An overview of diversity, equity, and inclusion in the United States transplant surgery workforce

Introduction

Transplantation remains the only durable treatment for end-stage organ disease (ESOD). The need for transplantation has grown steadily over the past 2 decades, with over 25,000 transplants performed per year in the last decade and over 40,000 transplants in 2022.¹ Despite increasing volume, there remain well-described inequities in the transplant system across all solid organs that affect racially and ethnically minoritized communities, as well as historically disenfranchised groups such as women, those with Medicaid, the uninsured, and rural or geographically distant populations.^2-4 The impact is felt across the continuum of transplant care: from disease incidence and diagnosis, to referral and evaluation, to waitlisting, transplantation and post-transplant outcomes.^5-12 The National Institute on Minority Health and Health Disparities (NIMHHD) roadmap for health disparities research describes how the domains of biological, psychosocial, and structural systems intersect with individual, community, and societal levels of influence to impact health.^13-18 Applying this intersectional framework to our understanding of inequitable outcomes along the transplant continuum paints a fuller picture of the causes of disparities in transplant and creates targets for where we might intervene.^2,4,19-23 However, one area with relatively little attention is the relationship between disparities in transplantation and the composition of the transplant workforce. The individuals that comprise the clinical and research workforce in transplantation contribute to our collective understanding of inequity in the transplant system and workforce diversity, equity, and inclusion (DEI) plays an important role in achieving equity in the system. In this review, we synthesize evidence highlighting the impact of DEI in the field of transplant through the lens of the transplant workforce in the US and discuss the current state of the policies and programs that support DEI in transplantation.

The importance of a diverse healthcare workforce

Diverse workforces have long been recognized as an important tool to addressing disparities.^24-27 The murder of George Floyd in May 2020 and the racial and ethnic disparities seen during the COVID-19 pandemic brought renewed attention to structural drivers of health inequities in the United States, including workforce diversity.^28-30 Decades of work has demonstrated that non-white physicians provide a disproportionate share of care for disenfranchised populations, and that patients have higher satisfaction and increased trust when receiving racially concordant care.^31-35 With regards to gender diversity, a growing body of evidence suggests that female patients experience worse outcomes when treated by male physicians, but have similar outcomes to male patients when treated by female physicians.^36,37 In surgery, recent observational studies have demonstrated lower rates of poor postoperative outcomes in the short and long-term for patients treated by female surgeons compared to male surgeons, even after accounting for patient, procedure, surgeon, and hospital characteristics.^38,39

Workforce diversity is particularly important in the field of transplantation, where a rigorous selection process can be influenced by individual bias, institutional policy, and structural challenges that contribute to disparate access to organ transplantation. Multidisciplinary selection committees comprised of surgeons, social workers, medical physicians, psychiatrists, and others collectively evaluate a candidate’s medical and psychosocial eligibility for transplant. While there is an over-representation of ESOD among disenfranchised groups, the transplant workforce has an underrepresentation of women, and racial and ethnic minority groups in the United States.^5,6,40,41 Evidence suggests that the transplant evaluation process is susceptible to subjectivity and bias. Recent reports have demonstrated increase denial for transplantation among minorities despite similar social risk scores.^42,43 Another US multicenter study evaluated selection committee meetings and their participants, highlighting how internal factors—such as implicit bias, explicit racism, and lack of diversity in transplant center teams—as well as external factors—such as national policies, national quality metrics, and lack of consistent eligibility guidelines—converge to reproduce disparities for disenfranchised populations.⁴⁴ Integration of a diverse transplant workforce is one facet of the multilevel changes needed to address the structural roots of inequity in transplantation.

Diversity in the transplant surgeon workforce

Many in transplant surgery have recognized the importance of diversifying the transplant pipeline in order to diversify the workforce, a mission that was the cornerstone of the ASTS “Boldly Against Racism” campaign.⁴⁵ Even so, a 2019 ASTS membership survey revealed how far we are from gender parity and highlighted the lack of data to describe racial and ethnic diversity within the workforce. From 2005 to 2015 only 18% of new surgeons being added to transplant surgery workforce identified as female, an increase from 1980 where only 3.7% were female.⁴⁶ Notably absent in this report is the dimension of race and ethnicity of the transplant surgery workforce which remains under-evaluated.

The goal of having a surgeon workforce that mirrors the population of the United States is at best a long-term goal rather than a tangible short-term reality due to the length of requisite training for transplant surgeons. While the number of women physicians in surgery training has shown dramatic improvement in the last 2 decades, the proportion of underrepresented minority general surgery trainees has declined.⁴⁷ Despite evidence in support of a diverse surgeon workforce, a lower percentage of Black and Latinx applicants match into general surgery residency programs compared to White applicants and when they matriculate into these programs they graduate with fewer cases, suggesting that differences in training quality and therefore career preparedness may exist.^48,49 Pipeline programs have been effective at enhancing diversity in residency programs, however mentorship upon entry into the field is also important, especially considering that among newly trained transplant surgeons there is up to 25% attrition within 3 years.^50,51

Lack of workforce diversity in transplantation persists through the levels of leadership. A recent study of transplant program directors identified that over 80% of program director respondents where male, while only 5% were Hispanic, and 5% Black.⁵² Another study identified that 90% of liver, pancreas and kidney transplant surgical directors were male, with roughly 55% non-Hispanic white surgical directors.⁵² A 2019-20 analysis of the ASTS organizational leadership revealed that only 20% of the council members were women, with 1 Asian member and no Hispanic or Black members on the 12-member council. Further, 76% of ASTS committee members were male and among these committee members, 16% were Asian, 8% Hispanic and 6.6% Black.⁵³ In total, there have been 51 presidents of the ASTS, but only 4 have been women: Dr. Nancy Ascher, Dr. Kim Olthoff, Dr. Elizabeth Pomfret and Dr. Ginny Bumgardner.⁵⁴ A similar trend among ASTS presidents is notable for race and ethnicity, although current demographic collection practices don’t allow for quantitative assessment of the racial and ethnic diversity of society presidents.

Parallel efforts have taken place to understand the importance of DEI in transplantation internationally. The International Liver Transplant Society (ILTS) DEI committee formed in 2017 reported a survey of 243 transplant centers and found that only 13.2% had at least 1 woman director of liver transplant, transplant surgery, or transplant hepatology. In surgery specifically, 152 of 833 transplant surgeons (18.2%) were female, and in ILTS leadership only 7 out of 26 positions were held by women.^55,56 As for the European Society of Transplantation (ESOT), it is notable that since founding in 1982, there has only been one female president, Dr. Carla Baan.⁵⁷ Respondents of another ILTS survey on discrimination, mentorship and gender revealed that there were high rates of experiences with racial and gender discrimination, lack of mentorship, and low rates of female leadership.⁵⁸

A few studies have also demonstrated a lack of gender and racial diversity among editors at high impact surgical journals.⁵⁹ In transplant journals more specifically, a review of editorial boards at 22 transplant journals found that women were < 40% of editors, and in a commentary on this review, another group noted that < 20% of Editors in Chief were women, and that 32% of 22 journals do not have women in top editorial positions.^60,61

Diversity in the multidisciplinary transplant team

Transplantation is a field that deeply relies on collaboration between multiple specialties to deliver high quality care. As such, diversity among the various transplant team members is of equal importance as diversity in the transplant surgical workforce. Across the medical transplant specialties, there is a lack of diversity across physicians in nephrology, hepatology, cardiology and pulmonology.^62-65 Paralleling work in the surgical societies, the American Society of Transplantation, and other transplantation societies have made commitments to advancing DEI across all levels of transplant teams through self-evaluation, education, and dedication of resources to mentoring and pipeline programs as well as advocacy to address inequitable policies and practice.^66-69

Additionally, the allied health professionals such as transplant coordinators, nurses, pharmacists, social workers and advanced practice providers (APPs) are vital members of the modern surgical workforce in transplant.⁶² There are little data on the full scope of diversity in the transplant team, but the effect of broad team diversity has been emphasized in studies of multidisciplinary selection committees.⁴² For example, the multi-faceted role of the transplant pharmacist goes far beyond patient facing clinical care, including research and advocacy. DEI in the transplant pharmacist workforce can play an important role in advancing equity in availability, dosing, and pricing of important transplant medications.^70-72

A 2023 report of the American Society of Transplant survey of APPs highlighted national practice patterns and the demographics of the APP workforce. Of the 237 respondents to the survey, 93.6% were female and 82.2% were Caucasian. Notably, 4.7% were Hispanic, 4.4% were Black, and 4.4% were Asian.⁷³ This survey characterized the important role transplant APPs play across inpatient and outpatient teams in caring for transplant patients and their roles in education, research, and policy. Importantly, the group identified that the APP workforce in transplant needs to make efforts to increase diversity in their workforce and recommended efforts to target inclusion of underrepresented groups in the APP pipeline, and in hiring practices.⁷³ DEI efforts in transplant must encompass the whole scope of the transplant team.

The role of diverse team members in interventions to improve equity in transplantation

In the field of transplant surgery, there have been champions of efforts to improve equity in access to the continuum of transplant care. In 1991, Dr. Clive Callender, a Black transplant surgeon, created the National Minority Organ Tissue Transplant Education Program (MOTTEP) to improve education about transplantation and increase rates of organ donation among Black Americans.^74,75 MOTTEP transitioned from an institutional initiative at Howard University to a lasting national movement that continues to advocate and improve trust and organ donation plans nationally.⁷⁶

Culturally concordant clinical programs have gained attention to increase equity in access to transplantation. The Northwestern Medicine’s Hispanic Kidney Transplant Program (HKTP), founded by Dr. Juan C Caicedo, is a culturally targeted and linguistically congruent approach to increasing access to transplantation waitlisting for LatinX patients. The program works in close partnership with local communities and transplant stakeholders and is focused on diverse transplant staff: from bilingual and bicultural outreach staff to Spanish-speaking physicians. Institutional and multisite trials of this program have shown significant improvement in waitlisting rates and living donor kidney transplantation for Hispanic/LatinX patients, and the program has demonstrated financial feasibility.^77-80 At the University of Colorado, Dr. Lillias Cervantes’s work on kidney disease in the Latinx community has impacted kidney and pancreas transplantation efforts alongside research on access to dialysis for undocumented immigrants that led to policy change expanding access to dialysis care.^81-85

Similarly, the African American Transplant Access Program (AATAP) at Northwestern Medicine spearheaded by Dr. Dinee Simpson was built to support Black patients who face structural disadvantage in the transplant process. AATAP provides Black patients with a culturally-congruent team to guide them through the transplant evaluation process.⁸⁶ The Black Liver Health Initiative based in Columbia University’s Center for Liver Disease and Transplantation partners with the Black community to provide better access to care, further health literacy, and advance policy and research.⁸⁷ By focusing on building strong relationships with patients these programs hope to rebuild the trust between the healthcare system and Black patients. Program champions with diverse lived experiences and a passion for disenfranchised communities demonstrate the institutional and societal power of a diverse transplant workforce.

Looking beyond efforts at individual transplant centers, leadership by minority transplant clinicians has been at the forefront of work to remove the vestiges of race-based medicine from the healthcare system. For decades, the equation widely used to calculate a patient’s estimated glomerular filtration rate (eGFR) incorporated a black race correction that systematically increased the eGFR for Black patients based on a stereotyped association of Black individuals with increased muscle mass.⁸⁸ For transplantation, this resulted in Black patients having to wait longer to reach the threshold for eligibility to join the kidney transplant waitlist due to eGFR overestimation.^89,90 A joint National Kidney Foundation and American Association of Nephrology taskforce described the impact of raced-based eGFR calculations and recommended the use of an improved race-free calculation.^90,91 The calls to action to change the eGFR policy were largely driven by providers who belong to racial and ethnic minority groups and their allies, highlighting the policy level impact on equity that can be accomplished by a unified and diverse workforce. Race neutral eGFR has now been operationalized through national policy that corrects eGFRs for Black candidates, and is affecting wait-list time across the country.⁹²

While removing race-based adjustments in this context will change access to kidney transplant for Black candidates, challenges to creatinine-based eGFR calculations remain. For example, using the new eGFR calculation reduced prevalence of chronic kidney disease stage 3 or greater in a cohort of US Asian people.⁹³ As we work to disentangle the social construct of race from the biological factors that affect eGFR, future research and policy may involve decreased emphasis on creatinine based calculation, and instead use cystatin-C based eGFR calculations that may more accurately approximate eGFR across populations.⁹⁴

Equity cannot be achieved by the work of a few individuals. Many of the interventions discussed here have been established for years with positive results both anecdotally as well as in the academic literature. And yet, the diffusion of these interventions has not reflected the success, perhaps testament to the gaps in the workforce to prioritize these efforts.

Going forward: policy as a lever of systemic change

While individuals in the transplant workforce can have an impact, it is the systems (transplant centers, healthcare infrastructure) and policies (at society, state and national levels) that are the durable levers of structural change in an inequitable system. Societies such as the ASTS, American Society of Transplantation, ESOT and others have sought to bring about permanent change in DEI efforts by investing time, effort, and resources into educational efforts, pipeline programs, and societal structural changes.^{62,64,66,67,69,95} The Transplantation Society has supported the Women in Transplant organization with the mission to achieve “worldwide gender equity and inclusiveness in transplantation”.⁹⁶ ESOT also hosted a special issue in Transplantation International titled “Diversity, Equity and Inclusion in Transplantation” in 2022 that not only emphasized changes in policy to address patient-facing inequities at a global level, but importantly advocated DEI in transplant research.⁹⁷ In the US, the American Society of Transplant Surgery (ASTS) “Boldly Against Racism” campaign developed committees, research grants, and pipeline support programs.^45,95 Though we are decades away from achieving a truly diverse workforce capable of gender and racial concordance between providers and patients that mirrors the general population, these efforts are first steps towards building a workforce suited to address structural drivers of health disparities through practice, research and policy.

The National Academies of Science, Engineering, and Medicine 2022 report “Realizing the Promise of Equity in the Organ Transplant System” outlined equity as a core principle that should guide the future of the transplant system.⁹⁸ Though the report did little to comment on the diversity of the workforce, this review highlights the value of a diverse workforce, and impact on patients. National policy can codify and scale these effects. In the US, policy beyond the transplant center or medical societies has a large role in effecting change across the system. Since the passage of the National Organ Transplant Act of 1984, the transplant system has been formalized as the Organ Procurement and Transplant Network.⁹⁹ National laws have the ability to mandate sweeping changes. One example is the Securing the US Organ procurement and Transplant Network Act of 2023 that is the first overhaul of the OPTN since it’s founding.^100-102 This modernization initiative seeks to restructure the OPTN to create greater accountability in organ procurement and transplantation practices across geography and populations. Policy within the OPTN, however, is not legislated, but created and administered according to the multidisciplinary board members priorities and influenced by public comment. It is at this level that committees such as Minority Affairs enact policy that impacts marginalized groups, such as with eliminating the use of race-based eGFR calculations.¹⁰³ Committee level diversity, and equitably minded policy holds promise to have an impact on the national scale.

Further levers of change at structural levels include prioritization in allocation of research monies through the National institutes of Health, or healthcare payment models through the Centers for Medicare and Medicaid Services (CMS). The Increasing Organ Transplant Access model is a coming example of a federally mandated trial through CMS that will emphasize equity in access to kidney transplants by implementing payment models that value addressing social drivers of health and other barriers to transplant.¹⁰⁴ As transplant centers look to integrate interventions to improve waitlisting and kidney transplant, they may benefit from incorporating well studied culturally and socially targeted interventions reviewed here.^77-80,86,87 These national efforts are valuable opportunities for structural implementation of change that can benefit from the experience of diverse leadership in the transplant workforce.

The future of DEI in transplantation is through integration across the transplant system. Pipeline programs remain important now more than ever to ensure a well-equipped and diverse multidisciplinary transplant workforce of the future. At the same time, grant funding supporting diverse research topics and researchers as well as diverse leadership engagement with the policy streams at a national level are mechanisms through which durable structural changes in the transplant system can be achieved. DEI in the transplant workforce is not only a benefit diverse patients of the transplant system, but the transplant system more broadly.