Diversity among endovascular neurointerventionalists in Canada results of a national survey 2022

Abstract

Aim

Neurointervention (NIR) is a relatively new developing filed of medicine. Diversity and inclusion in various medical fields has made a significant progress. However, many surgical and interventional fields are still lagging in this respect. The aim of this study was to evaluate the degree of diversity and inclusion amongst neurointerventionalists in Canada.

Materials and methods

A survey was completed in June 2022 by each neurointerventional division in Canada. The survey included questions regarding demographics, inclusivity, diversity, social and personal parameters. The collected data was analysed using semi-quantitative analysis.

Results

As of 2022, 85 physicians were actively practicing NIR in Canada. 52% were neuroradiologists, 38% neurosurgeons and 9% neurologists. 41% were immigrants to Canada (from 19 countries), for 35% English or French were not first language, 35% were visible minority. Women comprised only 21% of the practitioners, with comparable proportion of women in leadership positions. Most practitioners were in the 30–49 age group. 2.4% practitioners identified as LGBTQ. There was no gender difference in terms of life to work balance, with majority of practitioners being engaged in long term relationships and having children.

Conclusions

Our study shows encouraging results in terms of diversity and inclusion amongst Canadian neurointerventionalists regarding the representation of various specialty backgrounds, immigrants, and visible minorities. NIR centers are distributed according to population density and better coverage is needed in smaller communities and remote/isolated areas. Both women and men Canadian neurointerventionalists seem to have a favourable life-work balance. Gaps still exist regarding inclusion of first nations and women which are under-represented among Canadian Neurointerventionalists. Women however are proportionally serving in leadership positions.

Introduction

Neurointervention is a rapidly growing field of medicine, currently still in its developing stage. This field has made a significant leap in the last two decades, now encompassing a very wide range of endovascular approaches for the treatment of intracranial and spinal vascular pathologies, spanning from purely elective to hyperacute indications.

The practice of interventional neuroradiology has expanded significantly especially since the publication of the results of the ISUIA study ¹ regarding the treatment of brain aneurysms and randomised studies proving the clear advantage of endovascular treatment for acute ischemic stroke. ²

As this field has mainly developed in the last 25 years, we found it interesting to evaluate the diversity amongst the physicians practicing vascular neurointervention in Canada. We especially wanted to evaluate if the diversity of the Canadian society is reflected in this young subspecialty of Medicine.

Materials and methods

We have created a survey to evaluate the degree of diversity among neurovascular interventionalists in Canada. The anonymous survey was filled in person/online by representatives from each Canadian neurovascular group. The survey included demographic, professional, gender related and personal variables. The results of the survey were summarised and presented in a semi-quantitative manner.

Results

We were able to collects survey responses from all 23 Neurointerventional (NIR) centers in Canada with 85 NIR practitioners. 11 NIR centers were in Ontario, 3 in Quebec, 3 in British Columbia, 2 in Alberta, 1 in Manitoba, 1 in Saskatchewan, 1 in Nova Scotia and 1 in New Brunswick. To our knowledge, there were no NIR centers in Newfoundland, Prince Edward Island, Nunavut, and Northwest Territories or in Yukon. Table 1 summarises the association with size of population in each province/territory.

Table 1.

Geographic distribution of Canadian NIR centers and practitioners as it correlates to population density.

	NIR centers	INR practitioners	Population 2019
Ontario	11	37	14.57 M
Quebec	3	12	8.5 M
British Columbia	3	10	5.1 M
Alberta	2	11	4.4 M
Manitoba	1	3	1.4 M
Saskatchewan	1	3	1.2 M
Nova Scotia	1	8	0.98 M
New Brunswick	1	1	0.78 M
Newfoundland	0	0	0.52 M
Prince Edward Island	0	0	0.16 M
Nunavut	0	0	0.04 M
Northwestern Territories	0	0	0.04 M
Yukon	0	0	0.04 M
Total	23	85

Original speciality

Most NIR practitioners in Canada were neuroradiologists (44/85, 51.8%), while 32 (37.6%) were neurosurgeons, 8 (9.4%) were neurologists and 1(1.2%) general interventional radiologist. 14 other general IR practitioners were helping with stroke call in some centers. These physicians however did not practice NIR on a regular basis and were not included in this survey.

Gender and sexual identity

Out of the 85 physicians actively practicing NIR in Canada at the time of the survey completion, 67 (78.8%) were men and 18 (21.2%) women. About half of the centers (12/23, 52.2%) had both men and women practitioners, 10 (43.5%) had only men and one center only women (4.3%). In most centers (17/23, 74%) a man led the NIR service, in 5 centers (5/23, 21.7%) the leader was a woman, and in 1 center (4.3%) there was no appointed leader.

None of the practitioners included in our survey identified as other than their genetic gender. Two (2.4%) practitioners identified as members of the LGBTQ community.

Country of origin

35 (35/85, 41.2%) NIR practitioners were immigrants to Canada, most of which (30/35, 85.7%) immigrated to Canada after completing medical school and sometimes residency in their country of origin. 30 (35%) practitioners reported their first language to be other than English or French. Countries of origin of immigrant practitioners in the survey included: Belgium, Brazil, China, Columbia, France, Germany, India, Ireland, Israel, Lebanon, Libya, Philippines, Romania, Saudi Arabia, South Korea, Spain, Switzerland, and USA.

Thirty (35%) practitioners were of a visible minority.

While most of the practitioners (50/85, 59%) were born in Canada, none were representatives of the First Nations.

Age distribution

Regarding the age of NIR practitioners, data was available for 61/85 practioners.18 NIR practitioners were in the 30–39 age group, 19 in the 40–49 age group, 13 in the 50–59 age group, 10 in the 60–69 age group and 1 was 70 years old.

Family life

76 NIR practitioners were married or lived with a partner (76/85, 89%). This included 61 men (61/67, 91%) and 15 women (15/18, 83%). Half (46/85, 54%) had full time working spouses, 22 of which were full time working physician spouses. More than half of NIR practitioners (59/85, 59.4%) had children of all ages and 44 (44/85, 52%) practitioners had young children (bellow 10y). 43 male practitioners (43/67, 64%) and 16 female practitioners (16/18, 89%) had children.

Physical disability

None of the practitioners had reported a physical disability.

 Tables 1 and 2 summarise the above data.

Table 2.

Demographics of Canadian NIR practitioners.

	%		%
Immigrants to Canada	41.2	Men	78.8
Immigrants immigrated after MD or residency	85.7	Women	21.2
English as a second Language	35.0	Men NIR leads	74
Visible minority	35.0	Women NIR leads	21.7
Physical disability	0.0	No leader	4
LGBT community	2.4	Practitioners with partner (men, women)	89 (91, 83)
First Nations	0.0	Practitioners with children (men, women)	59.4 (64, 89)
		Practitioners with young children	52.0
		Working spouses	54.1
		Physician spouses	25.9

Discussion

In this project, we attempted to depict the diversity, demographics, professional background, and characteristics of neurointervention practice and practitioners in Canada. This, to our knowledge, is the first comprehensive analysis of NIR practice in Canada on a national level.

The distribution of neurointerventional centers in Canada shows a slight over-representation of centers in the province of Ontario, with no NIR service in any of the territories and selected provinces. However, overall, there was a correlation between population density and NIR service availability across Canada, with a still need for better NIR coverage in smaller communities and remote/isolated areas.

In the last two decades, inclusion and diversity among medical professionals was progressively accepted as an important goal to be implemented by medical leadership.^3–5 Nonsurgical medical specialties have made a great leap in this sense. ⁶ Significant progress was also made among surgical specialties; however, parameters of inclusion and diversity in these professions are still lagging. In general surgery, there had been a progressive trend towards higher diversity and inclusion in all parameters, both in trainee and staff physicians’ levels.^7–9 However, other surgical subspecialties, such as vascular or cardio-thoracic surgery are still relatively homogenous in terms of gender of practitioners and minority representation.^10,11 Neurosurgery, a speciality intimately related to the field of neurointervention, has made tremendous leaps in terms of technical and technological advancement, however, diversity and inclusion is progressing only very slowly over the last decades. ¹² The exact reasons for that discrepancy had been discussed extensively in the literature, with multiple reasons being suggested – such as a high level of competitiveness, overly consuming work hours, difficult and non-inclusive residency admission process, male gender-oriented environment, etc.^13,14 Neurointervention, although not a completely new field in medicine, has been reaching new technical and technological peak only in the last 15 years and has transformed itself into a structured sub-speciality with fellowship programs and an official recognised certification process in selected countries. ¹⁵ In addition, NIR in Canada, accepts into fellowship training – residency graduates from three major distinct medical specialties – Diagnostic radiology (commonly after initial fellowship in Neuroradiology), Neurosurgery (at times after or in conjunction with fellowship in Open Vascular Neurosurgery) and Neurology (at times after initial fellowship in Stroke Neurology). This provides a very fruitful ground towards diversification of the field, clearly reflected in our data, with diverse background specialties feeding into NIR in Canada. According to our data, Neuroradiology is currently the background sub-speciality of about half of NIR practitioners in Canadian centers. The reason for this dominancy is historical since NIR developed as a subspecialty by neuroradiologists, with slow progressive interest and inclusion of specialist from other related professions over the years.

In terms of gender representation, the percentage of female practitioners among NIR practitioners is Canada is low (21%) and does not represent their percentage in medical practice in Canada, which ranges between 30–56%. ¹⁶ This low representation of women is common to many surgical specialities in Medicine and is similar in many NIR practices worldwide, although changing in Europe and USA. ¹⁷ There are various reasons suggested to lead to this discrepancy, rooted in society's cultural and social aspects as well as in the nature of current medical and especially surgical training. ¹⁷ However, representation of women in NIR has been increasing consistently as previously reported in direct and indirect reports.^17,18 We are at least glad to report that in leadership positions female representation in Canada is well concorded with their percentage amongst the practitioners.

We found that NIR practitioners in Canada come from extremely diverse ethnical backgrounds. 41.2% were immigrants to Canada, most of which (85.7%) immigrated to Canada after completing medical school and sometimes residency in their country of origin. These physicians came from 18 different countries. This diversity is larger compared to that among the general population of physicians of Canada. The 2019 Canadian Medical Association census on medical specialists (IMG, Canadian Medical Association Masterfile, 2019) states that only 21% of MDs practicing in Canada were International Medical Graduates (IMG). This would include immigrants and Canadians graduating abroad. Our survey reveals overrepresentation of international medical graduates with over 35% NIR practitioners in Canada who had completed their medical school and sometimes their clinical training outside of Canada. NIR is practiced in academic centers in Canada, with an adaptive hiring policy of IMG via Academic Licencing pathways, which, combined with relatively liberal Canadian immigration policy, could explain this diversity.

Adding another dimension to diversity is the fact that 35% of NIR practitioners were a visible minority and 35% of practitioners reported their first language was other than English or French. It was disappointing to find that although most of the practitioners (59%) were born in Canada, none was First Nations. This finding was concordant with a remote survey of overwhelming underrepresentation of first nations amongst medical professionals in Canada, with only 0.25% First Nations Canadians in the medical fields in 2007 survey, which was ∼15 fold lower than First Nations proportion in Canadian population. ¹⁹

Majority of NIR practitioners in Canada were in the group age of 30–49, with almost equal representation of 30–39 and 40–49 age groups, with some decline of active neurointerventionalists beyond the age of 50, and minority of practitioners beyond the age of 60. Recent increasing demand for NIR practitioners, as this profession grows, could explain the younger population of practitioners. In addition, this trend is not surprising given the highly physical and emotional demands of this field.

Regarding work life balance in NIR, we found that the vast majority (89%) of NIR practitioners in Canada were married or lived with a partner. This was only mildly more common for men (91%) than for women (83%). Most practitioners (69%) had children. Being a parent was significantly more common for women practitioners (89%) than for men practitioners (64%). Having a family with children is thus common among Canadian NIR practitioners including for women, which more commonly have children than men practitioners. This finding contrasts with a reported recent study among worldwide NIR practitioners in which female practitioners were less likely to have partner or children compared to male NIR practitioners. ¹⁷ Another interesting fact is that only ∼50% of NIR practitioners have a full-time working spouse, with half of those being full time working physicians’ spouses.

Finally, the survey revealed no practitioner with physical disability. This finding is most likely explained by the nature of this profession, with long procedures requiring many hours of operation while standing. In the future, to involve physicians with physical disabilities significant adjustments will be needed to the angiography suite environment.

In summary, this comprehensive survey of demographics among Neurointerventional physicians in Canada shows overall encouraging results. There is high heterogeneity of practitioners with diverse background specialities feeding into this profession, many immigrants from multiple countries of origin, significant presence of visual minorities and generous age range. NIR centers are distributed according to Canadian population density with better NIR coverage needed in smaller communities and remote/isolated areas. Women are still severely underrepresented in Canadian Neurointerventional practice but are proportionally represented in NIR leadership positions.