduates (Dr. Leslie Cohen) to provide historical perspective. We also examine the current state and future direction of DEI recruitment and retention strategies among trainees and faculty at UofM in the context of national trends.

A History of Racial Exclusion

To fully appreciate the significance and challenges faced by the first URiM plastic surgeon at the UofM, we must first review the state of DEI in plastic surgery leading up to and during his training. The 1960s was a decade fraught with systemic hurdles that made it difficult for URiM to enter the field of plastic surgery. One of the first black plastic surgeons, Dr. Arthur L. Garnes, completed surgical residency at Harlem Hospital in New York and later served as a codirector of the newly formed plastic surgery clinic. He eventually became the nation's first black residency program director. ⁴ Dr. Walter Scott Brown was a contemporary of Dr. Garnes, who went on to practice plastic surgery and was appointed as a Clinical Associate Professor of Surgery at the University of Washington. He later received an honorary doctorate for excellence in teaching surgical residents. ⁴

Despite their contributions, black plastic surgeons, including Drs. Garnes and Brown, faced institutional barriers to board certification that prevented them from becoming members of the American Association of Plastic Surgeons (AAPS) and the American Society of Plastic Surgeons (ASPS). ⁴ The 1950s and 1960s Civil Rights era led to integration within the American Medical Association and its affiliated societies. On April 27, 1968, Dr. Vincent Porter became the first black physician to be certified by the American Board of Plastic Surgery (ABPS), a milestone in the field. ⁴ Unfortunately, URiM representation continued to remain low. ⁵

The First URiM Plastic Surgeon at the UofM

Dr. Reed Dingman established the Section of Plastic Surgery at UofM and became professor and chairman in 1964. ⁶ In 1971, Dr. James Norris, a black general surgeon, applied and interviewed for the plastic surgery residency program. Dr. Norris applied to six other programs ( Fig. 1 ). One residency program asked for a photograph, which he submitted. He did not receive a reply. A second program director offered Dr. Norris a residency position but advised him that he would train in Jamaica. Dr. Norris, astonished at the proposal, replied that he was not interested as “the only thing I have in common with Jamaicans is the color of my skin.” ⁷ In contrast to these encounters, Dr. Norris was met with hospitality and respect in his interview with Dr. Dingman. He was invited to round with Dr. Dingman, and later, Dr. Dingman informed him that he wanted him to train at UofM. Additionally, Dr. Dingman followed up with a telephone call to Dr. Norris to express his interest and emphasize that he believed Michigan would provide Dr. Norris with excellent training in all fields of plastic surgery. Dr. Norris was accepted at two other programs. ⁷

Fig. 1.

Dr. James Norris, University of Michigan (UofM) class of 1974.

In 1974, Dr. James Norris became the first URiM graduate of the UofM Plastic Surgery Residency ( Fig. 2 ). Dr. Norris's fondest memories while training at the UofM included the tremendous mentoring he received from Drs. Dingman, Grabb, and Oneal. Dr. Norris also praised the quality of training and the way he was treated at UofM. For Dr. Norris, Michigan Plastic Surgery stood out as “… an exciting environment where excellence reigned, where everyone was treated with respect and dignity, where innovation and new approaches to old problems were encouraged, and where we never for one moment were to forget that the most important person in our universe was the patient.”

Fig. 2.

Dr. James Norris with UofM plastic surgery residency class of 1974.

In the 1980s, approximately 15 black plastic surgeons practiced across the United States. ⁸ After completing his training, Dr. Norris faced challenges when attempting to pursue a faculty position. He fondly recalls support from Dr. Dingman, “… Look, if you want to go to New York City and work at Harlem Hospital, that is your decision, but do not let those New York fellows put you in a box and label you as a Black plastic surgeon. You are as well trained as any plastic surgeon in New York.” ^{7 9}

Interestingly, Dr. Norris and Dr. Arthur Garnes crossed paths during Dr. Norris's visit to New York, where he secured his first faculty position at Harlem Hospital. The interview was for staff privileges at Columbia Presbyterian. It was conducted by Dr. George Crikelair, director of Columbia Presbyterian's Plastic Surgery Program, with Dr. Garnes present. The interview was brief and included two questions: (1) “Jim, do you know how to treat burns?” and (2) “Do you know about electrolyte balance and fluid administration?” After confidently responding “Yes” and “Yes,” Dr. Norris's interview was over. ⁷ Dr. Crikelair instructed Dr. Garnes: “Arthur, put him on. Take Jim down and show him the unit.” ⁷ Although he was among the few black plastic surgeons at the time and faced significant barriers to gaining staff privileges at a “Class A hospital,” he went on to have, “a phenomenal practice in New York for 23 years.” His unique experience at the UofM prepared him to tackle any challenge and be highly successful. ⁷

The First Women Plastic Surgeons at the UofM

Like URiM candidates, women faced barriers to entering the field of plastic surgery, but the 1960s and 1970s witnessed an increase in the number of women in the field. Dr. Kathryn Lyle Stephenson broke barriers as the first woman to serve as an editor of Plastic and Reconstructive Surgery from 1963 to 1967, and the Plastic and Reconstructive Surgery Yearbook from 1967 to 1975. In addition, she was a founding member and president (1967–1968) of the California Society of Plastic Surgeons. ¹⁰ Plastic surgery societies introduced informal initiatives geared toward women. For example, the women's luncheon was started at ASPS. The luncheon provided an annual forum and space for women in the field to meet, exchange ideas, and support one another. ¹¹ Dr. Rose Lewis became the first black female plastic surgeon and began her residency in 1978, further widening the scope of diversity within the discipline. ¹¹ Dr. Lewis completed her training at Phoenix Hospital in 1980 and became the first black woman to receive ABPS certification in 1982. ¹²

In 1989, Dr. Christine Sullivan became the first female graduate of the UofM's plastic surgery residency program. Dr. Leslie Cohen followed in 1998. Dr. Cohen reflects positively on her time as a trainee at the UofM and is “grateful to have had the opportunity, as well as incredibly proud to have been among the earliest women graduates.” ¹³ Although the plastic surgery program had few female trainees, there were several females in the general surgery program, and she found the environment incredibly supportive and vibrant. She notes that Michigan gave her all the training and tools to succeed and provided a positive research environment, with mentorship from Dr. Cynthia Marcello and strong clinical support from Drs. William Kuzon and Vigen Darian. Although Dr. Cohen was among the few female residents, she praises the sense of “fellowship and community” she felt while training at the UofM. ¹³

Increasing the Number of URiM and Women in Plastic Surgery Nationally

The 1990s ushered in some advances in plastic surgery in terms of racial and ethnic diversity. Professional organizations opened the doors to membership, and Drs. William Matory and Ferdinand Ofodile became the first black members of the AAPS in 1994 and 1995, respectively. ⁴ The 2000s and 2010s continued the trend toward improving ethnic and racial diversity, but at a slower pace. In 2006, black and Hispanic representation among plastic surgery faculty remained stubbornly low at 1.4 and 3.6%, respectively. ² To amplify and advocate for more diversity and inclusion in plastic surgery, the Arthur Garnes Society was established in 2019; it continues to highlight the legacy of Black Pioneers in plastic surgery and achieve inclusive excellence within the workforce. ¹⁴ Although diversity and inclusion remained a goal in the specialty, substantial changes were slow to materialize. The proportion of URiM trainees and faculty remained stagnant throughout the 2010s. ¹⁵

Aspiring women plastic surgeons made greater gains. The formalization of the ASPS Women's Plastic Surgery Caucus in 1992 and the appointment of Dr. Mary McGrath as the first female president of the Plastic Surgery Foundation in 1995 represented tremendous milestones. ¹¹ Women began matriculating into plastic surgery residency programs at increased rates. From 1990 to 2007, female trainees in integrated programs increased from 14 to 22%. ^{16 17 18} In 2007, Dr. Roxanne Guy was elected the first female president of the ASPS, signaling another landmark in gender inclusion. ¹⁸ Female representation continued to grow in all domains. By 2015, women constituted 36.2% of trainees in integrated plastic surgery programs. By 2018, they represented 20.29% of society leaders, 13% of program directors, and 8% of department chairs. ^{16 19 20} In 2019, Dr. Kerri Woodberry was installed as the first black female chief of a plastic and reconstructive surgery division at West Virginia University. ⁴

Increasing URiM and Women Faculty in Plastic Surgery at the UofM

The UofM Section of Plastic Surgery hired Dr. Amy Alderman as its first female faculty member in 2004. In 2011, Dr. Adeyiza Momoh became the first URiM faculty member. The following year, Dr. Jennifer Waljee joined the plastic surgery faculty after training at Michigan in general, plastic, and hand surgery. As a leader in academic surgery, the Department of Surgery at UofM intentionally changed its hiring practices and embarked upon its vision to achieve workforce diversity and advance recruitment of URiM in surgery by creating the Michigan Promise Working Group . ²¹

The Michigan Promise Working Group created a recruitment committee and transformed how and where new faculty positions were posted, how the candidate pool was selected, and which members from the Department participated in faculty campus visits. The overarching and shared goal of the working group and the Department included developing and incorporating best practices to maximize the probability that diverse, talented, and well-qualified candidates were identified, recruited, and hired. ²² The recruitment committee consists of a diverse group of members who undergo rigorous mandatory training, including recognition and management of bias.

A critical aspect of this revolutionary change in recruitment included the implementation of a modified “Rooney rule,” which mandated the inclusion of at least two qualified candidates who bring diversity (race, ethnicity, gender, etc.) to the applicant pool. ²¹ Applicants undergo a group interview with the committee asking standardized questions, which are later used to create a written evaluation to rank candidates. ²¹ With this modification of UofM hiring practices, in the 2017 to 2018 academic year, women constituted 55% of the recruits and 50% of the hires, while URiM represented 15% of the recruits and 33% of the hires. ²¹

With the vision of the Michigan Promise, institutional and departmental support, the faculty complement within the Section of Plastic Surgery at the UofM has evolved; currently, there are 7 (30%) female faculty and 4 (17%) URiM faculty, 3 of whom are also female. Female and URiM faculty collectively represent several subspecialties within plastic surgery, including hand, craniofacial, breast reconstruction, and gender-affirmation surgery. Gender and racial diversity among faculty is important for patient care as well as trainee recruitment and experience. Currently, 54% of the residents and fellows at UofM are women; however, only 3% of trainees are URiM. Surgical programs with more women and URiM faculty tend to attract more trainees who identify as female and URiM. It remains to be seen whether the growth of URiM faculty will lead to an increase in the number of URiM trainees. ²³

Toward a More Diverse Workforce in Plastic Surgery

The current state of DEI in plastic surgery demonstrates both progress and persistent challenges. In 2020, women constituted only 20% of academic plastic surgery faculty in the United States and 27% in Canada. ¹ Further, women who identify as black, indigenous, or people of color held just 6.25% of faculty leadership positions in North America. ¹ Eighteen percent of integrated plastic surgery program directors and 5% of chiefs and chairpersons identified as female. ^{24 25} Although these numbers are relatively low, they represent substantial progress. Notably, within the past 3 years, URiM and female candidates have assumed leadership positions, including Dr. Milton Armstrong, appointed as the first black director of the ABPS in 2020, Dr. Jennifer Walden, elected the first female president of the Aesthetic Society in 2022, and Dr. Steve Williams, named the first black president of ASPS in 2023. ^{4 11}

Institutional and organizational support, forward-thinking leaders, and intentional changes to recruitment strategies have made a difference. Still, the path toward increasing workforce diversity in Plastic Surgery nationally and at the UofM is complex. It is marked by achievement and persistent obstacles. Although critical milestones have been attained, the overall pace and magnitude of change have been slow, with opportunities for improvement.

The UofM Section of Plastic Surgery largely mirrors national trends from a trainee standpoint; the complement of female and URiM faculty is noteworthy. Michigan's integrated plastic surgery residency program was led for 7 years by one of the country's few URiM faculties (Dr. Adeyiza Momoh). Female residents and fellows now comprise more than half of plastic surgery trainees. Dr. Cohen hopes the Section and the subspeciality “continues to dismantle barriers and increase equity for applicants of every gender and ethnicity.” ¹³ The barriers to URiM candidates are more persistent. When asked to reflect on the current residency complement, Dr. Norris states, “the University has a diverse group of residents which is laudable.” He also notes, however, “[among] the residents in your program, [there] is not a single man of color. That I find intriguing. I am neither oblivious to nor naïve about the status of men of color in our society … this is a national crisis.” ⁷

As a section, Plastic Surgery at the UofM recognizes the need to increase URiM trainees. It is working closely with the Office of Health Equity and Inclusion to increase the exposure of URiM medical students participating in subinternships. Many of the faculty have also been deliberate in their efforts to participate in programs such as Women of Color in Plastic Surgery as well as the Plastic Surgery Research, Education, and Preparation Promoting Equity and Diversity (PREPPED) to increase mentorship and exposure for URiM students.

Workforce diversity in Plastic Surgery, both at the UofM and nationally, continues to evolve. Our comparative analysis of national and local trends is encouraging. Improved pathways and pipelines into plastic surgery, as well as mentorship opportunities for URiM students, are some of the few strategies to reduce barriers to entering the field. Changes to the recruitment, interview, and evaluation of faculty candidates through the Michigan Promise Working Group have made remarkable changes at the plastic surgery faculty level and may serve to improve trainee ethnic and racial diversity as well. To that end, a strategic, evidence-based approach can serve as a blueprint for other institutions aspiring to cultivate an environment that appreciates, celebrates, and actively promotes DEI.

The story of DEI in plastic surgery is still being written. Both the UofM and the broader national community must continue to be proactive contributors to this narrative, realizing that the work is far from complete. It is our hope that the richness of our diverse population will one day be closely mirrored by the workforce within our specialty.